Medicaid Statistical Information System (MSIS)

MSISDDv5-2012.docx

MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary

Release 5
February 2014

This release provides additional information for full reporting of person-based
eligibility and claims from all Children’s Health Insurance Programs (CHIP),
regardless of whether it is a Medicaid expansion CHIP (M-CHIP) or a stand-alone,
separate CHIP program. Error conditions for data elements related to CHIP
reporting have been modified. Clarifications to the reporting of Medicare
Coinsurance and Deductible Amounts have been added, and the value set for the
reporting of TYPE-OF-SERVICE has been expanded to include reporting of Private
Health Insurance.
Additional changes include DIAGNOSIS-CODE and DIAGNOSIS-CODE-FLAG changes to
prepare for implementation of ICD-10 on 10/1/2014. Note that the actual
implementation of the changes related to ICD-10 does not take place before
10/1/2014.
February 2014 - Changes include adding a data element in the Eligibility (EL) type
quarterly file transmissions delivered to CMS. The new element is the ‘T-MSIS
ELIGIBILITY-GROUP’ This change enables states to have the ability to send the TMSIS Eligibility Group (representing ACA expanded Medicaid eligibility groups) data
element within the current MSIS application.
Prepared by:
Centers for Medicare and Medicaid Services
Center for Medicaid and CHIP Services
and
Office of Information Services

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TABLE OF CONTENTS
1. INTRODUCTION…………………………………………………………………………………….……………….…………………..2
2. NOTATION CONVENTIONS ………………………………………………………………………….…………...…………………..5
3. CODING DATA FIELDS …………………………………………………………………………….……………...…………………..6
4. FILE FORMATS ……………………………………………………………………………....……………………………………........9
5. MSIS ELIGIBLE FILE …………..………………………………………………………………………..……….………………...….18
6. MSIS CLAIMS FILES ……………………..………………………………….………………………….…….…..…………………..66
APPENDIX A – ERROR MESSAGE LIST………………….………………………………………………………………………......142
ATTACHMENT 1 - MSIS VALIDATION REPORT FORMAT……………………….………..……………………………………….144
ATTACHMENT 2 - COMPREHENSIVE ELIGIBILITY CROSSWALK……………………...…...………….……..………….……..146
ATTACHMENT 3- TYPES OF SERVICE REFERENCES …………...………………………..………………………………….….158
ATTACHMENT 4 - PROGRAM TYPE REFERENCES ………………...……………… .……………………………………….…169
ATTACHMENT 5 – T-MSIS ELIGIBILITY GROUP VALID VALUES TABLE ……………………………………………………. 173

APPENDIX B – CODING SCHEME FOR T-MSIS ELIGIBILITY GROUP

……………………………………………………. 187

END OF DOCUMENT …………………………………………………………………………………………………………………..188

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1.

INTRODUCTION

1.1

General Overview and Data Security Policy

This document provides State Medicaid and Chidren’s Health Insurance Program (CHIP)agency staffs with the information
they need to prepare and submit MSIS files. Since MSIS files contain personal information on Medicaid enrollees, CHIP
Medicaid expansion enrollees and separate (stand-alone) CHIP enrollees, the data are subject to the Privacy Act and must be
safeguarded. For this reason, all MSIS files must be encrypted before they are submitted to CMS. CMS has selected
SecureZip from PKWARE as the software solution for encryption of data containing personally identifiable information. This
product will allow CMS to receive MSIS data from the mainframe or mid-tier platforms of our external partner’s choice.
In order for our external partners to encrypt the data files, they will be required to install the SecureZIP Partner software, a
solution which enables the secure exchange of data files between a sponsor (CMS) and its external partners (States and/or
contractors).
All CMS partners will be required to have the SecureZIP Partner Link software, which is provided at no cost. To register for the
SecureZIP Partner software, go to PKWARE’s website:
http://securezippartner.pkware.com/
This URL will allow for the download of the software for each platform on which you plan to encrypt and send the MSIS data.
The following Sponsor (CMS) ID number: 7708 will need to be entered. If you need assistance with becoming a registered
Partner with CMS, PKWARE can be contacted via the information listed below.
Normal Business Hours (8:00am – 6:00pm CST)
Phone:
1-937-847-2687
Email:
[email protected]
24x7 Priority Support
Phone:
1-937-847-6149
The Sponsor Distribution Package is a Binary File/Key that is needed to prepare encrypted MSIS data files for CMS. This
license known as Partner Link is downloadable from PKWARE’s site on the Internet and it is limited for just CMS business.
Once MSIS data files have been encrypted with Secure Zip, there are two methods available to send the information to CMS.
One is the existing tape submission process (mail and login sheet) and the other is electronic file transfer (EFT) process either
through Connect:Direct or the alternative TIBCO Software, Inc. (TIBCO) suite of products.
This document:
-

defines terms;

-

identifies responsibilities;

-

describes the record layouts of the five primary MSIS data files;

-

characterizes data formatting requirements and validation rules; and

-

describes the methods for encryption and/or tape versus electronic file transfer (EFT).

This document is a reference for the creation of quarterly Eligibles and Claims files. The record formats and data element
specifications presented must be accurately observed. The record formats and editing rules established in this document are
the basis of CMS's tape file validation procedures. Any file that is found to contain errors in excess of the tolerances
documented in the following sections will require the State to make corrections and resubmit the file.

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1.2

Terms and Abbreviations

Acronym/Abbreviation

Description

ANSI
CMS
CMCS
COBOL
DSN
EFT
EBCDIC
EPSDT
FFY
FFYQ
HCFA
IBM
M-CHIP
MSIS
MMIS
OIS
OS
CHIP

1.3

American National Standards Institute
Centers for Medicare and Medicaid Services
Center for Medicaid, CHIP and Surveys and Certifications
Common Business Oriented Language
Data Set Name
Electronic File Transfer
Extended Binary-Coded-Decimal Interchange Code
Early and Periodic Screening Diagnosis and Treatment
Federal Fiscal Year
Federal Fiscal Year Quarter
Health Care Financing Administration
International Business Machines, Inc.
Medicaid Expansion CHIP (Children’s Health Insurance Program)
Medicaid Statistical Information System
Medicaid Management Information System
Office of Information Services
Operating System
Stand-alone, separate CHIP (Children’s Health Insurance Program)

Delivery Schedules

Quarterly Eligible and Claims files, whether they be in the form of tape or EFT submissions, should be submitted to CMS on
the following schedule:

FILE TYPE

FFY REPORTING QUARTER

* * * * * DUE DATES * * * * *
REGULAR
DELAYED

ELIGIBLE

1st
2nd
3rd
4th

(10/01-12/31)
(01/01-03/31)
(04/01-06/30)
(07/01-09/30)

02/15
05/15
08/15
11/15

CLAIM-XX

1st
2nd
3rd
4th

(10/01-12/31)
(01/01-03/31)
(04/01-06/30)
(07/01-09/30)

02/15
05/15
08/15
11/15

04/15
07/15
10/15
01/15

There are two different schedules for the submission of Eligible files. The choice of schedule determines how the State will
provide corrections to their Eligible records to CMS. The earlier (REGULAR) due date requires the State to submit correction
records as individual records included with their Eligible file submission. If the State cannot submit correction records but must
wait until they have updated their Eligible files before submitting their Eligible data, they must use the delayed (DELAYED) due
date.

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1.5 MSIS Contacts for Assistance - MSIS central E-mail address:
[email protected]
Questions may also be directed to the following individuals:
MSIS State Participation and Project Management:
Loretta Schickner
[email protected]
(410) 786-5151
MSIS technical contact:
Kathy Ranshous
[email protected]
(410) 786-0958
1.6 Electronic File Transmission (EFT)
EFT is utilized by all States using one of two processes, Connect:Direct or TIBCO products.
The first process is the Connect:Direct process, which has been in use for many years by States to transmit State buy in
data and MMA files to CMS. Connect:Direct is free of charge to all of CMS’ external partners, as long as they currently
hold a license.. The other process used is the Gentran process which is a suite of file transfer software products from
TIBCO. The suite of products are licensed by CMS and are provided free of charge to CMS’ external business partners.
This process allows the state to exchange files in a secure manner over the Internet using inexpensive, readily available
client software at the States.
Regardless of which process is used, all of the procedures for encrypting the files through the Secure Zip process up to
the point of tape submission remain the same. The only exceptions are that the tape login sheet does not need to be
prepared and the dataset name (DSN) for a SecureZipped file that will be transmitted electronically is different. For the
EFT process, the following DSN should be used for the name of the SecureZipped file:
P#[email protected]
where st = State abbreviation, ccyy = federal fiscal year, n = quarter number from 1 to 4, and ft = the 2 position alpha
abbreviation for the file type (EL, IP, LT, OT or RX).
Any questions regarding the processing of Secure Zip files may be directed to the CMS Help Desk at 410-786-2580 or
sent to the EFT mailbox at [email protected]

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2.
NOTATION CONVENTIONS
A number of standard notation conventions are used throughout this document:
a.

Literal Character Strings, when required, must be spelled out exactly as displayed. In this document, literal character
strings are always displayed enclosed in double quotes, as in "YR" or "QTR". Alphabetic characters that appear in literal
strings are always in Upper Case.

b.

User Supplied Variables take on values that depend on the user's specific application. Variables whose values may
include any alphanumeric character (any valid EBCDIC character) are represented by unquoted strings of X's (e.g.,
XXXX). Numeric variables, whose values can include only the characters {0, 1, 2, 3, 4, 5, 6, 7, 8, 9, +, -}, are
represented by unquoted strings of 9's (e.g., 99999). Alphabetic characters used to specify user supplied variables are
always in Upper Case. See Section 4.1 (File Formats) for an illustration of these rules.

c.

In the specifications of edit criteria, the Boolean operators "and" and "or" are written AND OR to distinguish them from
the more normal uses of these words. In this context, AND OR are used to connect and visually distinguish the terms
that comprise the logical expressions of specific validation edits.
Example: The edit criterion: "the value of BASIS-OF-ELIGIBILITY is in error if:
Value <> ‘0' AND DAYS-OF-ELIGIBILITY = "0"”
means that an error exists if BASIS-OF-ELIGIBILITY is not zero in any month in which there are no days of
eligibility.

d.

When relationships between fields that occur monthly are specified, it is understood, unless otherwise stated, that all field
values refer to the same month. Thus, in the previous example, it would be assumed that BASIS-OF-ELIGIBILITY and
DAYS-OF-ELIGIBILITY were evaluated for the same month, since there is no indication that any other condition is
required.

e.

For each MSIS file, the Physical record layouts reflect the order in which fields are physically stored in file records.
Relational edits involve comparisons of values in two or more fields. These are evaluated when the validation program
encounters the last field referenced by the edit criterion.

f.

Alphabetized ordering is used in the Data Field/Element Specifications sections to facilitate locating individual field
descriptions.

g.

Error codes are specified as three digit numbers throughout this document. Referring back to the discussion in Section
1.1, the error codes summarized in Appendix A can result from two kinds of edits.
1.

2.

Simple field edits involve only the value of a single field value. These edits result in very specific, detailed error
messages that are represented in the Validation Report by the same three-digit numbers that appear in Appendix
A.
Relational edits result in more generic error messages. The detailed, field specific information about each error
condition is contained in the Data Field/Element Specifications sections. The Validation Report provides the
necessary reference to the appropriate data dictionary error and the edit condition that failed.

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3.

CODING DATA FIELDS

3.1

Field Initialization
-

3.2

Numeric fields should be initialized to 0.
Each byte of every alphanumeric field should be initialized to a space character.

Valid Field Values

Valid Field Values must satisfy two sets of criteria. They must:
-

3.3

conform to the "COBOL PICTURE" clause specified for each field; and
lie within certain pre-defined ranges that are established based on Medicaid program rules and other logical
requirements.

COBOL PICTURE clauses

These are concatenations of:
-

the literal string "PIC ";
one or two characters indicating the type of data stored in the field;
a number enclosed in parentheses indicating the length of the field;

Examples of COBOL PICTURE clauses used in this document:
3.4

PIC X(3) describes an alphanumeric field of length 3;
PIC S9(6) describes a signed numeric field of length 6.

Indicating Inappropriate and Invalid Data

The MSIS system has established a convention to indicate not applicable and invalid data by filling fields with numbers that
are all eights or all nines.
A data field filled with eights specifies "not applicable" in the context of a particular record. For example, suppose an
ELIGIBLE file record has the field DUAL-ELIGIBLE-FLAG = 0, meaning that the Medicaid eligible is not a Medicare
beneficiary. In all CLAIMIP (inpatient hospital claim file) records submitted for this recipient, the fields MEDICAREDEDUCTIBLE-PAYMENT and MEDICARE-COINSURANCE-PAYMENT should be filled with Hex F8s since these data fields
are not relevant for this record.
A data field filled with nines indicates that the field requires valid entries and contain invalid data. For example, DATE-OFBIRTH must contain a valid value in all ELIGIBLE file records. If DATE-OF-BIRTH is not known, the field is filled with nines.
Filling a field with nines always results in a validation error that counts against the error tolerance established for the field.
Each byte in either of these types of alphanumeric fields contains a "9" or an "8". For example:
- a field filled with nines formatted as X(3) contains 999
- a field filled with eights formatted as S9(5) contains +88888;
3.5 Field Justification
All alphanumeric fields are to be left justified and numeric fields are to be right justified.

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3.6

Date Fields

Date fields must be in the format CCYYMMDD for any of the Eligibility or Claims files, as specified in the data dictionary page
for each such field, where:
CC is the 2 digit century (19, 20)
YY is a 2 digit year (85, 86, 87, . . .)
MM is the month (01, 02, . . ., 12)
DD is the day (01, 02, . . ., last valid day in month)
3.7

Blank Fields Are Illegal

Alphanumeric fields can never, legally, be completely filled with spaces, unless a string of space characters is logically defined
as a valid value. After initialization any such field must be either filled with a value that lies within the set of acceptable values
defined for that field, contain eights (888...) or contain nines (999...).
3.8

Validation Edits

MSIS edits can be grouped in two major categories. Data validation edits and distributional checks. Files will not be accepted
until all edits fall within tolerances, and all distributional anomalies have been resolved.
3.8.1

Data Validation Edits

Data validation edits can be grouped into four categories:
-

tests to see if numeric fields contain non-numeric data;

-

tests for eight or nine filled fields, which indicates that a field was not applicable in the context of a particular record
or could not be filled with valid data;

-

tests on a value to see if it falls within the range established for the data element;

-

relational tests that compare values of two or more data elements for consistency or according to a rationale or
formula;

States receive a Validation Report from the MSIS system ONLY when files fail the CMS validation edits. The error
messages that are used in the report are found in Appendix A of this document. These messages refer to the field
specific edit specifications that are presented in the Data Field/Element Specifications sections of this document. These
edit specifications are applied to the data submission in the order listed in this document during validation (see Section
2.e). Therefore, if the error message displayed was a result of the fourth edit, then the first three edits passed
successfully. Moreover, the validation process terminates and the remaining edits listed are not performed.
In some cases the error messages in Appendix A are identical to their corresponding field specific messages. For edits
involving comparisons of two or more field values or relational edits, the messages in Appendix A are generic
descriptions. These generic descriptions relate to several, more detailed, field specific messages that all use the same
error number.
When a numeric field (PIC 9) is found to contain non-numeric data, an 810 series error is assigned and the field is reset
to a default value. The non-numeric test is the first edit performed on each numeric field.
The degree to which States submit valid data values or fill fields with nines is edited next. This editing is next in order to
determine the degree the States have problems supplying valid data. The validation program obtains a count of the
number of cases in which valid data was not available for each data field.

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In addition to the error codes listed in the data dictionary there are special error codes, 99* series, which indicates an
informational error, only. Errors 99* occur when a relational edit is applied against a field flagged as in error by an earlier
edit. Recall that relational edits are performed only when the last field involved in the relation is encountered. By the
time a particular relational edit is performed, the system will have already checked whether any of the other fields in the
relation were in error. If an error is found in a relational edit that includes any field already found in error, the relational
error is flagged with code 99*. This prevents a single error from being counted more than once during validation.
NOTE:

Field error tolerances which appear within the dictionary are the default values. Adjustments are based on special
state circumstances.

3.8.2

Distributional Checks

Distributional checks involves a set of manual and automated analytical summaries of the data. These checks evaluate
means, ranges, frequency distributions, and payment totals against expected ranges of outcomes, including historically
reported ranges.

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4.

FILE FORMATS

CMS no longer accepts tape files.
4.1

Dataset Name Specifications

-

The dataset name (DSN) is required to follow the following standard naming convention:
MW00.XX.YR9999.QTR9.XXXXXXXX,
where:
"MW00" is a literal value;
XX is the state's two character Post Office abbreviation. A complete list of Post Office abbreviations is included in
the STATE-ABBREVIATION data element description located in the Header Record Data Field/Element
Specification subsection of this document;
"YR" is a literal value;
9999 is the four digit Federal Fiscal Year (FFY) covered by the file (e.g., "1999")
"QTR" is a literal value;
9 is the FFY quarter covered by the file. The FFY quarters are defined as follows:
Quarter 1 - October 1 through December 31
Quarter 2 - January 1 through March 31
Quarter 3 - April 1 through June 30
Quarter 4 - July 1 through September 30
XXXXXXXX is a valid MSIS file type:
CLAIMIP (inpatient hospital claims)
CLAIMLT (long term care claims)
CLAIMOT (other, non-institutional claims)
CLAIMRX (prescription drug claims)
ELIGIBLE (eligible file)

Example: California's FFY 1999, Quarter 4 file of non-institutional claims would have a dataset name of
"MW00.CA.YR1999.QTR4.CLAIMOT ".

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4.2

Record Length Specifications

Record Length depends on file type, as follows:

4.3

File Name

Record Length

ELIGIBLE
CLAIMIP
CLAIMLT
CLAIMOT
CLAIMRX

375
840
300
280
250

HEADER Record Specifications

The first data record of every MSIS file is a Header Record. The Header Record contains file identification information
required for accurate validation of the file and to facilitate further processing.
4.3.1 HEADER Record - Physical Data Record Layout
The following table specifies the record layout and COBOL PICTURE clauses for the Header Record. The COBOL PICTURE
clauses obey ANSI standard rules, which are summarized in Section 3.3. The Start and End Positions specify the exact
location of each field in the record.
HEADER RECORD SUMMARY

FIELD NAME
FILE-NAME
FILE-STATUS-INDICATOR
FILLER
STATE-ABBREVIATION
DATE-FILE-CREATED
START-OF-TIME-PERIOD
END-OF-TIME-PERIOD
SSN-INDICATOR
FILLER (ELIGIBLE)
(CLAIMIP)
(CLAIMLT)
(CLAIMOT)
(CLAIMRX)

<--- POSITION --->
START
END

COBOL PICTURE
X(8)
X(1)
X(2)
X(2)
9(8)
9(8)
9(8)
9(1)
X(337)
X(802)
X(262)
X(242)
X(212)

01
09
10
12
14
22
30
38
39
39
39
39
39

08
09
11
13
21
29
37
38
375
840
300
280
250

There are no error tolerances associated with Header fields. A single Header field validation error will cause the entire file to
be rejected.

4.3.2 HEADER Record Data Field/Element Specifications
This subsection presents detailed specifications for the fields in the MSIS Header Record. Header Record fields are listed in
alphabetical order in this subsection. Each data element description includes the content specifications, an example of a
proper entry, and a description of the edit criteria applied during the MSIS validation process. Edit criteria are presented in the
order in which they are applied.
Note that since every Header Record field must contain valid data. Header fields are never filled with eights or nines.

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HEADER RECORD

Data Element Name: DATE-FILE-CREATED
Definition: The date on which the file was created.
Field Description:
COBOL
PICTURE

Example
Value

9(8)

19870115

Coding Requirements:
-

Date must be in CCYYMMDD format.

-

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

Error Condition

Resulting Error Code

1.

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

2.

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

3.

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

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HEADER RECORD

Data Element Name: END-OF-TIME-PERIOD
Definition:

Last date of the reporting period covered by the file to which this Header Record is attached.

Field Description:
COBOL
PICTURE

Example
Value

9(8)

19871231

Coding Requirements:
Date must be in CCYYMMDD format.
Federal fiscal quarters end on December 31, March 31, June 30, and September 30.
For ELIGIBLE File submissions, END-OF-TIME-PERIOD must always contain a quarter ending date (12/31, 3/31,
6/30, 9/30).
For CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX File submissions, however, END-OF-TIME-PERIOD reflects the
date on which the state closes its fiscal accounting records for the quarter. Several states close their books on dates
other than the last day of each month or quarter. Therefore, MSIS allows reporting quarters to end on any date
between the fifteenth day of the third month of the quarter and the fifteenth day of the following quarter.
Example: The Dataset Name indicates that the reporting quarter is Quarter 3 of federal fiscal year 2008. The actual
start and end dates of this quarter are April 1, 2008 and June 30, 2008, respectively. END-OF-TIME-PERIOD may
be any date between June 15, 2008 and July 15, 2008 inclusive.
It is essential that states assure that claims for days on or near the quarterly fiscal cutoff date are counted in one and
only one quarter.

Error Condition

Resulting Error Code

1.

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

2.

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

3a.

For ELIGIBLE File submissions - ............................................................................................................................. 203
Value is <> quarter ending date
OR

3b.

For CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX File submissions - .................................................................... 203
Value is < 15th day of last month of reporting quarter
OR Value is > 15th day of the first month of the following
reporting quarter

4.

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

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HEADER RECORD

Data Element Name: FILE-NAME
Definition:

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

Field Description:
COBOL
PICTURE

Example
Value

X(8)

CLAIMOT

Coding Requirements:
Valid Values Code Definition
ELIGIBLE

Eligibles File

CLAIMIP

Inpatient Claim/Encounters File - Claims/encounters with TYPE-OF-SERVICE = 01, 24, 25, or
39.
(Note: In CLAIMIP, TYPE-OF-SERVICE 24 and 25 refer only to services received on an
inpatient basis.)

CLAIMLT

Long Term Care Claims/Encounters File - Claims/encounters with TYPE-OF-SERVICE 02, 04,
05 or 07 (all mental hospital, NF services).
(Note: Individual services billed by a long-term care facility belong in this file regardless of
service type.)

CLAIMOT

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

CLAIMRX

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

Error Condition

Resulting Error Code

1.

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

2.

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

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HEADER RECORD

Data Element Name: FILE-STATUS-INDICATOR
Definition:

The test or production status of the file. All files should be production ONLY. Test files will no longer be
accepted by CMS.

Field Description:
COBOL
PICTURE

Example
Value

X(1)

P

Coding Requirements:
Valid Values Code Definition
P

Production File - ELIGIBLE Production Files must contain:
-

one record for each person who was eligible for Medicaid or CHIP during the reporting
quarter;

-

for each person who was granted retroactive eligibility during the reporting quarter that
covered a portion of a prior quarter, one record must be included for each quarter covered;
and

-

records correcting prior quarter records that contained errors, if any.

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

one record of the appropriate claim/encounter type, for every separately adjudicated line
item of every claim processed during the reporting month; and

-

one record for every adjustment to a prior quarter claim/encounter that was adjudicated
during the reporting quarter.

Error Condition
1.

Resulting Error Code

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

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HEADER RECORD

Data Element Name: SSN-INDICATOR
Definition:

Indicates whether the state uses eligibles' social security numbers (SSN) as MSIS-IDENTIFICATIONNUMBERs.

Field Description:
COBOL
PICTURE

Example
Value

9(1)

1

Coding Requirements:
Valid Values Code Definition
0

State does not use SSN as MSIS-IDENTIFICATION-NUMBER

1

State uses SSN as MSIS-IDENTIFICATION-NUMBER

Section 5.1 provides a detailed explanation on the use of this field in conjunction with the States' unique personal
identification number.

Error Condition

Resulting Error Code

1.

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

2.

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

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HEADER RECORD

Data Element Name: START-OF-TIME-PERIOD
Definition:

Beginning date of the Federal Fiscal Quarter covered by this file.

Field Description:
COBOL
PICTURE

Example
Value

9(8)

19861001

Coding Requirements:
Date must be in CCYYMMDD format.
Federal fiscal quarters begin on October 1, January 1, April 1, and July 1.
For ELIGIBLE File submissions, START-OF-TIME-PERIOD must always contain a quarter starting date (10/1, 1/1,
4/1, 7/1).
For CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX File submissions, however, START-OF-TIME-PERIOD reflects
the date on which the state opens its fiscal accounting records for the quarter. Several states open their books on
dates other than the first day of each month or quarter. Therefore, MSIS allows reporting quarters to start on any date
between the fifteenth day of the third month of the previous quarter and the fifteenth day of the current reporting
quarter.
Example: The Dataset Name indicates that the reporting quarter is the Quarter 3 of federal fiscal year 1999. The
actual start and end dates of this quarter are 4/1/1999 and 6/30/1999, respectively. START-OF-TIME-PERIOD may
be any date between 3/15/1999 and 4/15/1999 inclusive.
It is essential that states assure that claims for days on or near the quarterly fiscal cutoff date are counted in one and
only one quarter.

Error Condition

Resulting Error Code

1.

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

2.

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

3a.

(For ELIGIBLE File submissions) - .......................................................................................................................... 203
Value <> quarter starting date
OR

3b.

(For CLAIMIP, CLAIMLT, CLAIMOT, and CLAIMRX File submissions) - ............................................................... 203
Value < 15th day of last month of previous calendar
quarter OR Value is > 15th day of reporting quarter

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HEADER RECORD

Data Element Name: STATE-ABBREVIATION
Definition:

U. S. Postal Service abbreviation for the state submitting the file.

Field Description:
COBOL
PICTURE
X(2)

Example
Value
ND

Coding Requirements:
Must be one of the following U.S. Postal Service State abbreviations:
AL = Alabama
AK = Alaska
AZ = Arizona
AR = Arkansas
CA = California
CO = Colorado
CT = Connecticut
DE = Delaware
DC = Dist of Col
FL = Florida
GA = Georgia
GU = Guam/Am Samoa
HI = Hawaii
ID = Idaho
IL = Illinois
IN = Indiana
IA = Iowa
KS = Kansas

KY = Kentucky
LA = Louisiana
ME = Maine
MD = Maryland
MA = Massachusetts
MI = Michigan
MN = Minnesota
MS = Mississippi
MO = Missouri
MT = Montana
NE = Nebraska
NV = Nevada
NH = New Hampshire
NJ = New Jersey
NM = New Mexico
NY = New York
NC = North Carolina
ND = North Dakota

Error Condition

OH = Ohio
OK = Oklahoma
OR = Oregon
PA = Pennsylvania
PR = Puerto Rico
RI = Rhode Island
SC = South Carolina
SD = South Dakota
TN = Tennessee
TX = Texas
UT = Utah
VT = Vermont
VI = Virgin Islands
VA = Virginia
WA = Washington
WV = West Virginia
WI = Wisconsin
WY = Wyoming

Resulting Error Code

1.

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

2.

Value is different from State abbreviation contained ................................................................................................. 402
in the Dataset Name

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5.

MSIS ELIGIBLE FILE

The first record in this file must be the Standard Header Record (See Section 4.3). The ELIGIBLE file contains:

5.1

-

one record for each person who was eligible for Medicaid or CHIP for at least one day during the reporting quarter
covered by this file;

-

one record for each individual for whom retroactive eligibility was established during the reporting quarter and, for
each prior reporting quarter covered by the retroactive eligibility;

-

corrections to ELIGIBLE File records submitted in prior quarters. Note: All correction records must be submitted as
complete records. Do not submit records that contain valid values only in the corrected fields. Correction records
will completely replace the eligible record previously provided.

Unique Personal Identifiers

MSIS identifies eligibles by means of a unique personal identification number that is assigned by the State. Some States use
social security numbers as unique personal identification numbers. All other States create their own unique identification
numbers according to some systematic scheme that is approved by CMS. Therefore, there are two alternatives for providing
the personal Identification number to MSIS (MSIS-ID). Those States using the SSN as the MSIS-ID are identified as SSNStates while those States that create the MSIS-ID are called Non-SSN States. A discussion of these alternatives, how the
MSIS-ID should be provided to MSIS, and the three inter-related fields used to provide this information follows. This
discussion is provided at this time to afford a better understanding on the use of these interrelating fields and the use of the
MSIS-ID in MSIS. Additional information pertaining to the specific fields and their edit criteria will be found on the appropriate
field definition pages.
All States must provide available SSNs on the eligible file, regardless of the use of this field as the unique MSIS
identifier.
Non-SSN States will assign each eligible only one permanent MSIS-ID in his or her lifetime. When reporting eligibility records
it is important that the SSN-INDICATOR in the Header record be set to 0 and the MSIS-ID for each record be provided in the
MSIS-IDENTIFICATION-NUMBER field; if the MSIS-IDENTIFICATION-NUMBER is not known then this field should be filled
with nines. The MSIS-ID identifies the individual and any claims submitted to the system.
-

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

Once unique permanent personal identification numbers are assigned to eligibles, they must be consistently used to
identify that individual, even if the individual is re-enrolled in a subsequent time period.
SSN States will use the SOCIAL-SECURITY-NUMBER field to provide the MSIS-ID when a permanent SSN is available for
the individual. For these States the SSN-Indicator in the header record will be set to 1 and the MSIS-IDENTIFICATIONNUMBER in the eligible record should be blank.
-

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

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Four examples are provided concerning the rules for filling in the SSN-INDICATOR, SOCIAL-SECURITY-NUMBER, and
MSIS-IDENTIFICATION-NUMBER fields:
(1)

The State uses the SSN as an MSIS unique identifier AND the eligible had a valid SSN at the time eligibility was first
established.
SSN-INDICATOR =
SOCIAL-SECURITY-NUMBER =
MSIS-IDENTIFICATION-NUMBER =

(2)

The State uses the SSN as an MSIS unique identifier AND the eligible does not have a valid SSN (the State assigned a
temporary ID).
SSN-INDICATOR =
SOCIAL-SECURITY-NUMBER =
MSIS-IDENTIFICATION-NUMBER =

(3)

1
Eligible's valid SSN
Temporary identification number assigned to Eligible (This should be
carried for at least one quarter)

The State does not use the SSN as an MSIS unique identifier AND the eligible has had the same, state-assigned,
permanent identification number since eligibility was established.
SSN-INDICATOR =
SOCIAL-SECURITY-NUMBER =
MSIS-IDENTIFICATION-NUMBER =

5.2

1
888888888
Temporary identification number assigned to Eligible

The State uses the SSN as an MSIS unique identifier AND the eligible had previously been assigned a temporary ID, but
has now been assigned a valid SSN.
SSN-INDICATOR =
SOCIAL-SECURITY-NUMBER =
MSIS-IDENTIFICATION-NUMBER =

(4)

1
Eligible's valid SSN
Spaces

0
Eligible's valid SSN.
State-assigned unique identifier

ELIGIBLE File Record Types

When the period of eligibility covered by a record is within the reporting quarter specified for the file, the record is a Current
Quarter record (TYPE-OF-RECORD = 1). Only one record per eligible can be a Current Quarter record in one ELIGIBLE file.
Do not include records flagged as "current quarter" for persons who were not eligible for Medicaid for at least one day during
the reporting quarter. MSIS will evaluate the first 500 records in a file to ensure the Current Quarter records fall within the
reported quarter. If more than 50% do not, the file is rejected without further evaluation.
The ELIGIBLE file may contain one or more records for an individual for whom eligibility was established during this reporting
quarter, retroactive to a prior quarter (TYPE-OF-RECORD = 2). Include one record for each prior quarter for which retroactive
eligibility was established.
The ELIGIBLE file may contain any number of Correction records that correct/update enrollment records submitted to CMS in
prior quarters' files (TYPE-OF-RECORD = 3). Note that only one correction should be submitted for any particular prior
quarter. If more than one correction record addresses the same reporting quarter, only the last one in the file will be effective.
When you submit correction or retroactive records for a prior quarter, those records must be coded using the specifications
that were in effect as of the quarter of eligibility being reported. Do not report retroactive records with coding that is acceptable
in the current quarter but was not permitted in the prior quarter for which the correction/retroactive record is being reported.

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5.3

Sorting Rules

The ELIGIBLE file must be sorted in standard EBCDIC ascending collating sequence as follows:
For Non-SSN States -

the primary sort key is MSIS-IDENTIFICATION-NUMBER (ascending);

-

the secondary sort key is FEDERAL-FISCAL-YEAR-QUARTER (ascending);

-

the tertiary (minor) sort key is TYPE-OF-RECORD (descending).

For SSN States -

the primary sort key is SOCIAL-SECURITY-NUMBER (ascending);

-

the secondary sort key is MSIS-IDENTIFICATION-NUMBER (ascending);

-

the tertiary sort key is FEDERAL-FISCAL-YEAR-QUARTER (ascending);

-

the fourth (minor) sort key is TYPE-OF-RECORD (descending).

The following example illustrates the sorting sequence of ELIGIBLE file records for FFY 1987, Quarter 2, for a Non-SSN State:
RECORD-NUMBER
1
2
3
4
5
6

MSIS-ID-NUM

FFYRQ

34567584323569
45673848569310
45673848569310
45673848569310
45673848569310
54667484958110

872
863
864
872
872
872

TYPE-OF-RECORD
1
2
3
3
2
1

A single ELIGIBLE file should never contain two records with the same MSIS-IDENTIFICATION-NUMBER (or SSN) and
FEDERAL-FISCAL-YEAR-QUARTER. By implication, this means that there will never be two records for the same eligible in
the same quarter that have different values of TYPE-OF-RECORD. Thus, the third sort key has no effect on a properly
constructed file. It is included only to help identify incorrect records. Improperly sorted files will be returned to the State.

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5.4

ELIGIBLE File - Physical Data Record Layout

The following table summarizes the fields in the ELIGIBLE file record in the order in which they physically occur in each
record. Fields whose values remain fixed for an entire quarter are referred to as quarterly fields; fields that vary monthly are
listed separately for each month.

ELIGIBLE RECORD SUMMARY

FIELD NAME

COBOL PICTURE

- POSITION START
END

DEFAULT
ERROR
TOLERANCE

QUARTERLY FIELDS
MSIS-IDENTIFICATION-NUMBER
DATE-OF-BIRTH
DATE-OF-DEATH
SEX-CODE
RACE-ETHNICITY-CODE
SOCIAL-SECURITY-NUMBER
COUNTY-CODE
ZIP-CODE
TYPE-OF-RECORD
FEDERAL-FISCAL-YEAR-QUARTER
QUARTERLY-DUAL-ELIGIBLE-FLAG
HIC-NUMBER
MSIS-CASE-NUMBER
RACE-CODE-1
RACE-CODE-2
RACE-CODE-3
RACE-CODE-4
RACE-CODE-5
ETHNICITY-CODE
FILLER

February 2014

X(20)
9(8)
9(8)
X(1)
9(1)
9(9)
9(3)
9(5)
9(1)
9(5)
9(2)
X(12)
X(12)
9(1)
9(1)
9(1)
9(1)
9(1)
9(1)
X(9)

21

01
21
29
37
38
39
48
51
56
57
62
64
76
88
89
90
91
92
93
94

20
28
36
37
38
47
50
55
56
61
63
75
87
88
89
90
91
92
93
102

0.1%
0.1%
5.0%
2.0%
2.0%
2.0%
5.0%
5.0%
2.0%
0.1%
2.0%
5.0%
0.1%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%

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ELIGIBLE RECORD SUMMARY

FIELD NAME
MONTHLY FIELDS
MONTH 1:
DAYS-OF-ELIGIBILITY
ELIGIBILITY-GROUP
MAINTENANCE-ASSISTANCE-STATUS
BASIS-OF-ELIGIBILITY
HEALTH-INSURANCE
TANF-CASH-FLAG
RESTRICTED-BENEFITS-FLAG
PLAN-TYPE-1
PLAN-ID-1
PLAN-TYPE-2
PLAN-ID-2
PLAN-TYPE-3
PLAN-ID-3
PLAN-TYPE-4
PLAN-ID-4
CHIP-CODE
INCOME-CODE
WAIVER-TYPE-1
WAIVER-ID-1
WAIVER-TYPE-2
WAIVER-ID-2
WAIVER-TYPE-3
WAIVER-ID-3
DUAL-ELIGIBLE-CODE
T-MSIS-ELIGIBILITY-GROUP
FILLER

February 2014

COBOL PICTURE

S9(2)
X(6)
X(1)
X(1)
9(1)
9(1)
X(1)
9(2)
X(12)
9(2)
X(12)
9(2)
X(12)
9(2)
X(12)
X(1)
X(2)
X(1)
X(2)
X(1)
X(2)
X(1)
X(2)
9(2)
X(2)
X(6)

22

DEFAULT
- POSITION ERROR
START
END TOLERANCE

103
105
111
112
113
114
115
116
118
130
132
144
146
158
160
172
173
175
176
178
179
181
182
184
186
188

104
110
111
112
113
114
115
117
129
131
143
145
157
159
171
172
174
175
177
178
180
181
183
185
187
193

2.0%
2.0%
0.1%
0.1%
5.0%
2.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
2.0%
2.0%

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ELIGIBLE RECORD SUMMARY

FIELD NAME
MONTHLY FIELDS

MONTH 2:
DAYS-OF-ELIGIBILITY
ELIGIBILITY-GROUP
MAINTENANCE-ASSISTANCE-STATUS
BASIS-OF-ELIGIBILITY
HEALTH-INSURANCE
TANF-CASH-FLAG
RESTRICTED-BENEFITS-FLAG
PLAN-TYPE-1
PLAN-ID-1
PLAN-TYPE-2
PLAN-ID-2
PLAN-TYPE-3
PLAN-ID-3
PLAN-TYPE-4
PLAN-ID-4
CHIP-CODE
INCOME-CODE
WAIVER-TYPE-1
WAIVER-ID-1
WAIVER-TYPE-2
WAIVER-ID-2
WAIVER-TYPE-3
WAIVER-ID-3
DUAL-ELIGIBLE-CODE
T-MSIS-ELIGIBILITY-GROUP
FILLER

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COBOL PICTURE

S9(2)
X(6)
X(1)
X(1)
9(1)
9(1)
X(1)
9(2)
X(12)
9(2)
X(12)
9(2)
X(12)
9(2)
X(12)
X(1)
X(2)
X(1)
X(2)
X(1)
X(2)
X(1)
X(2)
9(2)
X(2)
X(6)

23

- POSITION START
END

194
196
202
203
204
205
206
207
209
221
223
235
237
249
251
263
264
266
267
269
270
272
273
275
277
279

195
201
202
203
204
205
206
208
220
222
234
236
248
250
262
263
265
266
268
269
271
272
274
276
278
284

DEFAULT
ERROR
TOLERANCE

2.0%
2.0%
0.1%
0.1%
5.0%
2.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
2.0%
2.0%

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ELIGIBLE RECORD SUMMARY

- POSITION FIELD NAME
MONTHLY FIELDS
MONTH 3:
DAYS-OF-ELIGIBILITY
ELIGIBILITY-GROUP
MAINTENANCE-ASSISTANCE-STATUS
BASIS-OF-ELIGIBILITY
HEALTH-INSURANCE
TANF-CASH-FLAG
RESTRICTED-BENEFITS-FLAG
PLAN-TYPE-1
PLAN-ID-1
PLAN-TYPE-2
PLAN-ID-2
PLAN-TYPE-3
PLAN-ID-3
PLAN-TYPE-4
PLAN-ID-4
CHIP-CODE
INCOME-CODE
WAIVER-TYPE-1
WAIVER-ID-1
WAIVER-TYPE-2
WAIVER-ID-2
WAIVER-TYPE-3
WAIVER-ID-3
DUAL-ELIGIBLE-CODE
T-MSIS-ELIGIBILITY-GROUP
FILLER

COBOL PICTURE

S9(2)
X(6)
X(1)
X(1)
9(1)
9(1)
X(1)
9(2)
X(12)
9(2)
X(12)
9(2)
X(12)
9(2)
X(12)
X(1)
X(2)
X(1)
X(2)
X(1)
X(2)
X(1)
X(2)
9(2)
X(2)
X(6)

START

END

285
287
293
294
295
296
297
298
300
312
314
326
328
340
342
354
355
357
358
360
361
363
364
366
368
370

286
292
293
294
295
296
297
299
311
313
325
327
339
341
353
354
356
357
359
360
362
363
365
367
369
375

DEFAULT
ERROR
TOLERANCE

2.0%
2.0%
0.1%
0.1%
5.0%
2.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
2.0%
2.0%

The error tolerance describes, for each field, the maximum allowable percentage of records submitted that may have missing,
unknown, or invalid codes. Error rates in excess of the error tolerance level for any field will cause the entire file to be
rejected.

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ELIGIBLE File - Data Field/Element Specifications
The following pages contain detailed specifications for each data element (field) in the MSIS ELIGIBLE file record. In this
section, the data elements are listed in alphabetical order.
For each data element, edit criteria are presented in the order in which they are applied during validation. All edits performed
on monthly data elements are executed independently for each month in the reporting period. Unless stated otherwise, edits
involving two or more monthly data elements always relate data for the same month.

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ELIGIBLE FILE
Data Element Name: BASIS-OF-ELIGIBILITY
Definition: Monthly Field - A code indicating the individual's Basis of Eligibility as of the last day of the month referenced.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(1)

0.1%

Example
Value
4

Coding Requirements:
Valid Values

Code Definition

SEE ATTACHMENT 2 (Comprehensive Eligibility Crosswalk) FOR DEFINITIONS OF MSIS CODING CATEGORIES
0
1
2
3
4
5
6
7
8
A
9

Individual was not eligible for Medicaid (or Medicaid expansion CHIP(M-CHIP)) at any time during the
month, or Individual WAS eligible for separate CHIP.
Aged Individual
Blind/Disabled Individual
Not used
Child (not Child of Unemployed Adult, not Foster Care Child)
Adult (not based on unemployed status)
Child of Unemployed Adult (optional)
Unemployed Adult (optional)
Foster Care Child
Individual covered under the Breast and Cervical Cancer Prevention and Treatment Act of 2000
Eligibility status Unknown (counts against error tolerance)

Submit records only for people who were eligible for Medicaid or M-CHIP for at least one day during the FEDERALFISCAL-YEAR-QUARTER, or who are included as non-Medicaid, separate CHIP individuals.

Error Condition

Resulting Error Code

1.

Value is ‘9'-filled ............................................................................................................................................................. 301

2.

Value not equal to ‘0', ‘1, ‘2', ‘4', ‘5', ‘6', ‘7', ‘8' or 'A' ........................................................................................................ 203

3.

Relational Field in Error ................................................................................................................................................ 999

4.

Value <> ‘0' AND DAYS-OF-ELIGIBILITY = +00 ........................................................................................................... 502

5.

Value = ‘0' AND DAYS-OF-ELIGIBILITY <> +00 AND CHIP-CODE <> ‘3’..................................................................... 502

6.

Value = ‘8' AND MAINTENANCE- ................................................................................................................................ 503
ASSISTANCE-STATUS <> ‘4'

7.

(Value = ‘6' OR Value = ‘7') AND MAINTENANCE- ...................................................................................................... 503
-ASSISTANCE-STATUS <> ‘1'

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ELIGIBLE FILE
Data Element Name: BASIS-OF-ELIGIBILITY (continued)
Error Condition

Resulting Error Code

8.

Value = 'A' AND MAINTENANCE- ................................................................................................................................... 503
-ASSISTANCE-STATUS <> '3'

9.

Value = ‘1' AND DATE-OF-BIRTH implies Recipient .................................................................................................... 996
was NOT over 64 on the first day of the month

10.

(Value = ‘4' OR Value = ‘6' OR Value = ‘8') AND DATE-OF-BIRTH implies Recipient ................................................... 997
was NOT under 21 on the first day of the month

11.

Value is = ‘1', ‘2', ‘4', ‘5', ‘6', ‘7',‘8’, or ‘A' in any month later than the month that ............................................................ 504
included DATE-OF-DEATH

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ELIGIBLE FILE
Data Element Name: CHIP-CODE
Definition: Monthly Field - A code indicating the individual's inclusion in the CHIP program for the month.
Field Description:
COBOL
PICTURE

Error
Tolerance

X(1)

5.0%

Example
Value
2

Coding Requirements:
Valid Values
0
1
2
3
9

Code Definition
Individual was not a Medicaid eligible (including M-CHIP) and not eligible for separate CHIP for the
month.
Individual was Medicaid eligible, but was not included in either Medicaid expansion CHIP (M-CHIP) OR
a separate title XXI CHIP program for the month
Individual was included in the Medicaid expansion CHIP program (M-CHIP) and subject to enhanced
Federal matching for the month
Individual was not Medicaid (or M-CHIP) eligible, but was included in a separate title XXI CHIP program
for the month.
CHIP status unknown

Error Condition

Resulting Error Code

1.

Value is ‘9'-filled ............................................................................................................................................................. 301

2.

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

3.

Relational Field in Error ................................................................................................................................................ 999

4.

Value = ‘1' OR ‘2' AND DAYS-OF-ELIGIBILITY = +00 .................................................................................................. 502

5.

Value = ‘2' OR ‘3' AND DATE-OF-BIRTH implies eligible was NOT under 19 on the last day of the month................... 997

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ELIGIBLE FILE
Data Element Name: COUNTY-CODE
Definition: Quarterly Field - FIPS code indicating eligible individual's county of residence.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(3)

5.0%

Example
Value
037

Coding Requirements:
Use the National Bureau of Standards, Federal Information Processing Standards (FIPS) numeric county codes for each
State.
Value = 000 if the eligible resides out-of-State.
If code is missing or unavailable, 9-fill.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled ......................................................................................................................... 812

2.

Value is 999 .................................................................................................................................................................... 301

3.

Value is not a valid county code for this State ............................................................................................................... 201
AND Value <> 000

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ELIGIBLE FILE
Data Element Name: DATE-OF-BIRTH
Definition: Quarterly Field – Eligible individual's Date of Birth

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

0.1%

19670312

Coding Requirements:
Date format is CCYYMMDD (National Data Standard).
If a complete, valid date is not available fill with 99999999.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 00000000 ................................................................................................................... 810

2.

Value is 99999999 - Reset to 00000000 ........................................................................................................................ 301

3.

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

4.

Value is > END-OF-TIME-PERIOD in Header Record AND SEX-CODE <>”U’ .............................................................. 506

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: DATE-OF-DEATH
Definition: Quarterly Field – Eligible individual's Date of Death

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

5.0%

19670313

Coding Requirements:
Date format is CCYYMMDD (National Data Standard).
If Eligible is deceased, and a complete, valid date is not available, set field = 99999999 (counts against error tolerance)
If Eligible is not deceased, set field = 88888888.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 00000000 ................................................................................................................... 810

2.

Value is 99999999 - Reset to 00000000 ........................................................................................................................ 301

3.

Value is not a valid date - Reset to 00000000 ................................................................................................................ 102

4.

Relational Field in Error .................................................................................................................................................. 999

5.

Value is < DATE-OF-BIRTH OR - Reset to 00000000 .................................................................................................... 505
Value is > DATE-OF-BIRTH + 125 years

6.

Value is > DATE-FILE-CREATED in Header Record - Reset to 00000000 ..................................................................... 501

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data
Dictionary
ELIGIBLE FILE
Data Element Name: DAYS-OF-ELIGIBILITY
Definition: Monthly Field - The number of days an individual was eligible for Medicaid or CHIP during each month of
the quarter.

Field Description:
COBOL
PICTURE

Error
Tolerance

S9(2)

2.0%

Example
Value
+30

Coding Requirements:
Valid values are +00 through the total number of days in the month referenced.
If invalid or missing, fill with +99.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to +00 ............................................................................................................................. 810

2.

Value is +99 - Reset to +00 ............................................................................................................................................. 301

3.

Value is < +00 OR Value is > number of days in the ...................................................................................................... 203
month referred to.

4.

Relational Field in Error .................................................................................................................................................. 999

5.

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

______________________________________________________________________________________
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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data
Dictionary
ELIGIBLE FILE
Data Element Name: DUAL-ELIGIBLE-CODE
Definition: Monthly Field - Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and
eligible for some category of Medicaid or CHIP benefits.
Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

2.0%

Example
Value
00

Coding Requirements:
Valid Values
00
01
02
03
04
05
06
08
09
10
99

Code Definition
Eligible is not a Medicare beneficiary
Eligible is entitled to Medicare- QMB only
Eligible is entitled to Medicare- QMB AND Medicaid coverage including RX
Eligible is entitled to Medicare- SLMB only
Eligible is entitled to Medicare- SLMB AND Medicaid coverage including RX
Eligible is entitled to Medicare- QDWI
Eligible is entitled to Medicare- Qualifying individuals
Eligible is entitled to Medicare- Other Dual Eligibles (Non QMB, SLMB,QWDI or QI) with
Medicaid coverage including RX
Eligible is entitled to Medicare – Other Dual Eligibles
Separate CHIP Eligible is entitled to Medicare
Eligible's Medicare status is unknown.

00. Eligible Is Not a Medicare Beneficiary - The individual is not entitled to Medicare coverage.
Medicare Dual Eligibles - The following describes the various categories of individuals who, collectively, are known
as dual eligibles. Medicare has two basic coverages: Part A, which pays for hospitalization costs; and Part B, which
pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services.
Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of
Medicaid benefit.
01. Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only) - These individuals are entitled
to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice
the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A
premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance for Medicare services
provided by Medicare providers.
02. QMBs with Medicaid Coverage (QMB Plus). These individuals are entitled to Medicare Part A, have income
of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility. Through 2005, individuals in
this group qualify for one or more Medicaid benefits including prescription drug coverage. Effective 2006, they qualify
for one or more Medicaid benefits that do not include prescription drugs. Medicaid pays their Medicare Part A
premiums, if any, Medicare Part B premiums, and Medicare deductibles and coinsurance, and provides one or more
Medicaid benefits. QMB individuals with prescription drug coverage are included in this group through
December 2005. Beginning in January 2006, Part D provides drug coverage for these individuals, and
Medicaid drug benefits are not required for an individual to be reported in this group.
03. Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only) - These individuals
are entitled to Medicare Part A, have income of 100 -120% FPL and resources that do not exceed twice the limit for SSI
eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.

______________________________________________________________________________________
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ELIGIBLE FILE
Data Element Name: DUAL-ELIGIBLE-CODE (continued)

04. SLMBs with Medicaid Coverage (SLMB Plus). These individuals are entitled to Medicare Part A, have income of 100120% FPL and resources that do not exceed twice the limit for SSI eligibility. Individuals in this group qualify for one or more
Medicaid benefits excluding prescription drug coverage benefits.
Medicaid pays their Medicare Part B premiums and
provides one or more Medicaid benefits.
05. Qualified Disabled and Working Individuals (QDWIs) - These individuals lost their Medicare Part A benefits due to their
return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that
do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A
premiums only.
06. Qualifying Individuals (QIs) - There is an annual cap on the amount of money available, which may limit the number of
individuals in the group. These individuals are entitled to Medicare Part A, have income of 120 -135% FPL, resources that do
not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B
premiums only with 100% Federal funding.
08. Other Dual Eligibles with Medicaid Coverage (Non QMB, SLMB, QDWI or QI) - These individuals are entitled to
Medicare Part A and/or Part B and are eligible for one or more Medicaid benefits. They are not eligible for Medicaid as a
QMB, SLMB, QDWI or QI. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid
poverty group that exceeds the limits listed above. Medicaid pays for Medicaid services provided by Medicaid providers, but
only to the extent that the Medicaid rate exceeds any Medicare payment for services covered by both Medicare and Medicaid.
Payment by Medicaid of Part B premiums is a state option.
09. Other Dual Eligibles (e.g., Pharmacy + Waivers; states not including prescription drugs in Medicaid benefits for some
groups) – Special dual eligible groups not included above, but approved under special circumstances. This code is to be used
only with specific CMS approval.
10. Separate CHIP Dual Eligibles – These individuals are entitled to Medicare Part A and/or Part B and are eligible for
separate CHIP benefits.
NOTE: If the quarter being reported is prior to FY 2006, Quarter1, or if the reporting quarter is FY 2006, Quarter 1 or
later and includes retroactive or correction records for a prior quarter, the quarterly dual-eligible-flag must be
completed.
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled………………………………………………………….…….812

2.

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

3.

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

4.

Relational Field in Error…..……………………………………………………………………………….999

5.

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

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ELIGIBLE FILE
Data Element Name: ELIGIBILITY-GROUP
Definition: Monthly Field - The composite of eligibility mapping factors used to create the corresponding Maintenance
Assistance Status (MAS) and Basis of Eligibility (BOE) values. Examples of such mapping factors include:
State eligibility group or aid category
Payment status
Disability status
Family status
Person code
Money code
This field should not include information that already appears elsewhere on the Eligible-File record even if it is part
of the MAS and BOE algorithm (e.g., age information computed from DATE-OF-BIRTH or COUNTY-CODE).
Field Description:
COBOL
PICTURE

Error
Tolerance

X(6)

2.0%

Example
Value
10A01

Coding Requirements:
Concatenate alpha numeric representations of the eligibility mapping factors used to create monthly MAS and BOE.
In the example above, state x uses three fields, in addition to age, to determine MAS and BOE. The fields are a twobyte alpha numeric aid category (i.e., 10), a one-byte alpha numeric money code (i.e., A) a two-byte person code (i.e.,
01).
State needs to provide composite code reflecting the contents of this field (e.g., bytes 1-2 = aid category; bytes
3 = money code; bytes 4-5 = person code). If six bytes is insufficient to accommodate all of the eligibility factors, the
state should select the most critical factors and include them in this field.
Value = 000000 for individuals who were not eligible for at least one day during the month.
Value must be one of the valid codes submitted by the State. (States must submit lists of valid State specific eligibility
factor codes to CMS in advance of transmitting MSIS files, and must update those lists whenever changes occur.)
For this field, always report whatever is present in the State system, even if it is clearly invalid. Fill this field with "9"s
only when the State system contains no information.

Error Condition

Resulting Error Code

1.

Value = “999999" ............................................................................................................................................................. 301

2.

Value does not appear on the list of valid codes ............................................................................................................. 201
submitted by the State.

3.

Relational Field in Error ................................................................................................................................................... 999

4.

Value is <> “000000" AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’ ....................................................... 502

5.

Value = “000000" AND DAYS-OF-ELIGIBILITY NOT = +00 AND CHIP-CODE <> ‘3’ .................................................... 502

6.

Value is > “000000" in any month later than the month that ............................................................................................ 504
included DATE-OF-DEATH

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: ETHNICITY-CODE
Definition:

Quarterly Field - A code indicating if the eligible has indicated an ethnicity of Hispanic or Latino.

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

5.0%

1

Coding Requirements:
Use this code to indicate if the eligible’s demographics include an ethnicity of Hispanic or Latino. This determination
is independent of indication of RACE-CODE (1-5).
Valid Values
0
1
9

Code Definition

Not Hispanic or Latino
Hispanic or Latino
Ethnicity Unknown

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9 .............. ............. ............. .............. ............. ............. ........812

2.

Value is 9 ............ ............. ............................ ............. ............. .............. ............. ............. ........301

3.

Value not equal to 0 or 1or 9 ......................... ............. ............. .............. ............. ............. ........203

4.

Relational Field in Error…………………………………………………………………………………...999

5.

Value = 0 and Race/Ethnicity Code = 5 OR 7 . Reset to 9 ....... .............. ............. …………. .......550

6.

Value = 1 and Race/Ethnicity Code is not equal to 5 OR 7. Reset to 9………………………...….550

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: FEDERAL-FISCAL-YEAR-QUARTER
Definition: Quarterly Field - Indicates the Federal Fiscal Year and Quarter for the record.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(5)

0.1%

Example
Value
20011

Coding Requirements:
Values conform to the format "CCYYQ", where:
CCYY is the Federal Fiscal Year covered by this Eligibility Record (e. g., "2001" for FFY 2001); and
Q is the Federal Fiscal Quarter covered by this Eligibility Record:
1
2
3
4

Federal Fiscal Quarter 1 (10/01-12/31)
Federal Fiscal Quarter 2 (01/01-03/31)
Federal Fiscal Quarter 3 (04/01-06/30)
Federal Fiscal Quarter 4 (07/01-09/30)

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled .......................................................................................................................... 812

2.

Q is < 1 OR Q is > 4 ....................................................................................................................................................... 203

3.

CCYY is < 1984 ............................................................................................................................................................... 203

4.

Relational Field in Error ................................................................................................................................................... 999

5.

Value is > than the fiscal quarter specified in .................................................................................................................. 506
END-OF-TIME-PERIOD in Header Record

6.

Value is < than the fiscal quarter specified by ................................................................................................................. 701
START-OF-TIME-PERIOD in the Header Record AND
TYPE-OF-RECORD = {1}; (that is, a current quarter record
does not refer to the current quarter)

7.

Value is = fiscal quarter specified by START-OF-TIME-PERIOD .................................................................................... 701
in the Header Record AND TYPE-OF-RECORD = {2 or 3};
(that is, a prior quarter record refers to the current quarter)

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ELIGIBLE FILE
Data Element Name: HEALTH-INSURANCE
Definition: Monthly Field - A flag indicating whether this enrollee had private (individual or employer sponsored) health
insurance coverage during the month. This includes both coverage purchased or subsidized by the State,
purchased by the eligible or a family member, or provided at no cost to the eligible. Medicare is not considered
private health insurance. Enrollment in a Medicaid/Medicare HMO does not constitute health insurance for this
data element.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(1)

5.0%

Example
Value
1

Coding Requirements:
Valid Values
0
1
2
3
4
9

Code Definition
Not eligible for Medicaid or CHIP during month
Eligible did not have private (individual or employer-sponsored) insurance coverage
Eligible had private (individual or employer-sponsored) health insurance coverage purchased whole or
in part by eligible or family member, or provided at no cost to eligible
Eligible had private (individual or employer-sponsored) health insurance coverage purchased, or
subsidized, by the State
Both 2 and 3 apply
State had only invalid or missing information

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled .......................................................................................................................... 812

2.

Value is 9 ......................................................................................................................................................................... 301

3.

Value < 0 OR Value > 4 ................................................................................................................................................... 203

4.

Relational Field in Error ................................................................................................................................................... 999

5.

Value is <> 0 AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’ ................................................................... 502

6.

Value = 0 AND DAYS-OF-ELIGIBILITY NOT = +00 AND CHIP-CODE <> ‘3’ ................................................................ 502

7.

Value is > 0 in any month later than the month that ........................................................................................................ 504
included DATE-OF DEATH

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: HIC-NUMBER
Definition: Quarterly Field- The eligible’s Medicare Health Insurance Claim (HIC) Identification Number, if applicable.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
123456789A

Coding Requirements:
If eligible is enrolled in Medicare and HIC Number is not available, 9-fill field (counts against error tolerance).
If eligible is NOT enrolled in Medicare, 8-fill field.
Error Condition

Resulting Error Code

1.

Value is improperly “Space Filled” ................................................................................................................................... 303

2.

Value is 9-filled ................................................................................................................................................................ 301

3.

Value is 0-filled ................................................................................................................................................................ 304

4.

Relational Field in Error ................................................................................................................................................... 999

5.

Value is 8-filled AND DUAL-ELIGIBLE-CODE = {01,02,03,04,05,06, 08,09 OR 10} ....................................................... 537

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: INCOME-CODE
Definition: Monthly Field - (OPTIONAL FIELD) A code indicating the family income level associated with the CHIP program
reporting requirements for the month. Each code range is specified in relation to the Federal Poverty Level (FPL). This code is
to be reported for Medicaid expansion CHIP (M-CHIP) enrollees and non-Medicaid,separate CHIP eligibles reported by the
State. For States not opting to provide this data on ANY eligible records, blank-fill this field.
Field Description:
COBOL
PICTURE

Error
Tolerance

X(2)

5.0%

Example
Value
00

Coding Requirements:
Valid Values
BLANK
00
01
02
03
04
05
09
88

Code Definition
State has not opted to include this field for ANY Eligible-file records
Individual was not a Medicaid eligible and not eligible for CHIP for the month
Individual’s family income is from 0 to 100% of the FPL for the month
Individual’s family income is from 101 to 200% of the FPL for the month
Individual’s family income is from 201 to 250% of the FPL for the month
Individual’s family income is from 251 to 300% of the FPL for the month
Individual’s family income is over 300 to a State-specified % FLP for the month
Individual’s State-defined family income is UNKNOWN for the month
Individual was eligible for Medicaid, but not enrolled in the M-CHIP or separate CHIP program for the
month

.
Error Condition

Resulting Error Code

1.

Value is ‘09'-filled ............................................................................................................................................ 301

2.

Value not equal to ‘00, ‘01', ‘02', ‘03', ‘04', ‘05' OR ‘88' .................................................................................... 203

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ELIGIBLE FILE
Data Element Name: MAINTENANCE-ASSISTANCE-STATUS
Definition: Monthly Field - A code indicating an eligible's maintenance assistance status. See Attachment 2 for a description of
MSIS coding categories.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(1)

0.1%

Example
Value
1

Coding Requirements:
Valid Values
0
1
2
3
4
5
9

Code Definition
Individual was not Eligible for Medicaid (or M-CHIP) this month. Individual was elgible for separate
CHIP this month
Receiving Cash or Eligible under section 1931 of the Act
Medically Needy
Poverty Related
Other
1115 - Demonstration expansion eligibles
Status is unknown

Error Condition

Resulting Error Code

1.

Value is ‘9' ....................................................................................................................................................................... 301

2.

Value not equal to ‘0', ‘1,’ ‘2', ‘3', ‘4', or ‘5'....................................................................................................................... 203

3.

Relational Field in Error ................................................................................................................................................... 999

4.

Value is <> ‘0' AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’ .................................................................. 502

5.

Value is ‘0' AND DAYS-OF-ELIGIBILITY NOT = +00 AND CHIP-CODE <> ‘3’............................................................... 502

6.

Value is = ‘1', ‘2', ‘3', ‘4', or ‘5' in any month later than the month that ............................................................................ 504
included DATE-OF-DEATH

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: MSIS-CASE-NUMBER
Definition: Quarterly Field - The state-assigned number which uniquely identifies the case to which the enrollee belongs on
the last day of the current Federal Fiscal Year Quarter. The definition of a case varies. There are single-person
cases (mostly aged and blind/disabled) and multi-person cases, in which each member of the case has the same
case number, but a unique MSIS identification number. A warning for longitudinal research efforts: a person’s
case number may change over time.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

0.1%

Example
Value
1045329867

Coding Requirements:
This field must contain the case identification number assigned by the State.
identification number must be supplied to CMS with the State’s MSIS application.

Error Condition

The format of the Medicaid case

Resulting Error Code

1.

Duplicate Eligible Record (MSIS-IDENTIFICATION-NUMBER, MSIS-CASE-NUMBER, ............................................... 801
FEDERAL-FISCAL-YEAR-QUARTER, DATE-OF-BIRTH SOCIAL-SECURITY-NUMBER match)

2.

Value is improperly “Space Filled” ................................................................................................................................... 303

3.

Value is 9-filled ................................................................................................................................................................ 301

4.

Value is 0-filled ................................................................................................................................................................ 304

5.

Value is 8-filled ................................................................................................................................................................ 305

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: MSIS-IDENTIFICATION-NUMBER
Definition: Quarterly Field - A unique identification number used to identify a Medicaid or CHIP Eligible to MSIS (see section
5.1).

Field Description:
COBOL
PICTURE

Error
Tolerance

X(20)

0.1%

Example
Value
123456789

Coding Requirements:
For SSN States, this field should be space-filled unless a temporary identification number has been assigned. Whenever
such a temporary MSIS-ID is in effect, enter that number in this field. When a permanent SSN is assigned carry the
temporary number in this field for at least one quarter to enable CMS to establish a link between the SSN and the
temporary ID.
For Non-SSN States, this field must contain an identification number assigned by the State. The format of the state
MSIS-ID numbers must be supplied to CMS with the state's MSIS application.

Error Condition

Resulting Error Code

1.

Duplicate Eligible record (MSIS-IDENTIFICATION-NUMBER, MSIS-CASE-NUMBER, ................................................. 801
FEDERAL-FISCAL-YEAR-QUARTER, DATE-OF-BIRTH match)
Second record is not saved.

2.

Non-unique Duplicate (DATE-OF-BIRTH does not match; but ........................................................................................ 802
MSIS-IDENTIFICATION-NUMBER, FEDERAL-FISCAL-YEAR-QUARTER
do match - Eligible with oldest DATE-OF-BIRTH saved)

3.

Value is improperly "Space Filled” ................................................................................................................................... 303

4.

Value is 9-filled ................................................................................................................................................................ 301

5.

Value is 0-filled ................................................................................................................................................................ 304

6.

Value is 8-filled ................................................................................................................................................................ 305

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Names: PLAN-ID-1
PLAN-ID-2
PLAN-ID-3
PLAN-ID-4
Definition: Monthly Fields - Fields for specifying up to four managed care plan identification numbers under which the eligible
individual is covered during the month.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
MED001356

Coding Requirements:
Please fill in the monthly PLAN-ID fields in sequence (e.g., if an individual is enrolled in two managed care plans, only the
first and second set of monthly fields should be used; if only enrolled in one plan, code PLAN-ID-1 and 8-fill PLANID-2 through PLAN-ID-4).
Enter the managed care plan identification number assigned by the State.
If individual is not eligible for Medicaid or CHIP during the month, 0-fill all four fields.
If individual is not enrolled in any managed care plan during the month, 8-fill all four fields.

Error Condition

Resulting Error Code

1. Value is ”SPACE FILLED”.................................................................................................................................................... 303
2.

Value is <> “000000000000" AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’ ........................................... 502

3.

Value is = “000000000000" AND DAYS-OF-ELIGIBILITY NOT = +00 AND CHIP-CODE <> “3” .................................... 502

4.

Value is = “888888888888" AND corresponding PLAN-TYPE > = 01 and < = 08 ........................................................... 538

5.

Value is < > “888888888888" AND corresponding PLAN-TYPE = 88 ............................................................................. 538

6.

Value is > “000000000000" in any month later than the month that ............................................................................... 504
included DATE-OF-DEATH.

7.

Value appears more than once in monthly array AND VALUE<>”888888888888" OR “SPACE
Filled”................................................................................................................................................................................532

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Names: PLAN-TYPE-1
PLAN-TYPE-2
PLAN-TYPE-3
PLAN-TYPE-4
Definition: Monthly Fields - Codes for specifying up to four managed care plan types under which the eligible individual is
covered during the month.
Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

5.0%

Example
Value
01

Coding Requirements:
Please fill in the monthly PLAN-TYPE fields in sequence (e.g., if an individual is enrolled in two managed care plans, only
the first and second set of monthly fields should be used; if only enrolled in one plan, code PLAN-TYPE-1 and 8-fill
PLAN-TYPE-2 through PLAN-TYPE-4).
Values must correspond to associated PLAN-ID-NUMBER.
Valid Values
00
01
02
03
04
05
06
07
08
88
99

Code Definition
Individual was not eligible for Medicaid or CHIP this month
Eligible is enrolled in a medical or comprehensive managed care plan this month (e.g. HMO)
Eligible is enrolled in a dental managed care plan this month
Eligible is enrolled in a behavioral managed care plan this month
Eligible is enrolled in a prenatal/delivery managed care plan this month
Eligible is enrolled in a long-term care managed care plan this month
Program for All-Inclusive Care for the Elderly (PACE)
Eligible is enrolled in a primary care case management managed care plan this month
Eligible is enrolled in an other managed care plan this month
Not applicable, individual is eligible for Medicaid OR CHIP, but is NOT enrolled in a managed care plan
this month
Eligible's managed care plan status is unknown.

Error Condition
Code

Resulting Error

1.

Value is Non-Numeric - Reset to 99 ............................................................................................................................... 812

2.

Value is 9-filled ............................................................................................................................................................... 301

3.

Value is not valid ............................................................................................................................................................ 203

4.

Relational Field in Error ................................................................................................................................................... 999

5.

Value is <> 00 AND DAYS-OF-ELIGIBILITY= +00 AND CHIP-CODE <> ‘3’ .................................................................. 502

6.

Value = 00 AND DAYS-OF-ELIGIBILITY <> +00 AND CHIP-CODE <> ‘3’ ..................................................................... 502

7.

Value is > 00 in any month later than the month that ...................................................................................................... 504
included DATE-OF-DEATH

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8.

Value is 04 AND SEX-CODE <> “F” ................................................................................................................................ 539

9.

Value appears more than once in monthly array AND VALUE <>88 ............................................................................... 532

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
ELIGIBLE FILE
Data Element Name: RACE-CODE-1
Definition:

Quarterly Field - A code indicating if the eligible has indicated a race of White.

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

5.0%

1

Coding Requirements:
Use this code to indicate if the eligible’s race demographics includes a race of White. This determination is
independent of indications of other races. That is, for RACE-CODE-1 through RACE-CODE-5, any combination of
race codes is possible. If there is no available race information for the eligible, code all five RACE-CODE(s) as 0,
and the race for the eligible will be deemed to be unknown.

Valid Values
0
1

Code Definition
Non-White or Race Unknown
White

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .............. ............. ............. .............. ............. ............. ........810

2.

Value not equal to 0 OR 1 - Reset to 0 ......... ............. ............. .............. ............. ............. ........203

3.

Relational Field in Error…………………………………………………………………………………...999

4.

Value = 0 and Race/Ethnicity Code = 1 ......... ............. ............. .............. ............. …………. .......550

5.

Value = 1 and Race/Ethnicity Code is not equal to 1 or 7 or 8. Reset to 0. .……………………..550

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ELIGIBLE FILE
Data Element Name: RACE-CODE-2
Definition:

Quarterly Field - A code indicating if the eligible has indicated a race of Black or African-American.

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

5.0%

1

Coding Requirements:
Use this code to indicate if the eligible’s race demographics includes a race of Black or African-American. This
determination is independent of indications of other races. That is, for RACE-CODE-1 through RACE-CODE-5, any
combination of race codes is possible. If there is no available race information for the eligible, code all five RACECODE(s) as 0, and the race for the eligible will be deemed to be unknown.

Valid Values
0
1

Code Definition
Non-Black or African American or Race Unknown
Black or African American

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .............. ............. ............. .............. ............. ............. ........810

2.

Value not equal to (0 OR 1) - Reset to 0 ..... ............. ............. .............. ............. ............. ........203

3.

Relational Field in Error…………………………………………………………………………………...999

4.

Value = 0 and Race/Ethnicity Code = 2…...... ............. ............. .............. . ............ …………. .......550

5.

Value = 1 and Race/Ethnicity Code is not equal to 2 or 7 or 8. Reset to 0………………………..550

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ELIGIBLE FILE
Data Element Name: RACE-CODE-3
Definition:

Quarterly Field - A code indicating if the eligible has indicated a race of American Indian or Alaska Native.

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

5.0%

1

Coding Requirements:
Use this code to indicate if the eligible’s race demographics includes a race of American Indian or Alaska Native.
This determination is independent of indications of other races. That is, for RACE-CODE-1 through RACE-CODE-5,
any combination of race codes is possible. If there is no available race information for the eligible, code all five
RACE-CODE(s) as 0, and the race for the eligible will be deemed to be unknown.

Valid Values
0
1

Code Definition
Non-American Indian or Alaska Native or Race Unknown
American Indian or Alaska Native

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .............. ............. ............. .............. ............. ............. ........810

2.

Value not equal to 0 OR 1 - Reset to 0 ......... ............. ............. .............. ............. ............. ........203

3.

Relational Field in Error…………………………………………………………………………………...999

4.

Value = 0 and Race/Ethnicity Code = 3 ......... ............. ............. .............. ............. …………. .......550

5.

Value = 1 and Race/Ethnicity Code is not equal to 3 or 7 or 8. Reset to 0.………………………..550

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ELIGIBLE FILE
Data Element Name: RACE-CODE-4
Definition:

Quarterly Field - A code indicating if the eligible has indicated a race of Asian.

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

5.0%

1

Coding Requirements:
Use this code to indicate if the eligible’s race demographics includes a race of Asian. This determination is
independent of indications of other races. That is, for RACE-CODE-1 through RACE-CODE-5, any combination of
race codes is possible. If there is no available race information for the eligible, code all five RACE-CODE(s) as 0,
and the race for the eligible will be deemed to be unknown.

Valid Values
0
1

Code Definition
Non-Asian or Race Unknown
Asian

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .............. ............. ............. .............. ............. ............. ........810

2.

Value not equal to 0 OR 1 - Reset to 0 ......... ............. ............. .............. ............. ............. ........203

3.

Relational Field in Error…………………………………………………………………………………...999

4.

Value = 0 and Race/Ethnicity Code = 4 ......... ............. ............. .............. ............. …………. .......550

5.

Value = 1 and Race/Ethnicity Code is not equal to 4 or 7 or 8. Reset to 0.………………………..550

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ELIGIBLE FILE
Data Element Name: RACE-CODE-5
Definition:
Islander.

Quarterly Field - A code indicating if the eligible has indicated a race of Native Hawaiian or other Pacific

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

5.0%

1

Coding Requirements:
Use this code to indicate if the eligible’s race demographics includes a race of Native Hawaiian or other Pacific
Islander. This determination is independent of indications of other races. That is, for RACE-CODE-1 through RACECODE-5, any combination of race codes is possible. If there is no available race information for the eligible, code all
five RACE-CODE(s) as 0, and the race for the eligible will be deemed to be unknown.

Valid Values
0
1

Code Definition
Non-Native Hawaiian or Other Pacific Islander or Race Unknown
Native Hawaiian or Other Pacific Islander

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .............. ............. ............. .............. ............. ............. ........810

2.

Value not equal to 0 OR 1 - Reset to 0 ......... ............. ............. .............. ............. ............. ........203

3.

Relational Field in Error…………………………………………………………………………………...999

4.

Value = 0 and Race/Ethnicity Code = 6 ......... ............. ............. .............. ............. …………. .......550

5.

Value = 1 and Race/Ethnicity Code is not equal to 6 or 7 or 8. Reset to 0.………………………..550

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ELIGIBLE FILE
Data Element Name: RACE-ETHNICITY-CODE
Definition:

Quarterly Field - A code indicating the eligible individual's race/ethnicity.

Field Description:
COBOL Error
PICTURE

Tolerance

Example
Value

9(1)

2.0%

5

Coding Requirements:
Use the appropriate race/ethnicity code that best describes the eligible’s race/ethnicity grouping. If only one race is
known and no ethnicity is indicated, select one of the codes from 1-4 or 6. If only ethnicity is indicated and race is
not, code 5 should be used. If ethnicity is indicated and one or more races are known, use code 7. If more than one
race is known and ethnicity is not indicated, select code 8. Finally, if neither race nor ethnicity is known, code 9
should be used.
Valid Values
1
2
3
4
5
6
7
8
9

Error Condition

Code Definition
White
Black or African American
American Indian or Alaska Native
Asian
Hispanic or Latino (No race information available)
Native Hawaiian or Other Pacific Islander
Hispanic or Latino and one or more races
More than one race (Hispanic or Latino not indicated)
Unknown

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled ........ ............. ............. .............. ............. ............. ........810

2.

Value is 9 ............ ............. ............................ ............. ............. .............. ............. ............. ........301

3.

Value < 1. Reset to 9 ....... ............................ ............. ............. .............. ............. ............. ........203

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ELIGIBLE FILE
Data Element Name: RESTRICTED-BENEFITS-FLAG
Definition: Monthly Field - A flag that indicates the scope of Medicaid benefits to which an eligible is entitled during each
month.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(1)

5.0 %

Example
Value
2

Coding Requirements:
Valid Values
0
1
2
3
4
5

6
7
8

9
A

B
C

Code Definition
Individual is not eligible for Medicaid or CHIP during the month.
Individual is eligible for Medicaid or CHIP and entitled to the full scope of Medicaid or CHIP benefits.
Individual is eligible for Medicaid or M-CHIP, but only entitled to restricted benefits based on alien
status.
Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dualeligibility status (e.g., QMB, SLMB, QDWI, QI).
Individual is eligible for Medicaid or CHIP but only entitled to restricted benefits for pregnancy-related
services.
Individual is eligible for Medicaid or M-CHIP but, for reasons other than alien, dual-eligibility or
pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based upon
substance abuse, medically needy or other criteria).
Individual is eligible for Medicaid or M-CHIP but only entitled to restricted benefits for family planning
services.
Individual is eligible for Medicaid and entitled to Medicaid benefits under an alternative package of
benchmark-equivalent coverage, as enacted by the Deficit Reduction Act of 2005.
Individual is eligible for Medicaid and entitled to benefits under a “Money Follows the Person” (MFP)
rebalancing demonstration, as enacted by the Deficit Reduction Act of 2005, to allow States to develop
community based long term care opportunities.
Individual's benefit restrictions are unknown.
Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment
Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005.
PRTF grants assist States to help provide community alternatives to psychiatric resident treatment
facilities for children.
Individual is eligible for Medicaid and entitled to Medicaid benefits using a Health Opportunity Account
(HOA)
Individual is eligible for separate CHIP dental coverage (supplemental dental wraparound benefit to
employer-sponsored insurance)

Error Condition

Resulting Error Code

1.

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

2.

Value is 9 ......................................................................................................................................................................... 301

3.

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

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4.

Relational Field in Error ................................................................................................................................................... 999

5.

Value is <> 0 AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’ ................................................................... 502

6.

Value is 0 AND DAYS-OF-ELIGIBILITY NOT = +00 AND CHIP-CODE <> ‘3’ ................................................................ 502

7.

Value is > 0 in any month later than the month that ........................................................................................................ 504
included DATE-OF-DEATH.

8.

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

9.

Value = 4 AND SEX-CODE <> “F” ................................................................................................................................. 539

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ELIGIBLE FILE
Data Element Name: SEX-CODE
Definition: Quarterly Field - The eligible's gender.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(1)

2.0%

Example
Value
F

Coding Requirements:
Valid Values
F
M
U

Code Definition
Female
Male
Unknown

Error Condition

Resulting Error Code

1.

Value is Numeric - Reset to “U” ....................................................................................................................................... 812

2.

Value is “U” ...................................................................................................................................................................... 301

3.

Value is not “F”, “M”, “U” .................................................................................................................................................. 203

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ELIGIBLE FILE
Data Element Name: SOCIAL-SECURITY-NUMBER
Definition: Quarterly Field - The eligible's social security number.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(9)

0.1%

Example
Value
253981873

Coding Requirements:
For SSN States:
Value must = eligible's valid Social Security Number and SSN-INDICATOR = 1. If the SSN is not available and a
temporary identification number has been assigned in the MSIS-IDENTIFICATION-NUMBER field, this field must
= 888888888.
For NON-SSN States:
Value should = eligible's SSN or 999999999 if the SSN is unknown.
See Section 5.1 for some additional examples in context.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 8-filled .......................................................................................................................... 811

2.

Value is 999999999 ......................................................................................................................................................... 301

3.

Value=888888888 AND SSN-INDICATOR in the Header Record =1 AND MSIS-IDENTIFICATION-NUMBER is ........ 305
equal to spaces

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ELIGIBLE FILE
Data Element Name: T-MSIS-ELIGIBILITY-GROUP
Definition: Monthly Field – 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).

Field Description:
COBOL
PICTURE

Error
Tolerance

X(2)

2.0%

Example
Value
‘29’

Coding Requirements:
1.

Value must be equal to a valid value. (See: ‘Attachment 5 – T-MSIS Eligibility Group Valid Values Table’)

Error Condition
1.
2.
3.

Resulting Error Code

Value is not included in the valid code list. ...................................................................................................................... 201
Value is blank but DAYS-OF-ELIGIBILITY <> +00.......................................................................................... 502
Value present and not 72, 73, 74 or 75 but DAYS-OF-ELIGIBILITY = +00..................................................... 502

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ELIGIBLE FILE
Data Element Name: TANF-CASH-FLAG
Definition: Monthly Field - A flag that indicates whether the eligible received Temporary Assistance for Needy Families (TANF)
benefits during the month.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(1)

2.0%

Example
Value
1

Coding Requirements:
Valid Values
0
1
2
9

Code Definition
Individual was not eligible for Medicaid or CHIP at any time during the month.
Individual did not receive TANF benefits during the month
Individual did receive TANF benefits during the month.
Individual’s TANF status is unknown

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9 .................................................................................................................................. 812

2.

Value is 9-filled ................................................................................................................................................................ 301

3.

Value is < 0 or > 2 ........................................................................................................................................................... 203

4.

Relational Field in Error ................................................................................................................................................... 999

5.

Value <> 0 AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’ ....................................................................... 502

6.

Value = 0 AND DAYS-OF-ELIGIBILITY <> +00 AND CHIP-CODE <> ‘3’ ....................................................................... 502

7.

Value is > 0 in any month later than the month that ........................................................................................................ 504
included DATE-OF-DEATH

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ELIGIBLE FILE
Data Element Name: TYPE-OF-RECORD
Definition: Quarterly Field - A code indicating whether the eligibility information contained in this record refers to the current
fiscal quarter (the quarter specified in the Header Record) or to a previous quarter. A previous quarter could
pertain to either retroactive eligibility or to a record that corrects eligibility information submitted in an earlier
quarter.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(1)

2.0%

Example
Value
1

Coding Requirements:
Valid Values

Code Definition

1

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

2

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

3

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

9

If TYPE-OF-RECORD is unknown.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled .......................................................................................................................... 812

2.

Value = 9 ......................................................................................................................................................................... 301

3.

Value < 1 OR Value > 3 ................................................................................................................................................... 203

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ELIGIBLE FILE
Data Element Names: WAIVER-ID-1
WAIVER-ID-2
WAIVER-ID-3
Definition: Monthly Fields - Fields for specifying up to three waiver programs under which the eligible individual is covered
during the month. These Ids must be assigned by the State, using alpha or numeric codes, to uniquely identify
each specific waiver program(s) under which the individual is covered. The categories of waiver programs include
1915(b), 1915(c), combined (b)/(c) programs, and 1115 demonstrations. Individuals are to be associated with a
specific waiver only if they are enrolled in a waiver program.
In order to support more detailed analysis of the waiver data, States must submit a hard-copy baseline crosswalk
showing the MSIS WAIVER-ID number, and the associated approved full waiver ID number and name. Updates to
this crosswalk must be submitted when waivers are added or ID numbers are changed.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(2)

5.0%

Example
Value
C1

Coding Requirements:
Please fill in the monthly WAIVER-ID fields in sequence (e.g., if an individual is enrolled in two waivers, only the first and
second set of monthly fields should be used—8 fill the WAIVER-ID-3 field. If only enrolled in one waiver, code WAIVERID-1 and 8-fill WAIVER-ID-2 and WAIVER-ID-3).
Enter the coded WAIVER-ID number assigned by the State, and reported in the hard-copy crosswalk documentation.
If individual is not eligible for Medicaid or CHIP during the month, 0-fill all three fields.
If individual is not enrolled in waiver during the month, 8-fill all three fields.

Error Condition

Resulting Error Code

1.

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

2.

Relational Field in Error…………………………………………………………………………………………………………….999

3.

Value is (<> “00" AND <> “88") AND DAYS-OF-ELIGIBILITY = +00 AND CHIP-CODE <> ‘3’........................................ 502

4.

Value is = “00" AND DAYS-OF-ELIGIBILITY NOT = +00 AND CHIP-CODE <> ‘3’......................................................... 502

5.

Value is (<> “00" AND <> “88") AND corresponding WAIVER-TYPE = 0 or 8................................................................. 538

6.

Value is = “88" or “00” AND corresponding WAIVER-TYPE = 1 THROUGH 7 or 9 or F or A .......................................... 538

7.

Value is > “00" in any month later than the month that ................................................................................................... 504
included DATE-OF-DEATH.

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8.

Value appears more than once within a single monthly array AND VALUE
(<> “00" AND <> “88" and <> “SPACE Filled”) ………………………………….……..........................................................532

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ELIGIBLE FILE
Data Element Names: WAIVER-TYPE-1
WAIVER-TYPE-2
WAIVER-TYPE-3

Definition: Monthly Fields - Codes for specifying up to three waiver types under which the eligible individual is
covered during the month.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(1)

5.0%

Example
Value
3

Coding Requirements:
Please fill in the monthly WAIVER-TYPE fields in sequence (e.g., if an individual is enrolled in two waivers, only the first
and second set of monthly fields should be used; if only enrolled in one waiver, code WAIVER-TYPE-1 and 8-fill
WAIVER-TYPE-2 through WAIVER-TYPE-3).
Values must correspond to associated WAIVER-ID-NUMBER.
Valid Values
0
1

2
3

4

5

6

7
8
9
A
F

February 2014

Code Definition
Individual was not eligible for Medicaid or CHIP this month
The associated Waiver-ID-Number is for an 1115 waiver this month. May also be called a research,
experimental, demonstration or pilot waiver or refer to consumer-directed care or expanded eligibility.
May cover entire State or just a geographic entity or specific population.
The associated Waiver-ID-Number is for a 1915(b) waiver this month. May also be called managed
care, freedom-of-choice, state wideness, selective contracting, comparability, or program waiver.
The associated Waiver-ID-Number is for a 1915(c) waiver this month. May also be called 2176, Home
and Community Based Care, HCBS, HCB, and will often mention specific populations such as MR/DD,
aged, disabled/physically disabled, aged/disabled, AIDS/ARC, mental health, TBI/head injury, special
care children/technology dependent children.
The associated Waiver-ID-Number is a combined 1915(b)(c) waiver this month. Includes both
managed care and alternatives to institutional long term care such as: case management;
homemaker/home health aid; personal care services; adult day health; habilitation; respite.
The associated Waiver-ID-Number is for a HIFA (Health Insurance and Flexibility and Accountability)
waiver this month. May also be called demonstration waiver or refer to the eligibility expansion, and
will be a new waiver on or after August 2001.
The associated Waiver-ID-Number is for Pharmacy waiver coverage this month. Includes waivers
under 1115 demonstration authority which are primarily intended to increase coverage or expand
eligibility for pharmacy benefits.
The associated Waiver-ID-Number is for another type of waiver.
Not applicable, individual is eligible for Medicaid or CHIP, but is NOT enrolled in a waiver this month.
The associated Waiver-ID-Number is for an unknown type of waiver.
The associated Waiver-ID-Number is for a disaster-related waiver that allows for coverage related to a
hurricane or other disaster this month.
The associated Waiver-ID-Number is for a Family Planning-ONLY waiver this month. In these
waivers, the beneficiary’s Medicaid-covered benefits are restricted to Family Planning Services.
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Error Condition
Code

Resulting Error

1.

Value is 9-filled ................................................................................................................................................................ 301

2.

Value is not valid ............................................................................................................................................................. 203

3.

Relational Field in Error ................................................................................................................................................... 999

4.

Value is <> 0 AND DAYS-OF-ELIGIBILITY= +00 AND CHIP-CODE <> ‘3’ .................................................................... 502

5.

Value = 0 AND DAYS-OF-ELIGIBILITY <> +00 AND CHIP-CODE <> ‘3’ ....................................................................... 502

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ELIGIBLE FILE
Data Element Name: ZIP-CODE
Definition: Quarterly Field - Zip code of eligible's place of residence.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(5)

5.0%

Example
Value
21365

Coding Requirements:
Value must be a valid U. S. Postal Service ZIP Code for the State.
Value = 99999 if ZIP code is unknown.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9-filled .......................................................................................................................... 812

2.

Value is 99999 ................................................................................................................................................................. 301

3.

Value is not a valid ZIP Code for the State specified ....................................................................................................... 507
by STATE-ABBREVIATION in the Header Record

4.

Relational Field in Error ................................................................................................................................................... 999

5.

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

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6.

MSIS CLAIMS FILES

MSIS utilizes four claims files: Inpatient Claims (CLAIMIP), Long Term Care Claims (CLAIMLT), Other Claims (CLAIMOT), and
Prescription Drug Claims (CLAIMRX). Each Claim file submitted to CMS:
-

must begin with the Standard Header Record (See Section 4.3);

-

must contain one record for every claim of the appropriate type paid, or encounters processed, during the reporting
quarter; and

-

must conform to one of the four standard claims file record formats and data element lists, although many data
elements are common to all four claims files.

Claim files must include:
-

one record for each line item that is separately adjudicated;

-

all fully adjudicated current quarter claims that have completed the State's processing cycle, for which the State
has determined that it has liability to reimburse the provider;

-

all adjustments to prior quarter claims adjudicated in the reporting quarter;

-

adjudicated claims which passed all the States' eligibility and coverage edits, but which resulted in a zero liability
because of payments by responsible third parties;

-

claim records representing capitated payments or fees paid to capitated plans;

-

encounter claims (TYPE-OF-CLAIM=3 or C), to the extent that they are routinely received by the State;

-

Medicare/Medicaid Crossover claims, which are identified by the presence of valid values in the MEDICAREDEDUCTIBLE-PAYMENT and MEDICARE-COINSURANCE-PAYMENT fields.

Include any claim that relates to covered Medicaid or CHIP services. Do not include any claim that has been returned to the
provider because of insufficient information.
All claims records are edited by MSIS's validation program for completeness and validity. Edits are applied to adjustment
claim records, and count against each field's error tolerance, except where noted in the error condition specifications for each
field.
6.1

Unique Personal Identifiers

Claims file records are associated with eligibles by means of the MSIS Personal Identification Number (MSIS-ID)(or SSN, for
SSN States), discussed in section 5.1. The four claims files utilize the same MSIS-ID or MSIS-IDENTIFICATION-NUMBER
(or SSN, for SSN States) as the ELIGIBLE File.
6.2

Claims File Record Types

Claims files contain several types of valid records: current fee-for-service claims (TYPE-OF-CLAIM=1) for medical services,
capitated payments (TYPE-OF-CLAIM=2), and encounter claims (TYPE-OF-CLAIM=3). Encounter claims simulate claims that
would have been generated for HMO/HIO, PHP and PCCM patients if they were billed on a fee-for-service basis. Additionally
some States use “service-tracking” claims (TYPE-OF-CLAIM=4) for special purposes, such as tracking individual services
covered in a lump sum billing or for all non-claims based service expenditures such as DSH payments, drug rebates and year
end settlements. Do not include buy-in payments or payments for claims processing administration. The claim type can
always be distinguished by the value of the TYPE-OF-CLAIM field. Adjustment claims are identified and categorized by the
ADJUSTMENT-INDICATOR field. TYPE-OF-CLAIM 5 is used to identify supplemental payment (above capitation fee or
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above negotiated rate) (e.g., FQHC additional reimbursement). In addition claim types have been added for separate CHIP
claims such as fee for service claims (TYPE OF CLAIM=A), capitated payments (TYPE-OF-CLAIM=B), encounter separate
CHIP claims (TYPE-OF-CLAIM=3), service tracking claims (TYPE OF CLAIM=D) and adjustment separate CHIP claims
(TYPE-OF-CLAIM=E).
Note that the ADJUSTMENT-INDICATOR field identifies whether adjustment records involve negative or positive adjustments
to prior claims values. Where the adjustment involves reduced payment or quantity amounts (e.g., voids or credits), the
reduced fields must include negative values corresponding to the adjustment. For example, for a void of a prior claim with a
MEDICAID-AMOUNT-PAID of 100, the subsequent void adjustment would include a MEDICAID-AMOUNT-PAID of -100.
Negating amounts for these adjustments is required for all value and amount fields. The formats for fields where this can occur
are all established as signed numeric formats.
6.3

Sorting Rules

The claims files must be sorted in standard EBCDIC (ascending) collating sequence, using MSIS-IDENTIFICATION-NUMBER
as the sort key. Improperly sorted files will be returned.
6.4

Claims Files Contents

MSIS recognizes that Medicaid or CHIP claims do not always contain the same information. These differences are
accommodated through the use of four distinct claims files. The four claims files have similar logical structures. The
differences among the four files lie in the kinds of services they report and in some of the detailed information required by each
group of services.
All charges reported in MSIS claims files are recorded in whole dollars.
NOTE: Since claims are summarized based on date of payment, service category and other coding changes in effect as of
the date of adjudication must be used even if the service date is for a prior year.
6.4.1 CLAIMIP File
CLAIMIP file records identify Title XIX or Title XXI claims for inpatient hospital services.
Note: For the purposes of the CLAIMIP file, any service that is billed as inpatient care is considered an acute care inpatient
hospital service, and is included in the file. This file also includes records for services billed by Religious Non-Medical
institutions. Inpatient psychiatric services provided in a separately administered psychiatric wing or psychiatric hospital are not
considered acute and are not part of the CLAIMIP file. The latter are included in the Long Term Care Claims File (CLAIMLT).
6.4.2 CLAIMLT File
CLAIMLT file records identify Title XIX or Title XXI claims for long term care services received in an institution. The phrase
"long term care" includes services received in:
-

Nursing Facilities (NFs);

-

Intermediate Care Facilities for the Mentally Retarded (ICF-MRs);

-

Psychiatric Hospitals; and

-

Independent (free-standing) psychiatric wings of acute care hospitals.

6.4.3 CLAIMOT File
CLAIMOT file records cover all Medicaid or CHIP claims that are not included in either the CLAIMIP file, the CLAIMLT file, or
the CLAIMRX file. CLAIMOT file records include:
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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

-

Provider claims for all non-institutional Medicaid services;

-

Provider claims for all services received in hospitals, NFs, or ICF/MRs that are not billed as part of a long term care
or inpatient claim, such as claims for physician visits, services of private duty nurses, encounters,. etc;

-

Capitated payments; and

-

Claims for medical and non-medical services received under an approved Title XIX or Title XXI waiver.

CLAIMOT records may contain bills for multiple units of service, for example, several physician visits related to the same
illness. However, a single line item or claim record may refer to only one procedure code. Thus, lab and X-ray claims
related to a sequence of office visits must be recorded as separate line items with each having its own CLAIMOT record.
6.4.4 CLAIMRX File
CLAIMRX file records identify Title XIX or Title XXI claims for prescription drugs (including durable medical equipment and
supplies provided by a pharmacist under a prescription). Injectibles and other drugs dispensed as a bundled service are
reported for the provider administering the service (e.g. physician-administered inoculations are reported on the CLAIMOT
file as physician service).
6.5

CLAIMS Files - Physical and Logical Data Record Layouts

The tables in sections 6.5.1 - 6.5.4 summarize the fields in the four claims file records in the order in which they physically
occur in their respective records. The record layouts list the field name, and provide COBOL picture summaries, error
tolerances, and record position indicators for each field.
The COBOL PICTURE clauses obey ANSI standard rules. These rules are summarized in Section 3.3. The field start and
end positions indicate the exact position of the field within the record.
The error tolerance for each field demarcates the maximum allowable percentage of records submitted that may have
missing, unknown, or invalid code combinations. Error rates in excess of the error tolerance for any field will cause the
entire file to be rejected. Moreover, a file will be rejected if, within the first 500 records of a claim file, the current quarter
claims (TYPE-OF-CLAIM = 1) have a DATE-OF-PAYMENT that is not consistent with the reporting quarter. No detailed
error messages will be produced if this condition occurs.

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

6.5.1 CLAIMIP Physical Record Layout:
CLAIMIP RECORD SUMMARY

FIELD NAME
COBOL PICTURE
MSIS-IDENTIFICATION-NUMBER
X(20)
ADJUSTMENT-INDICATOR
9(1)
TYPE-OF-SERVICE
9(2)
TYPE-OF-CLAIM
9(1)
DATE-OF-PAYMENT-ADJUDICATION
9(8)
MEDICAID-AMOUNT-PAID
S9(8)
BEGINNING-DATE-OF-SERVICE
9(8)
ENDING-DATE-OF-SERVICE
9(8)
PROVIDER-ID-NUMBER-BILLING
X(12)
AMOUNT-CHARGED
S9(8)
OTHER-THIRD-PARTY-PAYMENT
S9(6)
PROGRAM-TYPE
9(1)
PLAN-ID-NUMBER
X(12)
MEDICAID-COVERED-INPATIENT-DAYS
S9(5)
MEDICARE-DEDUCTIBLE-PAYMENT
S9(5)
MEDICARE-COINSURANCE-PAYMENT
S9(5)
DIAGNOSIS-CODE-PRINCIPAL
X(7)
DIAGNOSIS-CODE-FLAG-1
X(1)
DIAGNOSIS-CODE-2
X(7)
DIAGNOSIS-CODE-FLAG-2
X(1)
DIAGNOSIS-CODE-3
X(7)
DIAGNOSIS-CODE-FLAG-3
X(1)
DIAGNOSIS-CODE-4
X(7)
DIAGNOSIS-CODE-FLAG-4
X(1)
DIAGNOSIS-CODE-5
X(7)
DIAGNOSIS-CODE-FLAG-5
X(1)
DIAGNOSIS-CODE-6
X(7)
DIAGNOSIS-CODE-FLAG-6
X(1)
DIAGNOSIS-CODE-7
X(7)
DIAGNOSIS-CODE-FLAG-7
X(1)
DIAGNOSIS-CODE-8
X(7)
DIAGNOSIS-CODE-FLAG-8
X(1)
DIAGNOSIS-CODE-9
X(7)
DIAGNOSIS-CODE-FLAG-9
X(1)
PROC-CODE-PRINCIPAL
X(8)
PROC-CODE-FLAG-PRINCIPAL
9(2)
PROC-CODE-MOD-PRINCIPAL
X(2)
PROC-CODE-2
X(8)
PROC-CODE-FLAG-2
9(2)
PROC-CODE-MOD-2
X(2)
PROC-CODE-3
X(8)
PROC-CODE-FLAG-3
9(2)
PROC-CODE-MOD-3
X(2)
PROC-CODE-4
X(8)
PROC-CODE-FLAG-4
9(2)
PROC-CODE-MOD-4
X(2)
PROC-CODE-5
X(8)
PROC-CODE-FLAG-5
9(2)
PROC-CODE-MOD-5
X(2)
6.5.1 CLAIMIP Physical Record Layout (continued):
February 2014

68

- POSITION START
END
01
20
21
21
22
23
24
24
25
32
33
40
41
48
49
56
57
68
69
76
77
82
83
83
84
95
96
100
101
105
106
110
111
117
118
118
119
125
126
126
127
133
134
134
135
141
142
142
143
149
150
150
151
157
158
158
159
165
166
166
167
173
174
174
175
181
182
182
183
190
191
192
193
194
195
202
203
204
205
206
207
214
215
216
217
218
219
226
227
228
229
230
231
238
239
240
241
242

DEFAULT
ERROR
TOLERANCE
0.1%
2.0%
0.1%
2.0%
2.0%
0.1%
2.0%
2.0%
5.0%
5.0%
2.0%
2.0%
2.0%
2.0%
2.0%
2.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

CLAIMIP RECORD SUMMARY - continued

FIELD NAME
COBOL PICTURE
PROC-CODE-6
X(8)
PROC-CODE-FLAG-6
9(2)
PROC-CODE-MOD-6
X(2)
ADMISSION-DATE
9(8)
PATIENT-STATUS
9(2)
DIAGNOSIS-RELATED-GROUP(DRG)
9(4)
DIAGNOSIS-RELATED-GROUP-INDICATOR
X(4)
PROC-DATE-PRINCIPAL
9(8)
UB-REV-CODE-1
9(4)
UB-REV-UNITS-1
S9(7)
UB-REV-CHARGE-1
S9(8)
UB-REV-CODE-2
9(4)
UB-REV-UNITS-2
S9(7)
UB-REV-CHARGE-2
S9(8)
UB-REV-CODE-3
9(4)
UB-REV-UNITS-3
S9(7)
UB-REV-CHARGE-3
S9(8)
UB-REV-CODE-4
9(4)
UB-REV-UNITS-4
S9(7)
UB-REV-CHARGE-4
S9(8)
UB-REV-CODE-5
9(4)
UB-REV-UNITS-5
S9(7)
UB-REV-CHARGE-5
S9(8)
UB-REV-CODE-6
9(4)
UB-REV-UNITS-6
S9(7)
UB-REV-CHARGE-6
S9(8)
UB-REV-CODE-7
9(4)
UB-REV-UNITS-7
S9(7)
UB-REV-CHARGE-7
S9(8)
UB-REV-CODE-8
9(4)
UB-REV-UNITS-8
S9(7)
UB-REV-CHARGE-8
S9(8)
UB-REV-CODE-9
9(4)
UB-REV-UNITS-9
S9(7)
UB-REV-CHARGE-9
S9(8)
UB-REV-CODE-10
9(4)
UB-REV-UNITS-10
S9(7)
UB-REV-CHARGE-10
S9(8)
UB-REV-CODE-11
9(4)
UB-REV-UNITS-11
S9(7)
UB-REV-CHARGE-11
S9(8)
UB-REV-CODE-12
9(4)
UB-REV-UNITS-12
S9(7)
UB-REV-CHARGE-12
S9(8)
UB-REV-CODE-13
9(4)
UB-REV-UNITS-13
S9(7)
UB-REV-CHARGE-13
S9(8)
UB-REV-CODE-14
9(4)

February 2014

69

- POSITION START
END
243
250
251
252
253
254
255
262
263
264
265
268
269
272
273
280
281
284
285
291
292
299
300
303
304
310
311
318
319
322
323
329
330
337
338
341
342
348
349
356
357
360
361
367
368
375
376
379
380
386
387
394
395
398
399
405
406
413
414
417
418
424
425
432
433
436
437
443
444
451
452
455
456
462
463
470
471
474
475
481
482
489
490
493
494
500
501
508
509
512
513
519
520
527
528
531

DEFAULT
ERROR
TOLERANCE
5.0%
5.0%
5.0%
5.0%
5.0%
100.0%
100.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

6.5.1 CLAIMIP Physical Record Layout (continued):
CLAIMIP RECORD SUMMARY - continued

FIELD NAME
UB-REV-UNITS-14
UB-REV-CHARGE-14
UB-REV-CODE-15
UB-REV-UNITS-15
UB-REV-CHARGE-15
UB-REV-CODE-16
UB-REV-UNITS-16
UB-REV-CHARGE-16
UB-REV-CODE-17
UB-REV-UNITS-17
UB-REV-CHARGE-17
UB-REV-CODE-18
UB-REV-UNITS-18
UB-REV-CHARGE-18
UB-REV-CODE-19
UB-REV-UNITS-19
UB-REV-CHARGE-19
UB-REV-CODE-20
UB-REV-UNITS-20
UB-REV-CHARGE-20
UB-REV-CODE-21
UB-REV-UNITS-21
UB-REV-CHARGE-21
UB-REV-CODE-22
UB-REV-UNITS-22
UB-REV-CHARGE-22
UB-REV-CODE-23
UB-REV-UNITS-23
UB-REV-CHARGE-23
NATIONAL-PROVIDER-ID
PROVIDER-TAXONOMY
INTERNAL-CONTROL-NUMBER-ORIG
INTERNAL CONTROL-NUMBER-ADJ
FILLER

February 2014

COBOL PICTURE
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
9(4)
S9(7)
S9(8)
X(12)
X(12)
X(21)
X(21)
X(57)

70

- POSITION START
END
532
538
539
546
547
550
551
557
558
565
566
569
570
576
577
584
585
588
589
595
596
603
604
607
608
614
615
622
623
626
627
633
634
641
642
645
646
652
653
660
661
664
665
671
672
679
680
683
684
690
691
698
699
702
703
709
710
717
718
729
730
741
742
762
763
783
784
840

DEFAULT
ERROR
TOLERANCE
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%

Release 5

6.5.2 CLAIMLT Physical Record Layout:
CLAIMLT RECORD SUMMARY

FIELD NAME
MSIS-IDENTIFICATION-NUMBER
ADJUSTMENT-INDICATOR
TYPE-OF-SERVICE
TYPE-OF-CLAIM
DATE-OF-PAYMENT-ADJUDICATION
MEDICAID-AMOUNT-PAID
BEGINNING-DATE-OF-SERVICE
ENDING-DATE-OF-SERVICE
PROVIDER-ID-NUMBER-BILLING
AMOUNT-CHARGED
OTHER-THIRD-PARTY-PAYMENT
PROGRAM-TYPE
PLAN-ID-NUMBER
MEDICAID-COVERED-INPATIENT-DAYS
MEDICARE-DEDUCTIBLE-PAYMENT
MEDICARE-COINSURANCE-PAYMENT
DIAGNOSIS-CODE-1
DIAGNOSIS-CODE-FLAG-1
DIAGNOSIS-CODE-2
DIAGNOSIS-CODE-FLAG-2
DIAGNOSIS-CODE-3
DIAGNOSIS-CODE-FLAG-3
DIAGNOSIS-CODE-4
DIAGNOSIS-CODE-FLAG-4
DIAGNOSIS-CODE-5
DIAGNOSIS-CODE-FLAG-5
ADMISSION-DATE
PATIENT-STATUS
ICF-MR-DAYS
LEAVE-DAYS
NURSING-FACILITY-DAYS
PATIENT-LIABILITY
NATIONAL-PROVIDER-ID
PROVIDER-TAXONOMY
INTERNAL-CONTROL-NUMBER-ORIG
INTERNAL CONTROL-NUMBER-ADJ
FILLER

February 2014

COBOL PICTURE
X(20)
9(1)
9(2)
9(1)
9(8)
S9(8)
9(8)
9(8)
X(12)
S9(8)
S9(6)
9(1)
X(12)
S9(5)
S9(5)
S9(5)
X(7)
X(1)
X(7)
X(1)
X(7)
X(1)
X(7)
X(1)
X(7)
X(1)
9(8)
9(2)
S9(5)
S9(5)
S9(5)
S9(6)
X(12)
X(12)
X(21)
X(21)
X(53)

71

- POSITION START
END
01
20
21
21
22
23
24
24
25
32
33
40
41
48
49
56
57
68
69
76
77
82
83
83
84
95
96
100
101
105
106
110
111
117
118
118
119
125
126
126
127
133
134
134
135
141
142
142
143
149
150
150
151
158
159
160
161
165
166
170
171
175
176
181
182
193
194
205
206
226
227
247
248
300

DEFAULT
ERROR
TOLERANCE
0.1%
2.0%
0.1%
2.0%
2.0%
0.1%
2.0%
2.0%
5.0%
5.0%
2.0%
2.0%
2.0%
2.0%
2.0%
2.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
5.0%
2.0%
5.0%
2.0%
2.0%
5.0%
5.0%
5.0%
5.0%

Release 5

6.5.3 CLAIMOT Physical Record Layout
CLAIMOT RECORD SUMMARY

FIELD NAME
MSIS-IDENTIFICATION-NUMBER
ADJUSTMENT-INDICATOR
TYPE-OF-SERVICE
TYPE-OF-CLAIM
DATE-OF-PAYMENT-ADJUDICATION
MEDICAID-AMOUNT-PAID
BEGINNING-DATE-OF-SERVICE
ENDING-DATE-OF-SERVICE
PROVIDER-ID-NUMBER-BILLING
AMOUNT-CHARGED
OTHER-THIRD-PARTY-PAYMENT
PROGRAM-TYPE
PLAN-ID-NUMBER
QUANTITY-OF-SERVICE
MEDICARE-DEDUCTIBLE-PAYMENT
MEDICARE-COINSURANCE-PAYMENT
DIAGNOSIS-CODE-1
DIAGNOSIS-CODE-FLAG-1
DIAGNOSIS-CODE-2
DIAGNOSIS-CODE-FLAG-2
PLACE-OF-SERVICE
SPECIALTY-CODE
SERVICE-CODE
SERVICE-CODE-FLAG
SERVICE-CODE-MOD
UB-92-REVENUE-CODE
PROVIDER-ID-NUMBER-SERVICING
NATIONAL-PROVIDER-ID
PROVIDER-TAXONOMY
INTERNAL-CONTROL-NUMBER-ORIG
LINE-NUMBER-ORIG
INTERNAL CONTROL-NUMBER-ADJ
LINE-NUMBER-ADJ
FILLER

February 2014

COBOL PICTURE
X(20)
9(1)
9(2)
9(1)
9(8)
S9(8)
9(8)
9(8)
X(12)
S9(8)
S9(6)
9(1)
X(12)
S9(5)
S9(5)
S9(5)
X(7)
X(1)
X(7)
X(1)
9(2)
X(4)
X(8)
9(2)
X(2)
9(4)
X(12)
X(12)
X(12)
X(21)
9(3)
X(21)
9(3)
X(48)

72

DEFAULT
- POSITION ERROR
START
END TOLERANCE
1
20
0.1%
21
21
2.0%
22
23
0.1%
24
24
2.0%
25
32
2.0%
33
40
0.1%
41
48
2.0%
49
56
2.0%
57
68
5.0%
69
76
5.0%
77
82
2.0%
83
83
2.0%
84
95
2.0%
96
100
2.0%
101
105
2.0%
106
110
2.0%
111
117
5.0%
118
118
5.0%
119
125
5.0%
126
126
5.0%
127
128
5.0%
129
132
100.0%
133
140
5.0%
141
142
5.0%
143
144
5.0%
145
148
100.0%
149
160
5.0%
161
172
5.0%
173
184
5.0%
185
205
5.0%
206
208
5.0%
209
229
5.0%
230
232
5.0%
233
280

Release 5

6.5.4 CLAIMRX Physical Record Layout
CLAIMRX RECORD SUMMARY

FIELD NAME
MSIS-IDENTIFICATION-NUMBER
ADJUSTMENT-INDICATOR
TYPE-OF-SERVICE
TYPE-OF-CLAIM
DATE-OF-PAYMENT-ADJUDICATION
MEDICAID-AMOUNT-PAID
DATE-PRESCRIBED
FILLER
PROVIDER-ID-NUMBER-BILLING
AMOUNT-CHARGED
OTHER-THIRD-PARTY-PAYMENT
PROGRAM-TYPE
PLAN-ID-NUMBER
QUANTITY-OF-SERVICE
DAYS-SUPPLY
NATIONAL-DRUG-CODE
PRESCRIPTION-FILL-DATE
NEW-REFILL-INDICATOR
PRESCRIBING-PHYSICIAN-ID-NUMBER
NATIONAL-PROVIDER-ID
PROVIDER-TAXONOMY
INTERNAL-CONTROL-NUMBER-ORIG
INTERNAL CONTROL-NUMBER-ADJ
FILLER

COBOL PICTURE
X(20)
9(1)
9(2)
9(1)
9(8)
S9(8)
9(8)
9(8)
X(12)
S9(8)
S9(6)
9(1)
X(12)
S9(5)
9(3)
X(12)
9(8)
9(2)
X(12)
X(12)
X(12)
X(21)
X(21)
X(47)

- POSITION START
END
01
20
21
21
22
23
24
24
25
32
33
40
41
48
49
56
57
68
69
76
77
82
83
83
84
95
96
100
101
103
104
115
116
123
124
125
126
137
138
149
150
161
162
182
183
203
204
250

DEFAULT
ERROR
TOLERANCE
0.1%
2.0%
0.1%
2.0%
2.0%
0.1%
2.0%
5.0%
5.0%
2.0%
2.0%
2.0%
2.0%
5.0%
5.0%
2.0%
2.0%
5.0%
5.0%
5.0%
5.0%
5.0%

The error tolerance describes, for each field, the maximum allowable percentage of records submitted that may have missing,
unknown, or invalid codes. Error rates in excess of the error tolerance level for any field will cause the entire file to be
rejected.

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6.6

Claims Files - Data Field/Element Specifications

The following Data Dictionary describes in detail the specifications for each data element (field) in the MSIS Claim type
records (excluding the Standard Header Record). Data elements are listed in alphabetical order to facilitate locating
information about a specific field. Each data element is explained, including the content specifications and edit criteria
applied to the data element by the MSIS Validation process. The edit criteria are presented in the order in which edit checks
occur. Examples are also provided which illustrate properly entered data elements.

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary
CLAIMS FILES
Data Element Name: ADJUSTMENT-INDICATOR
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX- Code indicating type of adjustment record claim/encounter
represents.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(1)

2.0%

Example
Value
2

Coding Requirements:
Valid Values
0
1
2
3
4
5
9

Code Definition
Original Claim/Encounter
Void of a prior submission
Re-submittal
Credit Adjustment (negative supplemental)
Debit Adjustment (positive supplemental)
Gross Adjustment. Adjustment represents adjustment at an aggregate level (e.g., provider
level adjustment rather than an adjustment at the claim/encounter level).
Unknown

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9 .................................................................................................................. 812

2.

Value = 9 .......................................................................................................................................................... 301

3.

Value is not included in the list of valid codes - Reset to 9 ................................................................................ 201

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value = 5 AND TYPE-OF-CLAIM <>4 - Reset to 9 ........................................................................................... 509

6.

Value <> 5 AND TYPE-OF-CLAIM = 4 - Reset to 9 .......................................................................................... 509

7.

Value = 5 AND first byte of MSIS-IDENTIFICATION-NUMBER <> “&” - Reset to 9 .......................................... 522

8.

Value <> 5 AND first byte of MSIS-IDENTIFICATION-NUMBER = “&”- Reset to 9 ........................................... 522

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CLAIMS FILES
Data Element Name: ADMISSION-DATE
Definition: CLAIMIP, CLAIMLT - The date on which the recipient was admitted to a hospital or long term care facility.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

5.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If admission date is not known, fill with 99999999

Error Condition
1.

Resulting Error Code

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = 99999999 ............................................................................................................................................. 301

3.

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

4.

Value CC <19 OR >20. Value is not a valid date. Reset to 000000. ............................................................... 102

5.

Relational Field in Error ..................................................................................................................................... 999

6.

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

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CLAIMS FILES
Data Element Name: AMOUNT-CHARGED
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The total charge for this claim as submitted by the provider.

Field Description:
COBOL
PICTURE

Error
Tolerance

S9(8)

5.0%

Example
Value
+00000950

Coding Requirements:
If the amount is missing or invalid, fill with +99999999.
If TYPE-OF-CLAIM = 3 or C (encounter record) this field should either be “00000000" filled or contain the
amount paid by the plan to the provider. If TYPE-OF-SERVICE =20, 21, 22 or 23, this field should be “00000000"
filled.
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810

2.

Value = +99999999 - Reset to 0 ........................................................................................................................ 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.
Value = +00000000 AND (TYPE-OF-SERVICE <> {20, 21, 22, 23}
AND
TYPE-OF-CLAIM<>3
AND
TYPE-OF-CLAIM
<>
‘C’
AND
ADJUSTMENT-INDICATOR<>0)
.....................................................................................................................................................................................304
5.

Value <> +00000000 AND TYPE-OF-CLAIM = {4 Gross Adjustment} .............................................................. 509

6.

Value < +00000000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .................................................................... 607

7.

Value > +00000000 AND ADJUSTMENT-INDICATOR = {1,3} ......................................................................... 607

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

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

2.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If date is not known, fill with 99999999

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810

2.

Value = 99999999 - Reset to 0 .......................................................................................................................... 301

3.

Value is not a valid date - Reset to 0 ................................................................................................................. 102

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value > END-OF-TIME-PERIOD in the Header Record .................................................................................... 605
AND TYPE-OF-SERVICE <> {20, 21, 22, 23}

6.

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

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CLAIMS FILES
Data Element Name: DATE-OF-PAYMENT-ADJUDICATION
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The date on which the payment status of the claim was finally
adjudicated by the State.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

2.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If date is not known, fill with 99999999
For Encounter Records (TYPE-OF-CLAIM=3 or C); use date the encounter was processed.
For Adjustment Records (ADJUSTMENT-INDICATOR<> 0), use date of final adjudication when possible.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 ................................................................................................................... 810

2.

Value = 99999999 - Reset to 0 .......................................................................................................................... 301

3.

Value is not a valid date - Reset to 0 ................................................................................................................. 102

4.

Relational Field in Error ..................................................................................................................................... 999

5.

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

6.

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

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CLAIMS FILES
Data Element Name: DATE-PRESCRIBED
Definition: CLAIMRX - Date the drug, device or supply was prescribed by the physician or other practitioner. This
should not be confused with the DATE-FILLED which represents the date the prescription was actually
filled by the provider.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

2.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If date is not known, fill with 99999999
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 ................................................................................................................... 810

2.

Value = 99999999 - Reset to 0 .......................................................................................................................... 301

3.

Value is not a valid date - Reset to 0 ................................................................................................................. 102

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value > PRESCRIPTION-FILL-DATE ............................................................................................................... 535

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CLAIMS FILES
Data Element Name: DAYS-SUPPLY
Definition: CLAIMRX - Number of days supply dispensed.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(3)

5.0%

Example
Value
031

Coding Requirements:
Values should be 1-365.
If Value is unknown, 9-fill.

Error Condition
1.

Resulting Error Code

Value is Non-Numeric - Reset to 0. .............................................................................................................. 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = 999 - Reset to 0 ............................................................................................................................... 301

3.

Value = 0 or Value > 365 .............................................................................................................................. 203

4.

Value < 0 AND ADJUSTMENT-INDICATOR = {0, 2, 4} ................................................................................ 607

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CLAIMS FILES
Data Element Name: DIAGNOSIS-CODE-PRINCIPAL
Definition: CLAIMIP - The ICD-9/10-CM code for the principal diagnosis for this claim. Principal diagnosis is the
condition established after study to be chiefly responsible for the admission. Even though another
diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is
entered.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

X(7)

5.0%

“V8319 “

Coding Requirements:
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.
Enter invalid codes exactly as they appear in the State system. Do not “8" or "9-fill".
Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

First character of Value is not {"0" through "9", or alpha character}................................................................... 101

2.

Second or third character of Value is not {"0" through "9"} ................................................................................ 101

3.

Fourth or fifth character of Value is not {" " or "0" through "9"}…………………………………………..………… 101

4.

Fourth character of Value = " " AND fifth character of Value <> " "…………………………………………..……101

5.

Sixth or seventh character of Value <>“ ” and DIAGNOSIS-CODE-FLAG-1 = 9 .............................................. 101

6.

Fifth character of value = “ “ and sixth character of Value <> “ ” and DIAGNOSIS-CODE-FLAG-1 = 0 ............ 101

7.

Sixth character of value = “ “ and seventh character of Value <> “ ” and DIAGNOSIS-CODE-FLAG-1 = 0 ...... 101

8.

Value = “9999999”..…………………………………………………………………………………………………...…301

9.

Value= “

10.

Value = “8888888”………..……………………………………………………………...………………………………305

11.

Relational Field in Error ..................................................................................................................................... 999
(will be issued when diagnosis code is NOT blank and the corresponding diagnosis code flag IS blank)

“ …………………………………………………..……………………………………………………….303

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CLAIMS FILES
Data Element Name: DIAGNOSIS-CODE-1

through

DIAGNOSIS-CODE-9

Definition: DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-2: CLAIMIP, CLAIMLT, CLAIMOT - The ICD-9/10-CM
code for the primary and secondary diagnosis for this claim (For CLAIMIP, DIAGNOSIS-CODEPRINCIPAL is used in place of DIAGNOSIS-CODE-1).
DIAGNOSIS-CODE-3 through DIAGNOSIS-CODE-5: CLAIMIP, CLAIMLT - The third through fifth ICD9/10-CM codes that appear on the claim.
DIAGNOSIS-CODE-6 through DIAGNOSIS-CODE-9: CLAIMIP- The sixth through ninth ICD-9/10-CM
codes that appear on the claim.
Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

X(7)

5.0%

“V8319 “

Coding Requirements:
Code valid ICD-9/10-CM codes (up to nine occurrences, depending on file type) 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.
If more than nine diagnosis codes appear on the claim, enter the codes for the first nine that appear. If less
than nine diagnosis codes are used, blank fill the unused fields.
Enter invalid codes exactly as they appear in the State system. Do not “8" or "9-fill".
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. The error tolerance for this field will be adjusted on a Statespecific basis to accommodate the absence of diagnosis codes.
CLAIMLT/CLAIMIP: Provide diagnosis coding as submitted on bill.

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = “9999999" ..……………………………………………………………………………………………………..301

2.

Value = “8888888"..............................................................................................................................................305

3.

Value <> “blank” AND first character of Value is not {"0" through "9", or alpha character} ................................ 101

4.

Value <> “blank” AND second or third character of Value is not {"0" through "9"} ............................................. 101

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CLAIMS FILES
Data Element Name: DIAGNOSIS-CODE-1 through DIAGNOSIS-CODE-9 (continued)

Error Condition

Resulting Error Code

5. Value <> “blank” AND fourth or fifth character of Value is not " " or "0" through "9"}……..…………….…...….…101
6. Value <> “blank” AND fourth character of Value = " " AND fifth character of Value <>“ “ …………………...…..101
7. Value <> “blank” AND sixth or seventh character of Value <>“ ”AND DIAGNOSIS-CODE-FLAG (1-9) = 9.…...101
8. Value <> ‘blank’ AND fifth character of Value = “ “AND sixth character of Value <> “ “ AND DIAGNOSIS-CODEFLAG (1-9) = 0…………………………………….………………………………………………….……………..……….101
9. Value <> ‘blank’ AND sixth character of Value = “ “AND seventh character of Value <> “ “ AND DIAGNOSISCODE-FLAG (1-9) = 0………………………………………………………………………………..…….……………….101
10. Value Diagnosis-Code-1= “blank”………….……………………….…………………………...……………………303
11. Value <> “blank” AND preceding DIAGNOSIS-CODE value(s) = “blank”........................................................542
12. Value appears in preceding field……….………….…………………………………………...…..………………...542
13. Relational field in error…………..……….………….…………………………………………...……….…………...999
(will be issued when diagnosis code is NOT blank and the corresponding diagnosis code flag IS blank)

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CLAIMS FILES
Data Element Name: DIAGNOSIS-CODE-FLAG (1 ) THRU DIAGNOSIS-CODE-FLAG (9)
Definition: CLAIMIP, CLAIMLT, CLAIMOT - A flag that identifies the coding system used for the DIAGNOSIS CODE 1
- 9.
DIAGNOSIS-CODE-FLAG-1 through DIAGNOSIS-CODE-FLAG-2: CLAIMIP, CLAIMLT, CLAIMOT –
Code flag for the Primary and Second ICD-9/10-CM code found on the claim.
DIAGNOSIS-CODE-FLAG-3 through DIAGNOSIS-CODE-FLAG-5: CLAIMIP, CLAIMLT – Code flag for
the third through fifth ICD-9/10-CM codes that appear on the claim.
DIAGNOSIS-CODE-FLAG-6 through DIAGNOSIS-CODE-FLAG9: CLAIMIP- Code flag for the sixth
through ninth ICD-9/10-CM codes that appear on the claim.
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.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(01)

5.0%

Example
Value
“0”

Coding Requirements: Required.
Valid Values
9
0

Code Definition
ICD-9
ICD-10

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 diagnosis code flag that is either ‘9’ or ‘0’.

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)
Error Condition

Resulting Error Code

1.

For OT Claims, Value = 0 AND Coding Scheme has not yet been implemented .............................................. 511
(BEGINNING-DATE-OF-SERVICE < implementation date of 10/01/2014)

2.

For IP and LT Claims, Value = 0 AND Coding Scheme has not yet been implemented................................... 517
(ENDING-DATE-OF-SERVICE < implementation date of 10/01/2014)

3.

For OT Claims, Value = 9 AND Coding Scheme has been retired .................................................................... 511
(BEGINNING-DATE-OF-SERVICE >= implementation date of 10/01/2014)

4.

For IP and LT Claims, Value = 9 AND Coding Scheme has been retired.......................................................... 517
(ENDING-DATE-OF-SERVICE >= implementation date of 10/01/2014)

5. Relational field in error…………………….……….………….………………………………………………………....999
(will be issued when diagnosis code is NOT blank and the corresponding diagnosis code flag IS blank, Or
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Beginning date of service is in error (OT claims) or Ending Date of Service is in error (IP and LT claims) )

CLAIMS FILES

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Data Element Name: DIAGNOSIS-RELATED-GROUP (DRG)
Definition: CLAIMIP - Code representing the Diagnosis Related Group that is applicable for the inpatient services
being rendered.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(4)

100%

Example
Value
0370

Coding Requirements:
Enter DRG used by the State.
If DRGs are not used, 8-fill the field.
If Value is unknown, 9-fill the field.

Error Condition
1.

Resulting Error Code

Value Not-Numeric - Reset to 0 ......................................................................................................................... 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = 8888 AND DIAGNOSIS-RELATED-GROUP-INDICATOR <> “8888"................................................... 540

3.

Value = 9999 AND DIAGNOSIS-RELATED-GROUP-INDICATOR <> “9999"................................................... 540

4.

Value <> 8888 AND Value ............................................................................................................................... 306
DIAGNOSIS-RELATED-GROUP-INDICATOR = “8888"

5.

Value <> 9999 AND DIAGNOSIS-RELATED-GROUP-INDICATOR = “9999"................................................... 540

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CLAIMS FILES
Data Element Name: DIAGNOSIS-RELATED-GROUP-INDICATOR
Definition: CLAIMIP - An indicator identifying the grouping algorithm used to assign DIAGNOSIS-RELATED-GROUP
(DRG) values.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(4)

100%

Example
Value
HG15

Coding Requirements:
Values are generated by combining two types of information:
Position 1-2, State/Group generating DRG:
If state specific system, fill with two digit US postal code representation for state.
If CMS Grouper, fill with “HG”.
If any other system, fill with “XX”.
Position 3-4, fill with the number that represents the DRG version used (01-98). For example, “HG15" would
represent CMS Grouper version 15. If version is unknown, fill with “99".
If no DRG system is used, fill the field with “8888".
If Value is unknown, fill the field with “9999".

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = “9999" ................................................................................................................................................... 301

2.

First and second characters of Value <> {“A” - “Z”} AND Value is NOT 8-Filled................................................ 101

3.

Third and fourth characters of Value <> {“01" - “98"} AND first and second ...................................................... 101
Value = {“HG”} AND Value is NOT 8-Filled

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CLAIMS FILES
Data Element Name: ENDING-DATE-OF-SERVICE
Definition: CLAIMIP, CLAIMLT, CLAIMOT - For services received during a single encounter with a provider, the date
the service covered by this claim was received. For services involving multiple encounters on different
days, or periods of care extending over two or more days, the date on which the service covered by this
claim ended. For capitation premium payments, the date on which the period of coverage related to this
payment ends/ended.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

2.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If date is not known, fill with 99999999

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to all 0's ............................................................................................................. 810

2.

Value = 99999999 - Reset to all 0's ................................................................................................................... 301

3.

Value is not a valid date - Reset to all 0's .......................................................................................................... 102

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value > END-OF-TIME-PERIOD in the Header Record .................................................................................... 605
AND TYPE-OF-SERVICE <> {20, 21, 22, 23}

6.

Value < BEGINNING-DATE-OF-SERVICE. ...................................................................................................... 511

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CLAIMS FILES
Data Element Name: ICF-MR-DAYS
Definition: CLAIMLT - The number of days of intermediate care for the mentally retarded should be included in this
claim that were paid for, in whole or in part, by Medicaid.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

2.0%

+00014

Coding Requirements:
ICF-MR-DAYS include every day of intermediate care facility services for the mentally retarded that is at least
partially paid for by the State, even if private or third party funds are used for some portion of the payment.
If value exceeds +99998 days, code as +99998. (e.g., code 100023 as +99998)
ICF-MR-DAYS is applicable only for TYPE-OF-SERVICE = 05.
For all claims for psychiatric services or nursing facility care services (TYPE-OF-SERVICE = 02, 04, or 07), fill
with +88888.
If value is not known or invalid, fill with +99999.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
OR Value = -88888

2.

Value = +99999 - Reset to 0 .............................................................................................................................. 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND TYPE-OF-SERVICE = {02, 04, or 07} ........................................................................... 306

5.

Value = +88888 AND TYPE-OF-SERVICE = {05} ............................................................................................. 305

6.

Value > +00000 AND NURSING-FACILITY-DAYS > +0 ................................................................................... 508

7.

Value > (ENDING-DATE-OF-SERVICE - BEGINNING-DATE .......................................................................... 603
OF-SERVICE) + 1

8.

Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .......................................................................... 607

9.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1, 3} .............................................................................. 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.

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CLAIMS FILES
Data Element Name: INTERNAL-CONTROL-NUMBER-ADJ
Definition: CLAIMIP, CLAIMLT, CLAIMOT and CLAIMRX - A unique claim number (up to 21 alpha/numeric
characters) assigned by the State’s payment system that identifies the adjustment claim for an original
transaction.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(21)

5.0%

Example
Value
“ABC111222333444555666”

Coding Requirements:
Record the value exactly as it appears in the State system. Do not pad.
This field should be 8-filled if the ADJUSTMENT-INDICATOR = 0
If Value is unknown, fill with "999999999999999999999".

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR GROSS ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=5)

1.

Value = "999999999999999999999" ................................................................................................................. 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

4.

Value = “888888888888888888888" AND ADJUSTMENT-INDICATOR IS NE 0 ............................................. 305

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CLAIMS FILES
Data Element Name: INTERNAL-CONTROL-NUMBER-ORIG
Definition: CLAIMIP, CLAIMLT, CLAIMOT and CLAIMRX - A unique number (up to 21 alpha/numeric characters)
assigned by the State’s payment system that identifies an original claim.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(21)

5.0%

Example
Value
“ABC000111222444555666”

Coding Requirements:
Record the value exactly as it appears in the State system. Do not pad.
If the ADJUSTMENT-INDICATOR is ‘0’ then this field must include the ICN for the original claim.
adjustment claims this field should show the ICN for the claim being adjusted.

On

If Value is unknown, or the claims is a service tracking claim, fill with "999999999999999999999".

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR GROSS ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=5)

1.

Value = "999999999999999999999" ................................................................................................................. 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

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CLAIMS FILES
Data Element Name: LEAVE-DAYS
Definition: CLAIMLT - The number of days, during the period covered by Medicaid, on which the patient did not
reside in the long term care facility.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

5.0%

+00999

Coding Requirements:
If value exceeds +99998, code as +99998 (e.g., code 100023 as +99998).
LEAVE-DAYS is applicable only for TYPE-OF-SERVICE = 05 or 07.
When TYPE-OF-SERVICE = 02 or 04 fill with +88888.
If invalid fill with +99999.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
OR Value = -88888

2.

Value = +99999 - Reset to 0 .............................................................................................................................. 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND TYPE-OF-SERVICE = {02 or 04}.................................................................................. 306

5.

Value = +88888 AND TYPE-OF-SERVICE = {05 or 07} .................................................................................... 305

6.

Value > 0 AND > NURSING-FACILITY-DAYS AND
TYPE-OF-SERVICE = 07 .................................................................................................................................. 508

7.

Value > 0 AND > ICF-MR-DAYS AND
TYPE-OF-SERVICE = 05 .................................................................................................................................. 608

8.

Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .......................................................................... 607

9.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1,3} ............................................................................... 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.

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CLAIMS FILES
Data Element Name: LINE-NUMBER-ADJ
Definition: CLAIMOT - A unique number to identify the transaction line number that is being identifies the line number
on the adjustment ICN.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(3)

5.0%

Example
Value
“001”

Coding Requirements:
Record the value exactly as it appears in the State system
This field should be 8-filled if the ADJUSTMENT-INDICATOR = 0.
If Value is unknown, fill with "999”.

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "999" ..................................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

4.

Value = “888" AND ADJUSTMENT-INDICATOR IS NE 0 ................................................................................. 306

February 2014

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Release 5

CLAIMS FILES
Data Element Name: LINE-NUMBER-ORIG
Definition: CLAIMOT - A unique number to identify the transaction line number that is being reported on the original
claim.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(3)

5.0%

Example
Value
“001”

Coding Requirements:
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.
If Value is unknown, fill with "999”.

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "999" ..................................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

4.

Value = “888" AND ADJUSTMENT-INDICATOR IS = 0 .................................................................................... 305

February 2014

95

Release 5

CLAIMS FILES
Data Element Name: MEDICAID-AMOUNT-PAID
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The amount paid by Medicaid on this claim or adjustment.

Field Description:
COBOL
PICTURE

Error
Tolerance

S9(8)

0.1%

Example
Value
+00000950

Coding Requirements:
If invalid or unknown, fill with +99999999.
TYPE-OF-CLAIM = 3 or C (encounter): If Medicaid or CHIP had no liability for the bill, 0-fill. Amount Paid
should reflect the
actual amount paid by Medicaid or CHIP. It is not intended to reflect fee-for-service
equivalents. If the claim contains the amount paid to a provider by a plan, please put that payment to the AMOUNT
CHARGED field.
For claims where the Medicaid-Amount–Paid is only available at the header level, include all payment
information on the header claim (including Medicaid–Amount-Paid, TPL and Medicare Coinsurance and
Deductibles). Submit the line item claims with $0 in all payment fields.
Exclude claims with $0 Medicaid-Paid-Amount if the original claims was denied when it was submitted for
payment. Include $0 paid claims if they contain, TPL, Medicare Coinsurance and/or Deductibles OR if they are
$0 paid line item claims associated with a header summary claim containing the payment information.
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.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810

2.

Value = +99999999 - Reset to 0 ........................................................................................................................ 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value < +00000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} ................................................................. 607

5.

Value > +00000000 AND ADJUSTMENT-INDICATOR = {1,3} ......................................................................... 607

February 2014

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Release 5

CLAIMS FILES
Data Element Name: MEDICAID-COVERED-INPATIENT-DAYS
Definition: CLAIMIP - The number of inpatient days covered by Medicaid on this claim. For states that combine
delivery/birth services on a single claim, include covered days for both the mother and the neonate in this
field.
CLAIMLT - The number of inpatient psychiatric days covered by Medicaid on this claim.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

2.0%

+00030

Coding Requirements:
This field is applicable when:
-

A CLAIMIP record includes at least one accommodation revenue code = (values 100-219) in UBREV-CODE-(1-23) fields.

-

A CLAIMLT record has TYPE-OF-SERVICE = 02 or 04 (inpatient mental health/psychiatric
services).

When this field is not applicable, fill with +88888.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
OR Value = -88888

2.

Value = +99999 - Reset to 0 .............................................................................................................................. 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND TYPE-OF-SERVICE = {05 or 07}.................................................................................. 306

5.

Value =+88888 AND TYPE-OF-SERVICE = {02 or 04} ..................................................................................... 305

6.

Value > (ENDING-DATE-OF-SERVICE - BEGINNING-DATE-OF- ................................................................... 603
SERVICE + 1 (in days))X2

7.

Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .......................................................................... 607

8.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1, 3} .............................................................................. 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.

February 2014

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CLAIMS FILES
Data Element Name: MEDICARE-COINSURANCE-PAYMENT
Definition: CLAIMIP, CLAIMLT, CLAIMOT - The amount paid by Medicaid, on this claim, toward the recipient's
Medicare coinsurance.
Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

2.0%

+99998

Coding Requirements:
This field is relevant only for Crossover (Medicare is third party payee) claims. Crossover claims with
coinsurance can only occur when TYPE-OF-SERVICE = (01, 02, 04, 07, 08, 10 through 12, 15, 19, 24 through
26, 30, 31, 33 through 39)
If claim is not a Crossover claim, fill with +88888.
If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that
amount in this field.
If Medicare coinsurance and deductible payments cannot be separated, fill this field with +99998 and code the
combined payment amount in MEDICARE-DEDUCTIBLE-PAYMENT.
For Crossover claims with no coinsurance payment, fill with +00000.
For Crossover claims with missing or invalid coinsurance amounts, fill with +99999.
For TYPE-OF-CLAIM = 3 or C (encounter record) fill with +88888.
If the state’s Medicaid reimbursement rate is lower than the Medicare rate, the state should report
the lower Medicaid paid amounts in MEDICARE-DEDUCTIBLE-PAYMENT and fill MEDICARECOINSURANCE-PAYMENT with +00000.
For Crossover claims with zero Medicaid paid amount, fill MEDICARE-COINSURANCE-PAYMENT and
MEDICARE-DEDUCTIBLE-PAYMENT with +00000.
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
OR Value = -88888

2.

Value = +99999 - Reset to 0 .............................................................................................................................. 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND (MEDICARE-DEDUCTIBLE-PAYMENT = ................................................................... 306
+88888 OR TYPE-OF=SERVICE = 13 OR TYPE-OF-CLAIM = 3)

5.

Value = +99998 AND MEDICARE-DEDUCTIBLE-AMOUNT = (+0, +99998) ................................................... 515

6.

Value > AMOUNT-CHARGED ......................................................................................................................... 606

February 2014

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7.

Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .......................................................................... 607

8.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1, 3} .............................................................................. 607

Note:During CMS’s “Valids File” processing, if value is 8-filled or Value = 99998, reset to 0.

February 2014

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CLAIMS FILES
Data Element Name: MEDICARE-DEDUCTIBLE-PAYMENT
Definition: CLAIMIP, CLAIMLT, CLAIMOT - The amount paid by Medicaid, on this claim, toward the recipient's
Medicare deductible.
Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

2.0%

+00200

Coding Requirements:
This field is relevant only for Crossover (when Medicare is the third party payee) claims. Crossover claims with
deductibles can only occur when TYPE-OF-SERVICE = {01, 02, 04, 08, 10 through 13, 15, 19, 24 through 26,
30, 31, 33 through 39).
If claim is not a Crossover claim, or if TYPE-OF-CLAIM = 3 or C (encounter claim) fill with +88888.
If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that
amount in this field.
If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined
payment amount and code +99998 in MEDICARE-COINSURANCE-PAYMENT.
For Crossover claims with no Medicare deductible payment, fill this field with +00000.
For Crossover claims with missing or invalid deductible amounts, fill this field with +99999.
If the state’s Medicaid reimbursement rate is lower than the Medicare rate, the state should report
the lower Medicaid paid amounts in MEDICARE-DEDUCTIBLE-PAYMENT and fill MEDICARECOINSURANCE-PAYMENT with +00000.
For Crossover claims with zero Medicaid paid amount, fill MEDICARE-COINSURANCE-PAYMENT and
MEDICARE-DEDUCTIBLE-PAYMENT with +00000.
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to all 0's ............................................................................................................. 810
OR Value = -88888

2.

Value = +99999 - Reset to all 0's ....................................................................................................................... 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND VALUE<> +00000 AND TYPE-OF=SERVICE = {05 or 07} ........................................ 306

5.

Value > AMOUNT-CHARGED ........................................................................................................................... 510

6.

Value < +00000 AND ADJUSTMENT -INDICATOR = {0, 2, or 4} ..................................................................... 607

7.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1, 3} .............................................................................. 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.
CLAIMS FILES
February 2014

100

Release 5

Data Element Name: MSIS-IDENTIFICATION-NUMBER
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A unique identification number used to identify a Medicaid
Eligible to MSIS (see section 5.1).

Field Description:
COBOL
PICTURE

Error
Tolerance

X(20)

0.1%

Example
Value
123456789

Coding Requirements:
For SSN States, this field must contain the Eligible's Social Security Number. If the SSN is unknown and a
temporary number is assigned, this field will contain that number.
For non-SSN States, this field must contain an identification number assigned by the State. The format of the
State ID numbers must be supplied to CMS.
For TYPE-OF-CLAIM = 4 or D (lump sum adjustments), this field must begin with an ‘&’.

Error Condition

Resulting Error Code

1.

Value is "Space Filled" ...................................................................................................................................... 303

2.

Value = all 9's .................................................................................................................................................... 301

3.

Value = all 0's .................................................................................................................................................... 304

4.

Value is 8-filled .................................................................................................................................................. 305

5.

Duplicate Claim Record - 100% match of all fields AND TYPE-OF-SERVICE<>09,11,13, OR 25 .................... 803

February 2014

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CLAIMS FILES
Data Element Name: NATIONAL-DRUG-CODE
Definition: CLAIMRX - A code indicating the drug, device or medical supply covered by this claim, in National Drug
Code (NDC) format.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
00039001460

Coding Requirements:
This field is applicable only for TYPE-OF-SERVICE = 16 or 19.
Drug code formats must be supplied by State in advance of submitting any file data. States must inform CMS of
the NDC segments used and their size (e.g., {5,4,2} or {5,4} as defined in the National Drug Code Directory).
If the Drug Code is less than 12 characters in length, the value must be left justified and padded with spaces.
If Durable Medical Equipment or supply is prescribed by a physician and provided by a pharmacy then HCPCS
or state-specific codes can be put in the NDC field.
Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = 9-filled................................................................................................................................................... 301

2.

Value = 0-filled................................................................................................................................................... 304

3.

Value is “Space Filled”....................................................................................................................................... 303

4.

Value is invalid AND TYPE-OF-SERVICE=16................................................................................................... 203
Position 1-5 must be Numeric
Position 6-9 must be Alpha Numeric,
Position 10-11 must be Alpha Numeric or blank,
Position 12 must be blank

February 2014

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CLAIMS FILES
Data Element Name: NATIONAL-PROVIDER-ID
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX –
For CLAIMOT files the unique number to identify the provider who treated the recipient (as opposed to
the provider “billing” for the service).
For CLAIMIP and CLAIMLT files the NPI should be that of the institution billing/caring for the beneficiary.
For CLAIMRX files, the unique number identifying the billing provider.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
“1234567890 “

Coding Requirements:
Record the value exactly as it appears in the State system.
If legacy identifiers are available for providers, then report the legacy IDs in the Provider ID field and the NPI in
this field. If only the legacy Provider ID is available, then 9-fill the National Provider ID and enter the legacy IDs in
the Provider ID fields.
8-fill field for capitation or premium payments (TYPE-OF-SERVICE = 20, 21, 22, 23)
If Value is unknown, fill with "999999999999".

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "999999999999" ................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

4.

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

5.

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

6.

Value = PROVIDER-ID-NUMBER-BILLING ……...………………………………………………………………….529

February 2014

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CLAIMS FILES
Data Element Name: NEW-REFILL-INDICATOR
Definition: CLAIMRX - Indicator showing whether the prescription being filled was a new prescription or a refill. If it is
a refill, the indicator will indicate the number of refills.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

2.0%

Example
Value
03

Coding Requirements:
00
01-98
99

=
=
=

New Prescription
Number of Refill
Unknown

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9- filled........................................................................................................... 812

2.

Value = 99 AND NATIONAL-DRUG-CODE <> “999999999999" ...................................................................... 536
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

3.

Value = 99 ......................................................................................................................................................... 301

February 2014

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CLAIMS FILES
Data Element Name: NURSING-FACILITY-DAYS
Definition: CLAIMLT - The number of days of nursing care included in this claim that were paid for, in whole or in
part, by Medicaid. Includes days during which nursing facility received partial payment for holding a bed
during patient leave days.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

2.0%

+00014

Coding Requirements:
NURSING-FACILITY-DAYS include every day of nursing care services that is at least partially paid for by the
State, even if private or third party funds are used for some portion of the payment.
If value exceeds +99998 days, code as +99998.
NURSING-FACILITY-DAYS is applicable only for TYPE-OF-SERVICE = 07.
For all claims for psychiatric services or intermediate care services for mentally retarded (TYPE-OF-SERVICE =
02, 04, or 05), fill with +88888.
If value is not known or invalid, fill with +99999.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
OR Value = -88888

2.

Value =+99999 - Reset to 0 ............................................................................................................................... 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND TYPE-OF-SERVICE = {02, 04, or 05} ........................................................................... 306

5.

Value =+88888 AND TYPE-OF-SERVICE = {07} .............................................................................................. 305

6.

Value > (ENDING-DATE-OF-SERVICE - ......................................................................................................... 603
BEGINNING-DATE-OF-SERVICE + 1)

7.

Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .......................................................................... 607

8.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1, 3} .............................................................................. 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.

February 2014

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CLAIMS FILES
Data Element Name: OTHER-THIRD-PARTY-PAYMENT
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - The total amount paid by all sources other than Medicaid,
Medicare, and the recipient's personal funds.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(6)

2.0%

+000200

Coding Requirements:
If amount is missing or invalid, fill with +999999.
If TYPE-OF-CLAIM = 3 or C (encounter record), enter the actual amount paid. If there was no paid amount, fill
with +000000.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810

2.

Value = +999999 - Reset to 0 ............................................................................................................................ 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value > (AMOUNT-CHARGED MINUS ............................................................................................................. 704
(MEDICARE-COINSURANCE-PAYMENT + MEDICARE-DEDUCTIBLE-PAYMENT)

5.

Value < +000000 AND ADJUSTMENT-INDICATOR = {0, 2 or 4} ..................................................................... 607

6.

Value > +000000 AND ADJUSTMENT-INDICATOR = {1, 3} ............................................................................ 607

February 2014

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CLAIMS FILES
Data Element Name: PATIENT-LIABILITY
Definition: CLAIMLT - The total amount paid by the patient for services where they are required to use their personal
funds to cover part of their care before Medicaid funds can be utilized.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(6)

2.0%

+000200

Coding Requirements:
If amount is missing or invalid, fill with +999999.
If TYPE-OF-CLAIM = 3 or C (encounter record) and no funds were used, fill with +000000.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810

2.

Value = +999999 - Reset to 0 ............................................................................................................................ 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value > AMOUNT-CHARGED-MEDICAID MINUS ..................................................................................... 704
(MEDICARE COINSURANCE-PAYMENT + MEDICARE-DEDUCTIBLE-PAYMENT)

5.

Value < +000000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} ........................................................................ 607

6.

Value > +000000 AND ADJUSTMENT-INDICATOR = {1, 3} ............................................................................ 607

February 2014

107

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CLAIMS FILE
Data Element Name: PATIENT-STATUS
Definition: CLAIMIP, CLAIMLT - A code indicating the Patients status as of the ENDING-DATE-OF-SERVICE.
Values used are from UB-04.
Field Description:
COBOL
PICTURE
9(2)

Error
Tolerance
5.0%

Example
Value
05

Coding Requirements:
Valid Values
01
02
03
04
05
06
07
08
09*
20
30
40
41
42
43
50
51
61
62
63
65
66
71
72
99
*

Code Definition
Discharged to home or self care (routine discharge)
Discharged/transferred to another short-term general hospital
Discharged/transferred to NF
Discharged/transferred to an ICF
Discharged/transferred to another type of institution (including distinct parts) or referred for
outpatient services to another institution
Discharged/transferred to home under care of organized home health service organization
Left against medical advice or discontinued care
Discharged/transferred to home under care of a home IV drug therapy provider
Admitted as an inpatient to this hospital
Expired
Still a patient
Expired at home
Expired in a medical facility such as a hospital, NF or freestanding hospice
Expired - place unknown
Discharged/transferred to a Federal hospital (effective 10/1/03)
Discharged home with Hospice care
Discharged to a medical facility with Hospice care
Discharged to a hospital-based Medicare approved swing bed
Discharged/transferred to another rehab facility/rehab unit of a hospital
Discharged/transferred to a long term care hospital
Discharged/transferred to a psych hospital/psych unit of a hospital (effective 4/1/04)
Discharged to Critical Access Hospital
Discharged/transferred to another institution for outpatient services (deleted as of 10/1/03)
Discharged/transferred to this institution for outpatient services (deleted as of 10/1/03)
Unknown

In situations where a patient is admitted before midnight of the third day following the day of an outpatient
service, the outpatient services are considered inpatient. Therefore, code 09 would apply only to services
that begin longer than 3 days earlier, such as observation following outpatient surgery, which results in
admission.

Error Condition
Resulting Error Code
1.
Value is Non-Numeric - Reset to 9-filled ............................................................................................................ 812

2.

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)
Value = 99 ......................................................................................................................................................... 301

3.
4.

Value < 01 OR Value > 72................................................................................................................................. 203
Value = {10-19, 21-29, 31-39, 44-49, 52-60, 64, 67-70, 73-98}......................................................................... 201

February 2014

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CLAIMS FILES
Data Element Name: PLACE-OF-SERVICE
Definition: CLAIMOT - A code indicating where the service was performed. CMS 1500 values are used for this data
element.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

5.0%

Example
Value
11

Coding Requirements:
Code
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18-19
20
21
22
23
24
25
26
27-30
31
32
33
34
35-40
41
42
43-48
49
50
51
52
February 2014

Definition
Unassigned
Pharmacy
Unassigned
School
Homeless Shelter
Indian Health Service Free Standing Facility
Indian Health Service Provider-based Facility
Tribal 638 Free-standing Facility
Tribal 638 Provider-based Facility
Prison/Correctional Facility
Unassigned
Office
Home
Assisted Living Facility
Group Home
Mobile Unit
Temporary Lodging
Walk-in Retail Health Clinic
Unassigned
Urgent Care Facility
Inpatient Hospital
Outpatient Hospital
Emergency Room – Hospital
Ambulatory Surgery Center
Birthing Center
Military Treatment Facility
Unassigned
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Unassigned
Ambulance (Land)
Ambulance (Air or Water)
Unassigned
Independent Clinic
Federally Qualified Health Center
Inpatient Psychiatric Facility
Psychiatric Facility Partial Hospitalization
109

Release 5

53
54
55
56
57
58-59
60
61
62
63-64
65
66-70
71
72
73-80
81
82-87
88
89-98
99

Community Mental Health Center
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Facility
Psychiatric Residential Treatment Center
Non-Residential Substance Abuse Treatment Facility
Unassigned
Mass Immunization Center
Comprehensive Inpatient Rehabilitation Facility
Comprehensive Outpatient Rehabilitation Facility
Unassigned
End Stage Renal Disease Treatment Facility
Unassigned
State or Local Public Health Clinic
Rural Health Clinic
Unassigned
Independent Laboratory
Unassigned
Not Applicable
Unassigned
Other Unlisted Place of Service

Note: Value = 99 will be counted as error.
If there are new valid CMS 1500 PLACE- OF- SERVICE codes that are not listed in this dictionary, these codes
may be used and will not trigger an error.
If TYPE-OF-SERVICE = {20, 21, 22, 23} (capitated payment), fill with 88.

Error Condition
1.

Resulting Error Code

Value is Non-Numeric - Reset to 9-filled ............................................................................................................ 812
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = 99 ......................................................................................................................................................... 301

3.

Value Not one of the listed valid codes (including unassigned .......................................................................... 203
Values = {00-02, 09-10, 16-19, 27-30, 35-40, 43-48, 58-59, 63-64,
66-70, 73-80, 82-87, 89-98})

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value = 88 AND TYPE-OF-SERVICE <> {20, 21, 22, 23} ................................................................................. 305

6.

Value <> 88 AND TYPE-OF-SERVICE = {20, 21, 22, 23} ................................................................................. 306

CLAIMS FILES

February 2014

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Data Element Name: PLAN-ID-NUMBER
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX- A unique number that represents the managed care health
plan under which the non-fee-for-service encounter was provided or the capitation payment was made.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

2.0%

Example
Value
53289

Coding Requirements:
Use the number as it is carried in the State’s system. This number should match the number used on the
eligible file. (TYPE-OF-CLAIM=3 or ‘C’ or TYPE-OF-SERVICE=20, 21, 22, 23).
If (TYPE-OF-CLAIM <> (3 and ‘C’)) (Encounter Record) AND TYPE-OF-SERVICE <> {20, 21, 22, 23}, 8-fill.
If Value is unknown, 9-fill.

Error Condition

Resulting Error Code

1.

Value is “Space Filled” ..................................................................................................................................... 303

2.

Value = all 9's ................................................................................................................................................... 301

3.

Value = all 0's ................................................................................................................................................... 304

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value = all 8's AND TYPE-OF-CLAIM = ( 3 or ‘C’) ........................................................................................... 509

6.

Value = all 8's AND TYPE OF SERVICE = {20, 21, 22, 23} .............................................................................. 521

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CLAIMS FILES
Data Element Name: PRESCRIBING-PHYSICIAN-ID-NUMBER
Definition: CLAIMRX - A unique identification number assigned to a provider which identifies the physician or other
provider prescribing the drug, device or supply. For physicians, this must be the individual’s ID number,
not a group identification number.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
01CA79300

Coding Requirements:
Valid formats must be supplied by the State in advance of submitting file data.
If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.
If Value is unknown, fill with "999999999999".
If the prescribing physician provider ID is not available, but the physician’s Drug Enforcement Agency (DEA) ID
is on the State file, then the State should use the DEA ID for this data element.

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "999999999999" ................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value = PROVIDER-IDENTIFICATION-BILLING .............................................................................................. 524

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CLAIMS FILES
Data Element Name: PRESCRIPTION-FILL-DATE
Definition: CLAIMRX- Date the drug, device or supply was dispensed by the provider

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

2.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If date is not known, fill with 99999999

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 ................................................................................................................... 810

2.

Value = 99999999 - Reset to 0 .......................................................................................................................... 301

3.

Value is not a valid date - Reset to 0 ................................................................................................................. 102

4.

Relational Field in Error ..................................................................................................................................... 999

5.

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

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CLAIMS FILES
Data Element Name: PROC-CODE-PRINCIPAL
Definition: CLAIMIP - A code used by the State to identify the principal procedure performed during the hospital stay
referenced by this claim. A principal procedure is performed for definitive treatment rather than for
diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to
complications that arise during other treatments.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(8)

5.0%

Example
Value
“123456 “

Coding Requirements:
If no principal procedure was performed, fill with "88888888".

ICD-9-CM codes are the HIPAA standard for procedure codes on inpatient claims. When ICD-9-CM coding
is used, the PROC-CODE-FLAG-PRINCIPAL=02. 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 PROC-CODE-FLAG-PRINCIPAL=07. Positions 17 must be alpha or numeric. Position 8 must be blank.
Value must be a valid code. If PROC-CODE-FLAG-PRINCIPAL = {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-CODE-FLAG-PRINCIPAL=01): Positions 1-5 should be numeric and position 6-7 must be
blank.
HCPCS (PROC-CODE-FLAG-PRINCIPAL=06): Position 1 must be an alpha character (“A”-“Z”) and position
6-7 must be blank.. Value can include both National and Local ( Regional) codes. For National codes
(position 1=“A”-“V” ) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be
alphanumeric (e.g., “X1234" or “WW234").
If value is unknown, fill with "99999999".

Note: An eighth character is provided for future expansion of this field.

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CLAIMS FILES
Data Element Name: PROC-CODE-PRINCIPAL (continued)

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "99999999" ........................................................................................................................................... 301

2.

Value = “00000000" ........................................................................................................................................... 304

3.

Value is “Space Filled”....................................................................................................................................... 303

4.

Relational Field In Error ..................................................................................................................................... 999

5.

Value <> "88888888" AND PROC-CODE-FLAG-PRINCIPAL = 88 ................................................................... 306

6.

Value = "88888888" AND PROC-CODE-FLAG-PRINCIPAL <> 88 ................................................................... 305

7.

Value is invalid as related to PROC-CODE-FLAG-PRINCIPAL=01 (CPT-4) ..................................................... 203

8.

Value is invalid as related to PROC-CODE-FLAG-PRINCIPAL=02 (ICD-9) ...................................................... 203

9.

Value is invalid as related to PROC-CODE-FLAG-PRINCIPAL=06 (HCPCS) .................................................. 203

10.

Value is invalid as related to PROC-CODE-FLAG-PRINCIPAL=07 (ICD-10) ................................................... 203

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CLAIMS FILES
Data Element Name: PROC-CODE-2

through

PROC-CODE-6

Definition: CLAIMIP - A series of up to five codes used by the State to identify the procedures performed in addition
to the principal procedure during the hospital stay referenced by this claim.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(8)

5.0%

Example
Value
“123456 “

Coding Requirements:
Enter as many procedures as are reported after the principal procedure up to five additional codes.
Remaining fields should be 8-filled (e.g., if claim contains two additional procedures, they would be reported
in PROC-CODE-2 and PROC-CODE-3. Remaining fields PROC-CODE-4 through PROC-CODE-6 would all
be 8-filled.)
ICD-9-CM codes are the HIPAA standard for procedure codes on inpatient claims. When ICD-9-CM coding
is used, the PROC-CODE-FLAG=02. 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 PROC-CODE-FLAG=07. Positions 1-7 must be
alpha or numeric. Position 8 must be blank.
Value must be a valid code. If PROC-CODE-FLAG = {10 through 87, state-specific coding systems} valid
codes must be supplied by the State.
For national coding systems, code should conform to the nationally recognized formats:
CPT (corresponding PROC-CODE-FLAG = 01): Positions 1-5 should be numeric and position 6-8 must be
blank.
ICD-9-CM (corresponding PROC-CODE-FLAG = 02): Positions 1-2 must be numeric, positions 3-4 must
be numeric or blank, positions 5-8 must be blank.
ICD-10-PCS (corresponding PROC-CODE-FLAG = 07): Positions 1-7 must be alpha or numeric. Position
8 must be blank.
HCPCS (corresponding PROC-CODE-FLAG = 06): Position 1 must be an alpha character (“A”-“Z”) and
position 6-7 must be blank.. Value can include both National and Local ( Regional) codes. For National
codes (position 1=“A”-“V” ) positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must
be alphanumeric (e.g., “X1234" or “WW234").
For other schemes which are not nationally recognized, states should supply CMS with lists of valid
values and any formats which should apply.
If value is unknown, fill with “99999999".
Note: An eighth character is provided for future expansion of this field.

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Data Element Name: PROC-CODE-2 through PROC-CODE-6 (continued)
Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value is = "99999999" ....................................................................................................................................... 301

2.

Value = “00000000" ........................................................................................................................................... 304

3.

Value is “Space Filled”....................................................................................................................................... 303

4.

Relational Field in Error ..................................................................................................................................... 999

5.

Value is <> "88888888" ..................................................................................................................................... 306
AND corresponding PROC-CODE-FLAG = 88

6.

Value is = "88888888" ...................................................................................................................................... 305
AND corresponding PROC-CODE-FLAG <> 88

7.

Value is invalid as related to corresponding PROC-CODE-FLAG= 01 (CPT-4) ............................................... 203

8.

Value is invalid as related to corresponding PROC-CODE-FLAG = 02 (ICD-9-CM). ........................................ 203

9.

Value is invalid as related to corresponding PROC-CODE-FLAG = 06 (HCPCS) ............................................. 203

10.

Value is invalid as related to corresponding PROC-CODE-FLAG = 07 (ICD-10) ............................................. 203

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CLAIMS FILES
Data Element Name: PROC-CODE-FLAG-PRINCIPAL
Definition: CLAIMIP - A flag that identifies the coding system used for the PROC-CODE-PRINCIPAL.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

5.0%

Example
Value
01

Coding Requirements:
Valid Values
01
02
03
04
05
06
07
10 - 87
88
99

Code Definition
CPT-4
ICD-9-CM
CRVS 74 (Obsolete)
CRVS 69 (Obsolete)
CRVS 64 (Obsolete)
HCPCS (Both National and Regional HCPCS)
ICD-10-PCS (Will be implemented on 10/1/2014)
Other Systems
Not Applicable
Unknown

If no principal procedure was performed, fill with 88.

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 99 .................................................................................................................. 812

2.

Value = 99 ......................................................................................................................................................... 301

3.

Value is not in the list of valid codes, above ...................................................................................................... 201

4.

Relational Field in Error ..................................................................................................................................... 999
(Issued when Medicaid-Covered-Days is in error, or Ending Date of Service is in error)

5.

Value <> 88 AND MEDICAID-COVERED-INPATIENT-DAYS= +00000 ........................................................... 520

6.

Value = 07 AND Coding Scheme has not yet been implemented ..................................................................... 517
(ENDING-DATE-OF-SERVICE < implementation date of 10/01/2014)

7.

Value = 02 AND Coding Scheme has been retired ........................................................................................... 517
(ENDING-DATE-OF-SERVICE >= implementation date of 10/01/2014)

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CLAIMS FILES
Data Element Name: PROC-CODE-FLAG-2

through

PROC-CODE-FLAG-6

Definition: CLAIMIP - A series of flags that identifies the coding system used for the associated procedure codes
(PROC-CODE-2 through PROC-CODE-6)

Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

5.0%

Example
Value
01

Coding Requirements:
Valid Values
01
02
03
04
05
06
07
10 - 87
88
99

Code Definition
CPT-4
ICD-9-CM
CRVS 74 (Obsolete)
CRVS 69 (Obsolete)
CRVS 64 (Obsolete)
HCPCS (Both National and Regional HCPCS)
ICD-10-PCS (Will be implemented on 10/1/2014)
Other Systems
Not Applicable
Unknown

If no Second Procedure was performed, fill with 88.
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 99 .................................................................................................................. 812

2.

Value is = 99...................................................................................................................................................... 301

3.

Value is not in the list of valid codes, above ...................................................................................................... 201

4.

Relational Field in Error ..................................................................................................................................... 999
(Issued when Medicaid-Covered-Days is in error, or Ending Date of Service is in error)

5.

Value <> 88 AND MEDICAID-COVERED-DAYS = +00000 .............................................................................. 520

6.

Value in PROC-CODE-FLAG-2 <> 88 AND PROC-CODE-FLAG-PRINCIPAL = “88" ...................................... 306

7.

Array range should not contain imbedded 88 coded fields (e.g., one
field has value 88, all remaining fields should also contain = 88). .................................................................. 306

8.

Value= 07 AND Coding Scheme has not yet been implemented ...................................................................... 517
(ENDING-DATE-OF-SERVICE < implementation date of 10/01/2014)

9.

Value = 02 AND Coding Scheme has been retired ........................................................................................... 517

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(ENDING-DATE-OF-SERVICE >= implementation date of 10/01/2014)

CLAIMS FILES

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Data Element Name: PROC-CODE-MOD-PRINCIPAL
Definition: CLAIMIP - The procedure code modifier used with the Principal Procedure Code. For example, some
States use modifiers to indicate assistance in surgery or anesthesia services.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(2)

5.0%

Example
Value
"RT"

Coding Requirements:
A list of valid codes must be supplied by the State prior to submission of any file data.
If no Principal Procedure was performed, fill with "88".
If a modifier is not applicable, fill with " ".

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Relational Field in Error .................................................................................................................................... 999

2.

Value = “88" AND PROC-CODE-PRINCIPAL <> “88888888" ........................................................................... 305

3.

Value <> “88" AND PROC-CODE-PRINCIPAL = “88888888" ........................................................................... 306

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CLAIMS FILES
Data Element Name: PROC-CODE-MOD-2

through

PROC-CODE-MOD-6

Definition: CLAIMIP - A series of procedure code modifiers used with the corresponding Procedure Codes. For
example, some States use modifiers to indicate assistance in surgery or anesthesia services.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(2)

5.0%

Example
Value
"LT"

Coding Requirements:
A list of valid codes must be supplied by the State prior to submission of any file data.
If no corresponding procedure (PROC-CODE-2 through PROC-CODE-6) was performed, fill modifier with "88".
If a modifier is not applicable, fill with " ".

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Relational Field in Error ..................................................................................................................................... 999

2.

Value = “88" AND corresponding PROC-CODE <> “88888888" ....................................................................... 305

3.

Value <> “88" AND corresponding PROC-CODE = “88888888" ....................................................................... 306

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CLAIMS FILES
Data Element Name: PROC-DATE-PRINCIPAL
Definition: CLAIMIP - The date on which the principal procedure was performed.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

9(8)

5.0%

19980531

Coding Requirements:
Value must be a valid date in CCYYMMDD format.
If date is not known, fill with 99999999
If PROC-CODE-PRINCIPAL = “88888888", fill with 88888888

Error Condition
1.

Resulting Error Code

Value is Non-Numeric - Reset to all 0's ............................................................................................................ 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = 99999999 - Reset to all 0's ................................................................................................................... 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> 88888888 AND PROC-CODE-PRINCIPAL = "88888888" ................................................................. 306

5.

Value = 88888888 AND PROC-CODE-PRINCIPAL <> "88888888" ................................................................. 305

6.

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

7.

Value < BEGINNING-DATE-OF-SERVICE. ...................................................................................................... 511

8.

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

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

CLAIMS FILES
Data Element Name: PROGRAM-TYPE
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX- Code indicating special Medicaid program under which the service was
provided. Refer to Attachment 5 for information on the various program types.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(1)

2.0%

Example
Value
0

Coding Requirements:
Valid Values
0
1
2
3
4
5
6
7
9

Code Definition
No Special Program
EPSDT
Family Planning
Rural Health Clinic
Federally Qualified Health Centers (FQHC)
Indian Health Services
Home and Community Based Care for Disabled Elderly and Individuals Age 65 and Older
Home and Community Based Care Waiver Services
Unknown

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 9 .................................................................................................................... 812

2.

Value = 9 .......................................................................................................................................................... 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value > 7 ........................................................................................................................................................... 201

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CLAIMS FILES
Data Element Name:

PROVIDER-ID-NUMBER-BILLING

Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A unique identification number assigned by the state to a provider or
capitation plan. This should represent the entity billing for the service. For encounter records (TYPE-OF-CLAIM =
3 or C), this represents the entity billing (or reporting) to the managed care plan (See PLAN-ID-NUMBER for
reporting capitation plan-ID). Capitation PLAN-ID should be used in this field only for premium payments (TYPEOF-SERVICE = 20, 21, 22, 23)

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
01CA79300

Coding Requirements:
Valid formats must be supplied by the State in advance of submitting file data.
If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.
If Value is unknown, fill with "999999999999".
Note: Once a national provider ID numbering system is in place, the national number should be used.
If the State’s legacy ID number is only available then that number can be entered in this field.

Error Condition

Resulting Error Code

1.

Value = "999999999999" ................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

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CLAIMS FILES
Data Element Name: PROVIDER-ID-NUMBER-SERVICING
Definition: CLAIMOT - A unique number to identify the provider who treated the recipient (as opposed to the provider “billing”
for the service, see PROVIDER-ID-NUMBER-BILLING)

Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
01CA79300

Coding Requirements:
Valid formats must be supplied by the State in advance of submitting file data.
If Value is invalid, record it exactly as it appears in the State system. Do not 9-fill.
If “Servicing” provider and the “Billing” provider are the same then use the same number in both fields.
For institutional billing providers (TYPE-OF-SERVICE = 11, 12) and other providers operating as a group,
the numbers should be different.
8-fill field for premium payments (TYPE-OF-SERVICE = 20, 21, 22, 23)
If Value is unknown, fill with "999999999999".
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.
Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "999999999999" ................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

4.

Relational Field in Error ..................................................................................................................................... 999

5.

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

6.

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

7.

Value = PROVIDER-ID-NUMBER-BILLING AND TYPE-OF-SERVICE = {11, 12} ............................................ 529

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CLAIMS FILES
Data Element Name: PROVIDER-TAXONOMY
Definition:

CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX

For CLAIMOT files, the taxonomy code for the provider who treated the recipient (as opposed to the provider “billing” for the
service).
For CLAIMIP and CLAIMLT files the taxonomy code for the institution billing/caring for the beneficiary.
For CLAIMRX files, the taxonomy code for the billing provider.
Field Description:
COBOL
PICTURE

Error
Tolerance

X(12)

5.0%

Example
Value
“2080P0202X”

Coding Requirements:
8-fill field for capitation or premium payments (TYPE-OF-SERVICE = 20, 21, 22, 23)
If Value is unknown, fill with "999999999999".
Generally, the provider taxonomy requires 10 bytes.
expansion.

However, two additional bytes have been provided for future

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = "999999999999" ................................................................................................................................... 301

2.

Value is “Space Filled”....................................................................................................................................... 303

3.

Value is 0-filled .................................................................................................................................................. 304

4.

Relational Field in Error ..................................................................................................................................... 999

5.

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

6.

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

7.

Value = PROVIDER-ID-NUMBER-BILLING AND TYPE-OF-SERVICE = {11, 12} ............................................ 529

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

CLAIMS FILES
Data Element Name: QUANTITY-OF-SERVICE
Definition: CLAIMOT, CLAIMRX - The number of units of service received by the recipient as shown on the claim record.

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(5)

2.0%

+00004

Coding Requirements:
This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the
number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of
a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not
identifiable or dispensed by a normal unit, e.g. powder-filled vials, use 1 as the number of units.
NOTE==> One prescription for 100 250-milligram tablets results in QUANTITY-OF-SERVICE=100.
Prior to fiscal year 1998, one prescription for 100 tablets resulted in QUANTITY-OF-SERVICE=1.
This field is not applicable for institutional services, dental services, laboratory and x-ray services, premium payments, or
miscellaneous services (includes claims with TYPES-OF-SERVICE 09, 15, 19, 20, 21, 22, 23). Fill with +88888 for these
types of services.
If invalid or missing, fill with +99999.

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
OR Value = -88888

2.

Value = +99999 - Reset to 0 .............................................................................................................................. 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value <> +88888 AND TYPE-OF-SERVICE = {09, 15, ..................................................................................... 306
19, 20, 21, 22, 23}

5.

Value = +88888 AND (TYPE-OF-SERVICE = {08, ............................................................................................ 305
10 through 13, 16, or 18} AND TYPE-OF-CLAIM = {1 or 2})

6.

Value < +00000 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .......................................................................... 607

7.

Value > +00000 AND ADJUSTMENT-INDICATOR = {1, 3} .............................................................................. 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.

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CLAIMS FILES
Data Element Name: SERVICE-CODE
Definition: CLAIMOT - The code used by the State to indicate the service provided during the period covered by this claim.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(8)

5.0%

Example
Value
“A23456 “

Coding Requirements:
Field should contain a code for each service or other administrative cost (e.g., premium payments, EPSDT group
screens) where the State has a national or local code to identify it. For situations where no code exists (e.g., end year
cost settlements), fill with “88888888".
For outpatient claims on which multiple line items are not separately adjudicated and the TYPE-OF-SERVICE = {20, 21,
22, 23}, fill with "88888888". Include service codes on crossover claims if available, otherwise they would be 8-filled.
For national coding systems, code should conform to the nationally recognized formats:
CPT (SERVICE-CODE-FLAG = 01): Positions 1-5 should be numeric and position 6-8 must be blank.
ICD-9-CM (SERVICE-CODE-FLAG = 02): Positions 1-2 must be numeric, positions 3-4 must be numeric or blank,
positions 5-8 must be blank.
ICD-10-PCS (SERVICE-CODE-FLAG = 07): Positions 1-7 must be alpha or numeric. Position 8 must be blank.
HCPCS (SERVICE-CODE-FLAG = 06): Position 1 must be an alpha character (“A”-“Z”) and position 6-8 must be
blank. Value can include both National and Local (Regional) codes. For National codes . (Position 1=“A”-“V”)
positions 2-5 must be numeric; for Local (Regional) codes, positions 2-5 must be alphanumeric (e.g., “X1234" or
“WW234").
For other schemes which are not nationally recognized, states should supply CMS with lists of valid values and any
formats which should apply.
If Value is unknown, fill with "99999999".
Note: An eighth character is provided for future expansion of this field.

Error Condition

Resulting Error Code

1.

Value = "99999999" .......................................................................................................................................... 301

2.

Value = “00000000" ........................................................................................................................................... 304

3.

Value is “Space Filled”....................................................................................................................................... 303

4.

Relational Field in Error ..................................................................................................................................... 999

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5.

Value <> "88888888" AND SERVICE-CODE-FLAG = 88 ................................................................................. 306

6.

Value = "88888888" AND SERVICE-CODE-FLAG <> 88 ………………………………………………. 305

7.

Value is invalid as related to SERVICE-CODE-FLAG = 01 (CPT 4) …………………………………… 203

8.

Value is invalid as related to SERVICE-CODE-FLAG= 02 (ICD-9) …………………………………….. 203

9.

Value is invalid as related to SERVICE-CODE-FLAG= 06 (HCPCS) …………………………………. 203

10.

Value is invalid as related to SERVICE-CODE-FLAG= 07 (ICD-10) …………………………………… 203

11.

SERVICE-CODE-FLAG = (10 through 87) AND …………………………………………………………. 998
State-specific Values have not been supplied.

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CLAIMS FILES
Data Element Name: SERVICE-CODE-FLAG
Definition: CLAIMOT - A flag that identifies the coding system used for SERVICE-CODE.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

5.0%

Example
Value
01

Coding Requirements:
Valid Values
01
02
03
04
05
06
07
10 - 87
88
99

Code Definition
CPT-4
ICD-9-CM
CRVS 74 (Obsolete)
CRVS 69 (Obsolete)
CRVS 64 (Obsolete)
HCPCS (Both National and Regional HCPCS)
ICD-10-PCS (Will be implemented on 10/1/2014)
Other Systems
Not Applicable
Unknown

This field is not applicable if:
multiple line items on outpatient claims are not separately adjudicated
claim is a crossover claim and the state does not collect service level detail.
TYPE-OF-SERVICE = {20, 21, 22, 23} and the state does not use service codes to identify premium
payments.
Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 99 .................................................................................................................. 812

2.

THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)
Value = 99 ........................................................................................................................................................ 301

3.

Relational Field in Error ..................................................................................................................................... 999

4.

Value = 88 AND (TYPE-OF-SERVICE <> {11,20, 21, 22, 23} ........................................................................... 305
OR MEDICARE-COINSURANCE-AMOUNT + MEDICARE-DEDUCTIBLE-AMOUNT = 0) AND
(UB-92-REVENUE CODE = 8888 OR 9999)

5.

Value is not in the list of valid codes above ....................................................................................................... 201

6.

Value = 07 AND Coding Scheme has not yet been implemented ..................................................................... 511
(BEGINNING-DATE-OF-SERVICE < implementation date of 10/1/2014).

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CLAIMS FILES
Data Element Name: SERVICE-CODE-MOD
Definition: CLAIMOT - A service code modifier can be used to enhance the Service Code.
(e.g., anesthesia or surgical assistance services billed separately from actual procedure)

Field Description:
COBOL
PICTURE

Error
Tolerance

X(2)

5.0%

Example
Value
“59”

Coding Requirements:
If modifiers other than standard HCPCS or CPT values are used, the State must supply a list of valid codes and their
definitions prior to submission of any data files.
If SERVICE-CODE = “8888888", fill with “88".
If a modifier is not applicable, fill with " ".

Error Condition

Resulting Error Code

1.

Relational Field in Error ..................................................................................................................................... 999

2.

Value <> “88" AND SERVICE-CODE= “8888888"............................................................................................. 306

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CLAIMS FILES
Data Element Name: SPECIALTY-CODE
Definition: CLAIMOT - Code which describes the area of specialty for the individual providing the service. Applies only to
Physicians, Osteopaths, Dentists and other Licensed Practitioners.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(4)

100%

Example
Value
1234

Coding Requirements:
There is currently no standard coding for this field. Therefore, States are instructed to carry the specialty code using the
coding system in place at the State level.
“Blank” fill if no specialty code is available.
Values must be one of the valid codes submitted by the State (States must submit lists of valid State Specific Specialty
Codes to CMS in advance of transmitting MSIS files, and must update those lists whenever changes occur.)

Error Condition

Resulting Error Code

None

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CLAIMS FILES
Data Element Name: TYPE-OF-CLAIM
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A code indicating what kind of payment is covered in this claim.

Field Description:
COBOL
PICTURE

Error
Tolerance

X(1)

2.0%

Example
Value
1

Coding Requirements:
Valid Values

Code Definition

1

Medicaid (including M-CHIP) claim: A Current Fee-For-Service Claim for medical services

2

Medicaid (including M-CHIP) claim: Capitated Payment

3

Medicaid (including M-CHIP) claim: Encounter (a.k.a. “Dummy”) record that simulates a bill for a
service rendered to a patient covered under some form of Capitation Plan. This includes billing records
submitted by providers to non-State entities (e.g., MCOs, health plans) for which the State has no
financial liability since the at-risk entity has already received a capitated payment from the State.

4

Medicaid (including M-CHIP) claim: A "Service Tracking Claim" (a.k.a. “Gross Adjustment”) that
documents services received by an individual patient, when the State accepts a lump sum bill from a
provider that covered similar services delivered to more than one patient, such as group screening for
EPSDT.

5

Medicaid (including M-CHIP) claim: Supplemental Payment (above capitation fee or above negotiated
rate) (e.g., FQHC additional reimbursement)

A

Separate CHIP claim: A Current Fee-For-Service Claim for medical services

B

Separate CHIP claim: Capitated Payment

C

Separate CHIP claim: Encounter (a.k.a. “Dummy”) record that simulates a bill for a service rendered to
a patient covered under some form of Capitation Plan. This includes billing records submitted by
providers to non-State entities (e.g., MCOs, health plans) for which the State has no financial liability
since the at-risk entity has already received a capitated payment from the State.

D

Separate CHIP claim: A "Service Tracking Claim" (a.k.a. “Gross Adjustment”) that documents services
received by an individual patient, when the State accepts a lump sum bill from a provider that covered
similar services delivered to more than one patient, such as group screening for EPSDT.

E

Separate CHIP claim: Supplemental Payment (above capitation fee or above negotiated
rate) (e.g., FQHC additional reimbursement)

9

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Unknown (Counts against error tolerance)

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Data Element Name: TYPE-OF-CLAIM (Cont’d.)
Error Condition

Resulting Error Code

1.

Value = 9 .......................................................................................................................................................... 301

2.

Value is not included in the list of valid codes.................................................................................................... 201

3.

Value = 4 or E AND first byte of MSIS-IDENTIFICATION-NUMBER <> “&" ...................................................... 522

4.

Value<>4 or E AND first byte of MSIS-IDENTIFICATION-NUMBER = “&”..........................................................522

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CLAIMS FILES
Data Element Name: TYPE-OF-SERVICE
Definition: CLAIMIP, CLAIMLT, CLAIMOT, CLAIMRX - A code indicating the type of service being billed.
‘Attachment 3 – Types of Service References’ for information on the various types of service.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(2)

0.1%

Example
Value
05

Coding Requirements:
Valid Values

Code Definition

01
02
04
05
07
08
09
10
11
12
13
15
16
19
20
21
22
23
24
25
26
30
31
33
34
35
36
37
38
39

Inpatient Hospital
Mental Hospital Services for the Aged
Inpatient Psychiatric Facility Services for Individuals Age 21 Years and Under
ICF Services for the Mentally Retarded
NF'S - All Other
Physicians
Dental
Other Practitioners
Outpatient Hospital
Clinic
Home Health
Lab and X-Ray
Prescribed Drugs
Other Services
Capitated Payment s to HMO, HIO or PACE Plan
Capitated Payments to Prepaid Health Plans (PHPs)
Capitated Payments for Primary Care Case Management (PCCM)
Capitated Premium Payments to Private Health Insurance
Sterilizations
Abortions
Transportation Services
Personal Care Services
Targeted Case Management
Rehabilitation Services
PT, OT, Speech, Hearing Language
Hospice Benefits
Nurse Midwife Services
Nurse Practitioner Services
Private Duty Nursing
Religious Non-Medical Health Care Institutions

40+
99

Invalid codes - included in error tolerance
Unknown - included in error tolerance

NOTE:

The following codes are invalid: 03, 06, 14, 17, 18, 27, 28, 29, 32, 40.

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CLAIMS FILES
Data Element Name: TYPE-OF-SERVICE (continued)
Valid Values for Each File Type
CLAIMIP Files may contain TYPE-OF-SERVICE Values: 01, 24, 25, or 39
CLAIMLT Files may contain TYPE-OF-SERVICE Values: 02, 04, 05 or 07
CLAIMOT Files may contain TYPE-OF-SERVICE Values: 08 THROUGH 13, 15, 19 THROUGH 26,
30, 31, 33 THROUGH 38
CLAIMRX Files may contain TYPE-OF-SERVICE Value: 16 or 19

Error Condition

Resulting Error Code

1.

Value is Non-Numeric - Reset to 99 .................................................................................................................. 812

2.

Value = 99 ........................................................................................................................................................ 301

3.

Value < 01 OR Value > 39 OR = {03, 06, 14, 17, 18, 27, 28, 29, 32} ................................................................ 201

4.

Value <> {01, 24, 25 or 39} AND FILE-NAME = "CLAIMIP" .............................................................................. 516

5.

Value <> {02, 04, 05 or 07} AND FILE-NAME = "CLAIMLT" ............................................................................. 516

6.

Value <> {08 through 13 OR 15 OR 19 through 26 OR ..................................................................................... 516
30 OR 31 OR 33 through 38}
AND FILE-NAME = "CLAIMOT"

7.

Value <> {16 OR 19} AND FILE-NAME = “CLAIMRX” ...................................................................................... 516

8.

Relational Field in Error AND FILE-NAME = “CLAIMOT” .................................................................................. 999

9.

Value = {20, 21, 22} AND TYPE-OF-CLAIM <> {2 OR 5} .................................................................................. 518

Note:All claims for inpatient psychiatric care provided in a separately administered psychiatric wing or psychiatric hospital are
included in the CLAIMLT file.

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CLAIMS FILES
Data Element Name: UB-92-REVENUE-CODE
Definition: CLAIMOT - UB-04 revenue code reported on the UB-04 line item that is represented on this claim/encounter
record.

Field Description:
COBOL
PICTURE

Error
Tolerance

9(4)

100%

Example
Value
0305

Coding Requirements:
Only valid codes as defined by the “National Uniform Billing Committee” should be used.
This field is only applicable to those providers using the UB-04 billing form for claim submission, TYPE-OF-SERVICE=11
(and others as relevant within the State).
For those TYPE-OF-SERVICE values where the information is not applicable, 8-fill.
If Value is missing, 9-fill
NOTE:

For States that collect both SERVICE-CODE and UB-92-REVENUE-CODE, both codes should be used. This
field is seen as a supplement to the SERVICE-CODE field and not a replacement.

Error Condition

Resulting Error Code
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

1.

Value = 9999 ..................................................................................................................................................... 301

2.

Value = 0000 ..................................................................................................................................................... 304

3.

Relational Field in Error .................................................................................................................................... 999

4.

Value is Non-Numeric – RESET TO 0000 ....................................................................................................... 810

5.

Value = 8888 AND TYPE-OF-SERVICE = 11 ................................................................................................... 521

6.

Value = SERVICE-CODE .................................................................................................................................. 530

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CLAIMS FILES
Data Element Name: UB-REV-CHARGE-1

through

UB-REV-CHARGE-23

Definition: CLAIMIP - The total charge for the related UB-04 Revenue Code (UB-REV-CODE-1 through UB-REV-CODE-23)
for the billing period. Total charges include both covered and non covered charges (as defined by UB-04 Billing
Manual)

Field Description:
COBOL
PICTURE

Error
Tolerance

S9(8)

5.0%

Example
Value
+00000450

Coding Requirements:
If the amount is missing or invalid, fill with +99999999
Enter charge for each UB-04 Revenue Code listed on the claim (up to 23 occurrences). If more than 23 codes are used,
enter the charges for the first 23 which appear. If less than 23 are present, fill the fields which are not applicable to the
claim with +88888888.
The sum of charges (UB-REV-CHARGE-1 through UB-REV-CHARGE-23) must be less than or equal to AMOUNTCHARGED.
If TYPE-OF-CLAIM = 3 (encounter record) enter the charge amount if available. If not available, fill with +00000000.

Error Condition
1.

Resulting Error Code

Value is Non-Numeric - Reset to 0 .................................................................................................................... 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = +99999999 -Reset to 0 ......................................................................................................................... 301

3.

Relational Field In Error ..................................................................................................................................... 999

4.

Value <> +88888888 AND corresponding UB-REV-CODE Value = 8888 ......................................................... 306

5.

Value = +88888888 AND corresponding UB-REV-CODE Value < > 8888 ........................................................ 305

6.

Value < 0 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .................................................................................... 607

7.

Sum of (UB-REV-CHARGE-1 through UB-REV-CHARGE-23) ......................................................................... 510
>AMOUNT-CHARGED+23

Note:During CMS’s “Valids” File processing, if value is 8-filled, reset to 0.

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CLAIMS FILE
Data Element Name: UB REV-CODE-1 through

UB-REV-CODE-23

Definition: CLAIMIP - “A code which identifies a specific accommodation, ancillary service or billing calculation” (as defined by
UB-04 Billing Manual)

Field Description:
COBOL
PICTURE

Error
Tolerance

9(4)

5.0%

Example
Value
0202

Coding Requirements:
Only valid codes as defined by the “National Uniform Billing Committee” should be used.
Enter all UB-04 Revenue Codes listed on the claim (up to 23 occurrences). If more than 23 codes are used, enter the
first 23 which appear. When less than 23 codes are present, 8-fill fields which are not applicable to the claim (e.g., if
claim contains 10 revenue line items, enter codes in fields 1-10 and 8-fill fields 11-23).
Value must be a valid code.
If Value invalid, record it exactly as it appears in the State system. Do not 9-fill.
If Value is unknown, fill with 9999.
Error Condition
1.

Resulting Error Code

Value is Non-Numeric (reset applicable field to 0) ............................................................................................. 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value = 0000 ..................................................................................................................................................... 304

3.

Value = 9999 ..................................................................................................................................................... 301

4.

Relational Field In Error ..................................................................................................................................... 999

5.

Array range should not contain imbedded 8-filled fields (e.g., once an 8-filled field .......................................... 306
appears, remaining fields should also be 8-filled)

6.

No accommodation revenue code (100-219) exists within array of values, ...................................................... 520
AND MEDICAID-COVERED-INPATIENT-DAYS not {0, +88888}

Note:During CMS’s “Valids” File processing, if value is 8-filled, reset to 0.

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CLAIMS FILE
Data Element Name: UB-REV-UNITS-1 through

UB-REV-UNITS-23

Definition: CLAIMIP - Units associated with UB-04 Revenue Code fields (UB-REV-CODE-1 through UB-REV-CODE-23). “A
quantitative measure of services rendered by revenue category to or for the patient to include items such as
number of accommodation days, miles, pints of blood , or renal dialysis treatments, etc.” (as defined by UB-04
Billing Manual).

Field Description:
COBOL
PICTURE

Error
Tolerance

Example
Value

S9(7)

5.0%

+0000007

Coding Requirements:
Enter units for each UB-04 Revenue Code listed on the claim (up to 23 occurrences). If more than 23 codes are used,
enter the units for the first 23 which appear. When less than 23 are present, 8-fill fields which are not applicable to the
claim (e.g., if claim contains 10 revenue line items, enter codes in fields 1-10 and 8-fill fields 11-23).
If Value is unknown, fill with +9999999.

Error Condition
1.

Resulting Error Code

Value in one or more fields is Non-Numeric (reset applicable field to 0) ........................................................... 810
THE FOLLOWING EDITS WILL NOT COUNT AGAINST THE ERROR TOLERANCE
FOR ADJUSTMENT RECORDS (ADJUSTMENT INDICATOR=1, 2, 3, 4, OR 5)

2.

Value in one or more field = +9999999 (reset field to 0) .................................................................................... 301

3.

Relational Field In Error ..................................................................................................................................... 999

4.

Value = +8888888 AND corresponding UB92-REV-CODE (1-23) <> 8888 ...................................................... 305

5.

Value <> +8888888 AND corresponding UB92-REV-CODE-(1-23) = 8888 ...................................................... 306

6.

Value < 0 AND ADJUSTMENT-INDICATOR = {0, 2, 4} .................................................................................... 607

Note:During CMS’s “Valids File” processing, if value is 8-filled, reset to 0.

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APPENDIX A. ERROR MESSAGE LIST
The following is a list of the actual error messages that will appear on the Validation Report.
ERROR
CODE
000
101
102
201
202
203
301
303
304
305
306
307
401
402
421
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528

February 2014

ERROR
MESSAGE
Field has passed all edits
Value is not in required format
Value is not a valid date
Value is not included in the valid code list
Value is not one of the allowable file names
Value out of range
Value is "9-filled"
Value is "Space-filled"
Value is "0-filled" (invalid default setting)
Value is illegally "8-filled"
Value is not "8-filled" and field is not applicable.
Value is not “0-filled” and field is not applicable
Value is inconsistent with the fiscal quarter specified in the File Label Internal Dataset Name
Value is different from file name contained in the File Label Internal Dataset Name
Value is not the date immediately following END-OF- TIME-PERIOD in the corresponding Header
Record submitted for the previous reporting quarter
Relational edit with DATE-FILE-CREATED failed
Relational edit with DAYS-OF-ELIGIBILITY failed
Relational edit with MAINTENANCE-ASSISTANCE-STATUS failed
Relational edit with DATE-OF-DEATH failed
Relational edit with DATE-OF-BIRTH failed
Relational edit with END-OF-TIME-PERIOD in Header Record failed
Relational edit with STATE-ABBREVIATION failed
Relational edit with NURSING-FACILITY-DAYS failed
Relational edit with TYPE-OF-CLAIM failed
Relational edit with AMOUNT-CHARGED failed
Relational edit with BEGINNING-DATE-OF-SERVICE failed
Relational edit with ADMISSION-DATE failed
Relational edit with DATE-OF-PAYMENT-ADJUDICATION failed
Relational edit with START-OF-TIME-PERIOD in Header Record failed
Relational edit with MEDICARE-DEDUCTIBLE-AMOUNT failed
Relational edit with FILE-NAME failed
Relational edit with ENDING-DATE-OF-SERVICE failed
Relational edit with TYPE-OF-COVERAGE failed
Relational edit with SOCIAL-SECURITY-NUMBER failed
Relational edit with MEDICAID-COVERED-INPATIENT-DAYS failed
Relational edit with TYPE-OF-SERVICE failed
Relational edit with MSIS-IDENTIFICATION-NUMBER failed
Not used
Relational edit with PROVIDER-IDENTIFICATION-NUMBER-BILLING failed
Not used
Not used
Not used
Not used

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APPENDIX A. ERROR MESSAGE LIST (continued)
ERROR
CODE
529
530
531
532
533
534
535
536
537
538
539
540
541
542
550
601
602
603
604
605
606
607
608
701
702
703
704
801
802
803
810
811
812
813
814
996
997
998
999
CQC

February 2014

ERROR
MESSAGE
Relational edit with TYPE-OF-SERVICE AND PROVIDER-IDENTIFICATION-NUMBER-BILLING
Relational edit with SERVICE-CODE failed
Relational edit with COUNTY-CODE failed
Relational edit among eligibility data element monthly array failed
Relational edit with BASIS-OF-ELIGIBILITY failed
Relational edit with TANF-FLAG failed
Relational edit with PRESCRIPTION-FILL-DATE failed
Relational edit with NATIONAL-DRUG-CODE
Relational edit with DUAL-ELIGIBLE-FLAG failed
Relational edit with corresponding monthly PLAN-TYPE or WAIVER-TYPE field failed
Relational edit with SEX-CODE failed
Relational edit with DIAGNOSIS-RELATED-GROUP-INDICATOR failed
Relational edit with DIAGNOSIS-PRINCIPAL failed
Relational edit with PRECEDING DIAGNOSIS failed
Relational edit with RACE-ETHNICITY-CODE and ETHNICITY-CODE or RACE-CODE failed
Relational edit with FEDERAL-FISCAL-YEAR and FEDERAL-FISCAL-QUARTER failed
Relational edit with MSIS-IDENTIFICATION-NUMBER and SSN-INDICATOR failed
Relational edit with BEGINNING-DATE-OF-SERVICE and ENDING-DATE-OF-SERVICE failed
Relational edit with ACCOMMODATION-CHARGES and AMOUNT-CHARGED failed
Relational edit with END-OF-TIME-PERIOD and TYPE-OF-SERVICE failed
Relational edit with MEDICARE-DEDUCTIBLE-AMOUNT and AMOUNT-CHARGED failed
Relational edit with ADJUSTMENT-INDICATOR failed
Relational edit with ICF/MR Days failed
Relational edit with FEDERAL-FISCAL-YEAR, FEDERAL-FISCAL-QUARTER, and TYPE-OF-RECORD
failed
Relational edit with DATE-OF-BIRTH, MAINTENANCE-ASSISTANCE-STATUS, and DAYS-OFELIGIBILITY failed
Relational edit with MSIS-IDENTIFICATION-NUMBER, TEMPORARY-IDENTIFICATION-NUMBER, and
SSN-INDICATOR failed
Relational edit with AMOUNT-CHARGED, MEDICARE-COINSURANCE-PAYMENT, and MEDICAREDEDUCTIBLE-PAYMENT failed
Duplicate Eligible Record (Exact match on: ID, FFY, QTR, SEX, DOB)
Non-Unique Duplicate Eligible Record (Exact match on: ID, FFY, QTR, SEX and/or DOB do not match)
Duplicate Claim Record - 100% match on all fields
Non-Numeric Value Provided - Reset to 0
Non-Numeric Value Provided - Reset to 8-filled
Non-Numeric Value Provided - Reset to 9-filled
Non-Numeric Value Provided - Reset to 41(obsolete)
Non-Numeric Value Provided in Header Record
INFORMATIONAL - Value = 1 and DATE-OF-BIRTH implies Recipient was not over 64 on the first day of
the month
INFORMATIONAL - Value not consistent with eligible’s age
INFORMATIONAL - State specific values not available
INFORMATIONAL - Relational edit not performed because the related field was already flagged in error
CURRENT QUARTER CHECK - File appears to be for the wrong quarter. More than 50% of the Current
Quarter records contained within the first 500 records of the file are outside of the reporting quarter.
Comparison is done between the beginning and ending quarter dates of the file header record versus the
Date-of-Payment-Adjudication on each data record.

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MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary Attachments

MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary Attachments

ATTACHMENT 1 - MSIS Validation Report Format

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VALIDATION REPORT
A validation report is generated at the conclusion of the data validation process. This report provides a file specific
analysis of the State's data.
Report Page 1
Report Identification

-

Descriptive information about the report, including: state, date, file type, reporting
period, and number of validation attempts.

Validation Status

-

The outcome of the data validation process. This indicates whether or not the
validation process reached completion or encountered a fatal error. The remainder
of the report is meaningful only if the complete file could be successfully validated.

Error Tolerance Analysis

-

A statistical summary of the file's records in error.

Variable Error Analysis

-

This section displays every data element contained in the file type. For each field,
the report shows: error tolerance (allowable), number of records in error, and error
percentage achieved.

Error Frequency Analysis

-

Counts of records grouped by the frequency of errors generated by individual
records.

Verdict (File Status)

-

The final ACCEPTED/REJECTED status of the file.

Report Identification

-

Descriptive information about the report, including: state, date, file type, reporting
period, and number of validation attempts.

Edit Specifications

-

Specific error codes with explanations for each field found in error. A count of
records failing each edit is included.

Filler

-

filler

Report Page 2

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MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary Attachments

ATTACHMENT 2 - Comprehensive Eligibility Crosswalk

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MAS/BOE - INDIVIDUALS COVERED UNDER SEPARATE CHILDREN’S HEALTH INSURANCE PROGRAMS
(separate CHIP)
MSIS Coding (MAS-0, BOE-0)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Children covered under a Title XXI separate CHIP
42 CFR 457.310, §2110 (b) of the
Act.
2
Legal immigrant children and pregnant women covered
§2107(e)(1) of the Act, P.L. 111under a Title XXI separate CHIP.
3.
3
Children receiving dental-only coverage under a Title
§2102 and 2110 (b) of the Act,
XXI separate CHIP
PL 111-3.
4

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

§2112 of the Act, PL 111-3.

Infants under age 1 born to targeted low-income
pregnant women made eligible under a Title XXI
separate CHIP.

§2112 of the Act, PL 111-3.

6

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

42 CFR 457.355, §2105 of the
Act.

7

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

§2112 of the Act, PL 111-3.

8

Caretaker relatives and children covered under the
authority of an 1115 waiver and a Title XXI separate
CHIP.

§2107(e) of the Act.

5

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF
THE ACT-AGED
MSIS Coding (MAS-1, BOE-1)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Aged individuals receiving SSI, eligible spouses or
42 CFR 435.120,
persons receiving SSI pending a final determination of
§1619(b) of the Act,
disposal of resources exceeding SSI dollar limits; and
§1902(a)(10)(A)(I)(II) of the Act,
persons considered to be receiving SSI under
PL 99-643, §2.
§1619(b) of the Act.
2
Aged individuals who meet more restrictive
42 CFR 435.121,
requirements than SSI and who are either receiving or
§1619(b)(3) of the Act,
not receiving SSI; or who qualify under §1619 of the
§1902(f) of the Act,
Act.
PL 99-643, §7.
3
Aged individuals receiving mandatory State
42 CFR 435.130.
supplements.
4
Aged individuals who receive a State supplementary
42 CFR 435.230,
payment (but not SSI) based on need.
§1902(a)(10)(A)(ii) of the Act.

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MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT
- BLIND/DISABLED
MSIS Coding (MAS-1, BOE-2)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Blind and/or disabled individuals receiving SSI, eligible
42 CFR 435.120,
spouses or persons receiving SSI pending a final
§1619(b) of the Act,
determination of blindness, disability, and/or disposal of
§1902(a)(10)(A)(I)(II) of the Act,
resources exceeding SSI dollar limits; and persons
PL 99-643, §2.
considered to be receiving SSI under §1619(b) of the
Act.
2
Blind and/or disabled individuals who meet more
42 CFR 435.121,
restrictive requirements than SSI and who are either
§1619(b)(3) of the Act,
receiving or not receiving SSI; or who qualify under
§1902(f) of the Act,
§1619.
PL 99-643, §7.
3
Blind and/or disabled individuals receiving mandatory
42 CFR 435.130.
State supplements.
4
Blind and/or disabled individuals who receive a State
42 CFR 435.230,
supplementary payment (but not SSI) based upon need.
§1902(a)(10)(A)(ii)of the Act.
MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT
- CHILDREN
MSIS Coding (MAS-1, BOE-4)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Low Income Families with Children qualified under §1931
42 CFR 435.110,
of the Act.
§1902(a)(10)(A)(I)(I) of the Act,
§1931 of the Act.
2
Children age 18 who are regularly attending a secondary
42 CFR 435.110,
school or the equivalent of vocational or technical
§1902(a)(10)(A)(I)(I).
training.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 OF THE ACT
- ADULTS
MSIS Coding (MAS-1, BOE-5)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Adults deemed essential for well-being of a recipient [see
42 CFR 435.110,
45 CFR 233.20(a)(2)(vi)] qualified for Medicaid under
§1902(a)(10)(A)(I)(I)of the Act,
§1931 of the Act.
§1931 of the Act.
2
42 CFR 435.110,
• Pregnant women who have no other eligible
§1902(a)(10)(A)(I)(I)of the Act.
children.
• Other adults in "adult only" units.

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MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 -U
CHILDREN
MSIS Coding (MAS-1, BOE-6) - (OPTIONAL)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Unemployed Parent Program - Cash assistance
42 CFR 435.110,
benefits to low income individuals in two parent families
§1902(a)(10)(A)(I)(I) of the Act,
where the principle wage earner is employed fewer than
§1931 of the Act.
100 hours a month.
2
Children age 18 who are regularly attending a
42 CFR 435.110,
secondary school or the equivalent of vocational or
§1902(a)(10)(A)(I)(I) of the Act.
technical training.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE UNDER SECTION 1931 - U ADULTS
MSIS Coding (MAS-1, BOE-7) - (OPTIONAL)
ITEM
DESCRIPTION
CFR/PL CITATIONS
1
Adults deemed essential for well-being of a recipient
42 CFR 435.110,
(see 45 CFR 233.20(a)(2)(vi)) qualified under §1931 of
§1902(a)(10)(A)(I)(I) of the Act,
the Act (Low Income Families with Children).
§1931 of the Act.
2
42 CFR 435.110,
• Pregnant women who have no other eligible
§1902(a)(10)(A)(I)(I) of the Act.
children.
• Other Adults in "adult only" units.

ITEM
1

2

MAS/BOE - MEDICALLY NEEDY - AGED
MSIS Coding (MAS-2, BOE-1)
DESCRIPTION
CFR/PL CITATIONS
Aged individuals who would be ineligible if not enrolled in
42 CFR 435.326.
an HMO. Categorically needy individuals are covered
under
42 CFR 435.212, and the same rules apply to medically
needy individuals.
Aged
42 CFR 435.320,
42 CFR 435.330.

ITEM
1

MAS/BOE - MEDICALLY NEEDY - BLIND/DISABLED
MSIS Coding (MAS-2, BOE-2)
DESCRIPTION
CFR/PL CITATIONS
Blind and/or disabled individuals who would be ineligible
42 CFR 435.326.
if not enrolled in an HMO. Categorically needy
individuals are covered under 42 CFR 435.212 and the
same rules apply to medically needy individuals.

2

Blind/Disabled

3

Blind and/or disabled individuals who meet all Medicaid
requirements except current blindness and/or disability
criteria, and have been continuously eligible since 12/73
under the State's requirements.

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42 CFR 435.322,
42 CFR 435.324,
42 CFR 435.330.
42 CFR 435.340.

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1
2

3
4

ITEM
1
2
3

ITEM
1

2

3

4

MAS/BOE - MEDICALLY NEEDY - CHILDREN
MSIS Coding (MAS-2, BOE-4)
DESCRIPTION
CFR/PL CITATIONS
Individuals under age 18 who, but for income and
§1902(a)(10)(C)(ii)(I) of the Act,
resources, would be eligible.
PL 97-248, §137.
Infants under the age of 1 and who were born after
§1902(e)(4) of the Act,
9/30/84 to and living in the household of medically needy
PL 98-369, §2362.
women.
Other financially eligible individuals under age 18-21, as
42 CFR 435.308.
specified by the State.
Children who would be ineligible if not enrolled in an
42 CFR 435.326.
HMO. Categorically needy individuals are covered under
42 CFR 435.212 and the same rules apply to medically
needy individuals.
MAS/BOE - MEDICALLY NEEDY - ADULTS
MSIS Coding (MAS-2, BOE-5)
DESCRIPTION
CFR/PL CITATIONS
Pregnant women.
42 CFR 435.301.
Caretaker relatives who, but for income and resources,
42 CFR 435.310.
would be eligible.
Adults who would be ineligible if not enrolled in an HMO.
42 CFR 435.326.
Categorically needy individuals are covered under 42
CFR 435.212 and the same rules apply to medically
needy individuals.
MAS/BOE - POVERTY RELATED ELIGIBLES - AGED
MSIS Coding (MAS-3, BOE-1)
DESCRIPTION
CFR/PL CITATIONS
Qualified Medicare Beneficiaries (QMBs) who are
§§1902(a)(10)(E)(I) and
entitled to Medicare Part A, whose income does not
1905(p)(1) of the Act,
PL 100-203, §4118(p)(8),
exceed 100% of the Federal poverty level, and whose
PL 100-360, §301(a) & (e),
resources do not exceed twice the SSI standard.
PL 100-485, §608(d)(14),
PL 100-647, §8434.
Specified Low-Income Medicare Beneficiaries (SLMBs)
§4501(b) of OBRA 90, as
who meet all of the eligibility requirements for QMB
amended in §1902(a)(10)(E) of
status, except for the income in excess of the QMB
the Act.
income limit, but not exceeding 120% of the Federal
poverty level.
Qualifying individuals having higher income than allowed
§1902(a)(10)(E)(iv) of the Act.
for QMBs or SLMBs.

Aged individual not described in S 1902(a)(10)(A)(1) of
the Act, with income below the poverty level and
resources within state limits, who are entitled to full
Medicaid benefits.

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§1902(a)(10)(A)(ii)(X),
1902(m)(1) of the Act,
PL 99-509, §§9402 (a) and (b).

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ITEM
1

2

3
4
5

ITEM
1

2

3

4

5

MAS/BOE - POVERTY RELATED ELIGIBLES - BLIND/DISABLED
MSIS Coding (MAS-3, BOE-2)
DESCRIPTION
CFR/PL CITATIONS
Qualified Medicare Beneficiaries (QMBs) who are
§§1902(a)(10)(E)(I) and
entitled to Medicare Part A, whose income does not
1905(p)(1) of the Act,
PL 100-203, §4118(p)(8),
exceed 100% of the Federal poverty level, and whose
PL 100-360, §301(a) & (e),
resources do not exceed twice the SSI standard.
PL 100-485, §608(d)(14),
PL 100-647, §8434.
Specified Low-Income Medicare Beneficiaries (SLMBs)
§4501(b) of OBRA 90 as
who meet all of the eligibility requirements for QMB
amended in §1902(a)(10)(E)(I)
status, except for the income in excess of the QMB
of the Act.
income limit, but not exceeding 120% of the Federal
poverty level.
Qualifying individuals having higher income than allowed
§1902(a)(10)(E)(iv) of the Act.
for QMBs or SLMBs.
Qualified Disabled Working Individuals (QDWIs) who are
§§1902(a)(10)(E)(ii) and 1905(s)
entitled to Medicare Part A.
of the Act.
Disabled individuals not described in §1902(a)(10)(A)(1)
§§1902(a)(10)(A)(ii)(X),
of the Act, with income below the poverty level and
1902(m)(1) and (3) of the Act,
P.L. 99-509, §§9402 (a) and (b).
resources within state limits, which are entitled to full
Medicaid benefits.

MAS/BOE - POVERTY RELATED ELIGIBLES - CHILDREN
MSIS Coding (MAS-3, BOE-4)
DESCRIPTION
CFR/PL CITATIONS
Infants and children up to age 6 with income at or below
§§1902(a)(10)(A)(I)(IV) & (VI),
133% of the Federal Poverty Level (FPL).
1902(l)(1)(A), (B), & (C) of the
Act,
PL 100-360, §302(a)(1), PL 100485, §608(d)(15).
Children under age 19 (born after 9/30/83) whose
§1902(a)(10)(A)(I) (VII) of the
income is at or below 100% of the Federal poverty level
Act.
within the State's resource requirements.
Infants under age 1 whose family income is below 185%
§§1902(a)(10)(A)(ii) (IX) and
of the poverty level and who are within any optional
1902(l)(1)(D) of the Act,
State resource requirements.
PL 99-509, §§9401(a) & (b),
PL 100-203, §4101.
Children made eligible under the more liberal income
§1902(r)(2) of the Act.
and resource requirements as authorized under
§1902(r)(2) of the Act when used to disregard income
on a poverty-level-related basis.
Children made eligible by a Title XXI Medicaid
P.L. 105-100.
expansion under the Child Health Insurance Program
(CHIP)

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ITEM
1

2

3

4

ITEM
1

ITEM
1

2

3

4

5
6
7

MAS/BOE - POVERTY RELATED ELIGIBLES - ADULTS
MSIS Coding (MAS-3, BOE-5)
DESCRIPTION
CFR/PL CITATIONS
Pregnant women with incomes at or below 133% of the
§1902(a)(10)(A)(I),
Federal Poverty Level.
(IV) and (VI); §1902(l)(1)(A), (B),
& (C) of the Act,
PL 100-360, §302(a)(1),
PL 100-485, §608(d)(15).
Women who are eligible until 60 days after their
§§1902(a)(10)(A)(ii)(IX) and
pregnancy, and whose incomes are below 185% of the
1902(l)(1)(D) of the Act,
PL 99-509, §§9401(a) & (b),
FPL and have resources within any optional State
resource requirements.
PL 100-203, §4101.
Caretaker relatives and pregnant women made eligible
§1902(r)(2) of the Act.
under more liberal income and resource requirements of
§1902(r)(2) of the Act when used to disregard income
on a poverty-level related basis.
Adults made eligible by a Title XXI Medicaid expansion
Title XXI of the Social Security
under the Child Health Insurance Program (CHIP).
Act.
MAS/BOE - POVERTY RELATED ELIGIBLES - ADULTS
MSIS Coding (MAS-3, BOE-A)
DESCRIPTION
CFR/PL CITATIONS
Women under age 65 who are found to have breast or
§1902(a)(10)(a)(ii)(XVIII), P.L.
cervical cancer, or have precancerous conditions.
106-354.

MAS/BOE - OTHER ELIGIBLES - AGED
MSIS Coding (MAS-4, BOE-1)
DESCRIPTION
CFR/PL CITATIONS
Aged individuals who meet more restrictive
42 CFR 435.121,
requirements than SSI and who are either receiving or
§1619(b)(3) of the Act,
not receiving SSI; or who qualify under §1619 of the
§1902(f) of the Act,
Act.
PL 99-643, §7.
Aged individuals who are ineligible for optional State
42 CFR 435.122.
supplements or SSI due to requirements that do not
apply under title XIX.
Aged essential spouses considered continuously
42 CFR 435.131.
eligible since 12/73; and some spouses who share
hospital or nursing facility rooms for 6 months or more.
Institutionalized aged individuals who have been
42 CFR 435.132.
continuously eligible since 12/73 as inpatients or
residents of Title XIX facilities.
Aged individuals who would be SSI/SSP eligible except
42 CFR 435.134.
for the 8/72 increase in OASDI benefits.
Aged individuals who would be eligible for SSI but for
42 CFR 435.135.
title II cost-of-living adjustment(s).
Aged aliens who are not lawful, permanent residents or
PL 99-509, §9406.
who do not have PRUCOL status, but who are
otherwise qualified, and who require emergency care.

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ITEM
8

DESCRIPTION
Aged individuals who would be eligible for AFDC, SSI,
or an optional State supplement if not in a medical
institution.

CFR/PL CITATIONS
42.CFR 435.211,
§1902(a)(10)(A)(ii) and §1905(a)
of the Act.

9

Aged individuals who meet income and resource
requirements for AFDC, SSI, or an optional State
supplement.
Aged individuals who have become ineligible and who
are enrolled in a qualified HMO or "§1903(m)(2)(G)
entity" that has a risk contract.

42 CFR 435.210,
§1902(a)(10)(A)(ii) and §1905 of
the Act.
42 CFR 435.212
§1902(e)(2),
PL 99-272, §9517,
PL 100-203, §4113(d).
42 CFR 435.217,
§1902(a)(10)(A)(ii),
(VI); 50 PL 100-13.

10

11

12

13

ITEM
1

2

3

4

5

6
7

8

Aged individuals who, solely because of coverage under
a home and community based waiver, are not in a
medical institution, but who would be eligible if they
were.
Aged individuals who elect to receive hospice care who
would be eligible if in a medical institution.
Aged individuals in institutions who are eligible under a
special income level specified in Supplement 1 to
Attachment 2.6-A of the State's title XIX Plan.

§1902(a)(10)(A)(ii),
(VII) of the Act,
PL 99-272, §9505.
42 CFR 435.236,
§1902(a)(10)(A)(ii) of the Act.

MAS/BOE - OTHER ELIGIBLES - BLIND/DISABLED
MSIS Coding (MAS-4, BOE-2)
DESCRIPTION
CFR/PL CITATIONS
Blind and/or disabled individuals who meet more
42 CFR 435.121,
restrictive requirements than SSI, including both those
§1619(b)(3) of the Act,
receiving and not receiving SSI payments
§1902(f) of the Act,
PL 99-643, §7.
Blind and/or disabled individuals who are ineligible for
42 CFR 435.122.
optional State supplements or SSI due to requirements
that do not apply under title XIX.
Blind and/or disabled essential spouses considered
42 CFR 435.131.
continuously eligible since 12/73; and some spouses
who share hospital or nursing facility rooms for 6
months or more.
Institutionalized blind and/or disabled individuals who
42 CFR 435.132.
have been continuously eligible since 12/73 as
inpatients or residents of Title XIX facilities.
Blind and/or disabled individuals who would be
42 CFR 435.134.
SSI/SSP, eligible except for the 8/72 increase in OASDI
benefits.
Blind and/or disabled individuals who would be eligible
42 CFR 435.135,
for SSI but for title II cost-of-living adjustment(s).
§503 PL 94-566.
Blind and/or disabled aliens who are not lawful,
PL 99-509, §9406.
permanent residents or who do not have PRUCOL
status, but who are otherwise qualified, and who require
emergency care.
Blind and/or disabled individuals who meet all Medicaid
42 CFR 435.133.
requirements except current blindness, or disability

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ITEM

9

10

11

12

13
14

15

16

17

18

19

20

21

ITEM
1

DESCRIPTION
criteria, who have been continuously eligible since
12/73 under the State's 12/73 requirements.
Blind and/or disabled individuals, age 18 or older, who
became blind or disabled before age 22 and who lost
SSI or State supplementary payments eligibility
because of an increase in their OASDI (childhood
disability) benefits.
Blind and/or disabled individuals who would be eligible
for AFDC, SSI, or an optional State supplement if not in
a medical institution.
Qualified severely impaired blind or disabled individuals
under age 65, who, except for earnings, are eligible for
SSI.

Blind and/or disabled individuals who meet income and
resource requirements for AFDC, SSI, or an optional
State supplement.
Working disabled individuals who buy-in to Medicaid
Blind and/or disabled individuals who have become
ineligible who are enrolled in a qualified HMO or
"§1903(m)(2)(G) entity" that has a risk contract.
Blind and/or disabled individuals who, solely because of
coverage under a home and community based waiver,
are not in a medical institution and who would be
eligible if they were.
Blind and/or disabled individuals who elect to receive
hospice care, and who would be eligible if in a medical
institution.
Blind and/or disabled individuals in institutions who are
eligible under a special income level specified in
Supplement 1 to Attachment 2.6-A of the State's title
XIX Plan.
Blind and/or disabled widows and widowers who have
lost SSI/SSP benefits but are considered eligible for
Medicaid until they become entitled to Medicare Part A.
Certain Disabled children, 18 or under, who live at
home, but who, if in a medical institution, would be
eligible for SSI or a State supplemental payment.
Continuation of Medicaid eligibility for disabled children
who lose SSI benefits because of changes in the
definition of disability.
Disabled individuals with medically improved disabilities
made eligible under the Ticket to Work and Work
Incentives Improvement Act (TWWIIA) of 1999.

CFR/PL CITATIONS

§1634(c) of the Act; PL 99-643,
§6.

42 CFR 435.211,
§§1902(a)(10)(A)(ii) and 1905(a)
of the Act.
§§1902(a)(10)(A)(I)(II) and
1905(q) of the Act,
PL 99-509, §9404 and
§1619(b)(8) of the Act,
PL 99-643, §7
42 CFR 435.210,
§§1902(a)(10)(A)(ii) and 1905 of
the Act.
§1902(a)(10)(A)(ii)(XIII).
42 CFR 435.212
§1902(e)(2) of the Act; PL 99272, §9517; PL 100-203,
§4113(d).
42 CFR 435.217,
§1902(a)(10)(A)(ii)(VI) of the Act,
50 PL 100-13.
§1902(a)(10)(A)(ii)(VII),
PL 99-272, §9505
42 CFR 435.231.
§1902(a)(10)(A)(ii) of the Act.

§1634 of the Act,
PL 101-508, §5103.
42 CFR 435.225;
§1902(e)(3) of the Act.
§1902(a)(10)(A)(ii) of the Act;
P.L. 15-32, §491.
§1902(a)(10)(A)(ii)(XV) of the
Act.

MAS/BOE - OTHER ELIGIBLES - CHILDREN
MSIS Coding (MAS-4, BOE-4)
DESCRIPTION
CFR/PL CITATIONS
Children of families receiving up to 12 months of
§1925 of the Act,
extended Medicaid benefits (for those eligible after
PL 100-485, §303.

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ITEM
2

DESCRIPTION
4/1/90).
"Qualified children" under age 19 born after 9/30/83 or at
an earlier date at State option, who meet the State's
AFDC income and resource requirements.

3

Children of individuals who are ineligible for AFDCrelated Medicaid because of requirements that do not
apply under title XIX.

4

Children of individuals who would be eligible for Medicaid
under §1931 of the Act (Low income families with
children) except for the 7/1/72 (PL 92-325) OASDI
increase and were entitled to OASDI and received cash
assistance in 8/72.
Children whose mothers were eligible for Medicaid at the
time of childbirth, and are deemed eligible for one year
from birth as long as the mother remained eligible, or
would have if pregnant, and the child remains in the
same household as the mother.
Children of aliens who are not lawful, permanent
residents or who do not have PRUCOL status, but who
are otherwise qualified, and who require emergency
care.
Children who meet income and resource requirements
for AFDC, SSI, or an optional State supplement

5

6

7

8

Children who would be eligible for AFDC, SSI, or an
optional State supplement if not in a medical institution.

9

Children who have become ineligible who are enrolled in
a qualified HMO or "§1903(m)(2)(G) entity" that has a risk
contract.

10

Children of individuals who elect to receive hospice care,
and who would be eligible if in a medical institution.
Children who would be eligible for AFDC if work-related
child care costs were paid from earnings rather than
received as a State service.
Children of individuals who would be eligible for AFDC if
the State used the broadest allowable AFDC criteria.

11

12

13

14

Children who solely because of coverage under a home
and community based waiver, are not in a medical
institution, but who would be eligible if they were.
Children not described in §1902(a)(10)(A)(I) of the Act,
"Ribikoff Kids", who meet AFDC income and resource
requirements, and are under a State-established age
(18-21).

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CFR/PL CITATIONS
§§1902(a)(10)(A)(I)(III) and
1905(n) of the Act,
PL 98-369, §2361,
PL 99-272, §9511,
PL 100-203, §4101.
42 CFR 435.113.

42 CFR 435.114.

42 CFR 435.117,
§1902(e)(4) of the Act,
PL 98-369, §2362.

PL 99-509, §9406.

42 CFR 435.210,
§1902(a)(10)(A)(ii) and §1905 of
the Act.
42 CFR 435.211,
§1902(a)(10)(A)(ii) and §1905(a)
of the Act.
42 CFR 435.212,
§1902(e)(2) of the Act,
PL 99-272, §9517,
PL 100-203, §4113(d).
§1902(a)(10)(A)(ii)(VII),
PL 99-272, §9505.
42 CFR 435.220.

42 CFR 435.223,
§§1902(a)(10)(A)(ii) and 1905(a)
of the Act.
42 CFR 435.217,
§1902(a)(10)(A)(ii)(VI) of the
Act.
§§1902(a)(10)(A)(ii) and
1905(a)(I) of the Act,
PL 97-248, §137.

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ITEM
1
2

3

4

5

6

7

8

9

10

11
12

13

14

MAS/BOE - OTHER ELIGIBLES - ADULTS
MSIS Coding (MAS-4, BOE-5)
DESCRIPTION
CFR/PL CITATIONS
Families receiving up to 12 months of extended
§1925 of the Act,
Medicaid benefits (if eligible on or after 4/1/90).
PL 100-485, §303.
Qualified pregnant women whose pregnancies have
§§1902(a)(10)(A)(I)(III) and
been medically verified and who meet the State's AFDC
1905(n) of the Act,
PL 98-369, §2361,
income and resource requirements.
PL 99-272, §9511,
PL 100-203 §4101.
Adults who are ineligible for AFDC-related Medicaid
42 CFR 435.113.
because of requirements that do not apply under title
XIX.
Adults who would be eligible for Medicaid under §1931
42 CFR 435.114.
of the Act (Low income families with children) except for
the 7/1/72 (PL 92-325) OASDI increase; and were
entitled to OASDI and received cash assistance in 8/72.
Women who were eligible while pregnant, and are
§1902(e)(5) of the Act,
eligible for family planning and pregnancy related
PL 98-369,
services until the end of the month in which the 60th day
PL 100-203, §4101,
occurs after the pregnancy
PL 100-360, §302(e).
Adult aliens who are not lawful, permanent residents or
PL 99-509, §9406.
who do not have PRUCOL status, but who are
otherwise qualified, and who require emergency care.
Adults who meet the income and resource requirements
42 CFR 435.210,
for AFDC, SSI, or an optional State Supplement.
§§1902(a)(10)(A)(ii) and 1905 of
the Act.
Adults who would be eligible for AFDC, SSI, or an
42 CFR 435.211,
optional State Supplement if not in a medical institution.
§§1902(a)(10)(A)(ii) and 1905(a)
of the Act.
Adults who have become ineligible who are enrolled in a
42 CFR 435.212,
qualified HMO or "§1903(m)(2)(G) entity" that has a risk
§1902(e)(2)(A) of the Act,
contract.
PL 99-272, §9517,
PL 100-203, §4113(d).
Adults who solely because of coverage under a home
42 CFR 435.217,
and community based waiver, are not in a medical
§1902(a)(10)(A)(ii)(VI) of the Act.
institution, but who would be eligible if they were.
Adults who elect to receive hospice care, and who
§1902(a)(10)(A)(ii),
would be eligible if in a medical institution.
(VII); PL 99-272, §9505.
Adults who would be eligible for AFDC if work-related
42 CFR 435.220.
child care costs were paid from earnings rather than
received as a State service.
Pregnant women who have been granted presumptive
§§1902(a)(47) and 1920 of the
eligibility.
Act,
PL 99-509, §9407.
Adults who would be eligible for AFDC if the State used
42 CFR 435.223,
the broadest allowable AFDC criteria.
§§1902(a)(10)(A)(ii) and 1905(a)
of the Act.

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

ITEM
1
2

3

MAS/BOE - OTHER ELIGIBLES - FOSTER CARE CHILDREN
MSIS Coding (MAS-4, BOE-8)
DESCRIPTION
CFR/PL CITATIONS
Children for whom the State makes adoption assistance
42 CFR 435.145,
or foster care maintenance payments under Title IV-E.
§1902(a)(10)(A)(i)(I) of the Act.
Children with special needs covered by State foster
§1902(a)(10)(A)(ii) (VIII) of the
care payments or under a State adoption assistance
Act,
agreement which does not involve Title IV-E.
PL 99-272, §9529.
Children leave foster care due to age.
Foster Care Independence Act of
1999.

ITEM
1

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-1)
DESCRIPTION
CFR/PL CITATION
Aged individuals made eligible under the authority of a
§1115(a)(1), (a)(2) & (b)(1) of the
§1115 waiver due to poverty-level related eligibility
Act,
§1902(a)(10), and
expansions.
§1903(m) of the Act.

ITEM
1

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-2)
DESCRIPTION
CFR/PL CITATION
Blind and/or disabled individuals made eligible under the
§1115(a)(1), (a)(2) & (b)(1) of the
authority of a §1115 waiver due to poverty-level-related
Act,
§1902(a)(10), and
eligibility
§1903(m) of the Act.

ITEM
1

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-4)
DESCRIPTION
CFR/PL CITATION
Children made eligible under the authority of a §1115
§1115(a)(1), (a)(2) & (b)(1) of the
waiver due to poverty-level-related eligibility expansions.
Act,
§1902(a)(10), and §1903(m) of
the Act.

ITEM
1

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-5)
DESCRIPTION
CFR/PL CITATION
Caretaker relatives, pregnant women and/or adults
§1115(a)(1) and (a)(2) of the Act,
without dependent children made eligible under the
§1902(a)(10), §1903(m).
authority of at §1115 waiver due to poverty-level-related
eligibility expansions.

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary Attachments

ATTACHMENT 3 - Types of Service Reference

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

DEFINITIONS OF TYPES OF SERVICE

The following definitions are adaptations of those given in the Code of Federal Regulations. These definitions,
although abbreviated, are intended to facilitate the classification of medical care and services for reporting purposes.
They do not modify any requirements of the Act or supersede in any way the definitions included in the Code of
Federal Regulations (CFR).
Effective FY 1999, services provided under Family Planning, EPSDT, Rural Health Clinics, FQHC’s, and Home-andCommunity-Based Waiver programs will be coded according to the types of services listed below. Specific programs
with which these services are associated will be identified using the program type coding as defined in ‘Attachment 4
– Program Type References.’
1.

Unduplicated Total.--Report the unduplicated total of recipients by maintenance assistance status (MAS) and by
basis of eligibility (BOE). A recipient receiving more than one type of service is reported only once in the
unduplicated total.

2.

Inpatient Hospital Services (MSIS Code=01)(See 42 CFR 440.10).--These are services that are:
o

Ordinarily furnished in a hospital for the care and treatment of inpatients;

o

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

o

Furnished in an institution that:
-

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

-

Is licensed or formally approved as a hospital by an officially designated authority for State standard
setting;

-

Meets the requirements for participation in Medicare (except in the case of medical supervision of
nurse-midwife services per 42 CFR 440.165); and

-

Has in effect a utilization review plan applicable to all Medicaid patients that meets the requirements in
42 CFR 482.30 unless a waiver has been granted by the Secretary of Health and Human Services.

Inpatient hospital services do not include nursing facility services furnished by a hospital with swing-bed
approval. However, include services provided in a psychiatric wing of a general hospital if the psychiatric wing is
not administratively separated from the general hospital.

3.

Mental Health Facility Services (See 42 CFR 440.140, 440.160, and 435.1009).--An institution for mental
diseases is a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis,
treatment or care of individuals with mental diseases, including medical care, nursing care, and related services.
Report totals for services defined under 3a and 3b.

3a. Inpatient Psychiatric Facility Services for Individuals Age 21 and Under (MSIS Code=04)(See 42 CFR 440.160
and 441.150(ff)). --These are services that:
o

Are provided under the direction of a physician;

o

Are provided in a psychiatric facility or inpatient program accredited by the Joint Commission on the
Accreditation of Hospitals; and,

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

o

Meet the requirements set forth in 42 CFR Part 441, Subpart D (inpatient psychiatric services for individuals
age 21 and under in psychiatric facilities or programs).

3b. Other Mental Health Facility Services (Individuals Age 65 or Older) (MSIS Code=02)(See 42 CFR 440.140(a)
and Part 441, Subpart C).--These are services provided under the direction of a physician for the care and
treatment of recipients in an institution for mental diseases that meets the requirements specified in 42 CFR
440.140(a).

4.

Nursing Facilities (NF) Services(MSIS Code=07)(See 42 CFR 440.40 and 440.155).--These are services
provided in an institution (or a distinct part of an institution) which:
o

Is primarily engaged in providing to residents:
-

Skilled nursing care and related services for residents who require medical or nursing care;

-

Rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or

-

On a regular basis, health-related care and services to individuals who, because of their mental or
physical condition, require care and services (above the level of room and board) which can be made
available to them only through institutional facilities, and is not primarily for the care and treatment of
mental diseases; and;

o Meet the requirements for a nursing facility described in subsections 1919(b), (c), and (d) of the Act
regarding:
-

Requirements relating to provision of services;

-

Requirements relating to residents’ rights; and

-

Requirements relating to administration and other matters.

NOTE: ICF Services - All Other.--This is combined with nursing facility services.

5.

ICF Services for the Mentally Retarded(MSIS Code=05) (See 42 CFR 440.150 and Part 483 of Subpart I).-These are services provided in an institution for mentally retarded persons or persons with related conditions if
the:
o

Primary purpose of the institution is to provide health or rehabilitative services to such individuals;

o

Institution meets the requirements in 42 CFR 442, Subpart C (certification of ICF/MR); and

o

The mentally retarded recipients for whom payment is requested are receiving active treatment as defined in
42 CFR 483.440(a).

6. Physicians' Services (MSIS Code=08)(See 42 CFR 440.50).--Whether furnished in a physician's office, a
recipient's
home, a hospital, a NF, or elsewhere, these are services provided:
o

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

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o

By, or under, the personal supervision of an individual licensed under State law to practice medicine or
osteopathy, or dental medicine or dental surgery if State law allows such services to be provided by either a
physician or dentist.

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8.

9.

7.

Outpatient Hospital Services (MSIS Code=11)(See 42 CFR 440.20).--These are preventive, diagnostic,
therapeutic, rehabilitative, or palliative services that are furnished:

o

To outpatients;

o

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

o

By an institution that:
-

Is licensed or formally approved as a hospital by an officially designated authority for State standard
setting; and

-

Except in the case of medical supervision of nurse midwife services (see 42 CFR 440.165), meets the
requirements for participation in Medicare as a hospital.

Prescribed Drugs (MSIS Code=16)(See 42 CFR 440.120(a)).--These are simple or compound substances or
mixtures of substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance that
are:
o

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

o

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

o

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

Dental Services (MSIS Code=09)(See 42 CFR 440.100 and 42 CFR 440.120 (b)).--These are diagnostic,
preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her
profession, including treatment of:
o

The teeth and associated structures of the oral cavity; and

o

Disease, injury, or an impairment that may affect the oral or general health of the recipient.

A dentist is an individual licensed to practice dentistry or dental surgery. Dental services include dental screening
and dental clinic services.
NOTE: Include services related to providing and fitting dentures as dental services. Dentures mean artificial
structures made by, or under the direction of, a dentist to replace a full or partial set of teeth.
Dental services do not include services provided as part of inpatient hospital, outpatient hospital, non-dental
clinic, or laboratory services and billed by the hospital, non-dental clinic, or laboratory or services which meet the
requirements of 42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or
physician under State law).

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10. Other Licensed Practitioners' Services (MSIS Code=10)(See 42 CFR 440.60).--These are medical or remedial
care or services, other than physician services or services of a dentist, provided by licensed practitioners within the
scope of practice as defined under State law. The category “Other Licensed Practitioners' Services” is different than
the “Other Care” category. Examples of other practitioners (if covered under State law) are:
o

Chiropractors;

o

Podiatrists;

o

Psychologists; and

o

Optometrists.

Other Licensed Practitioners' Services include hearing aids and eyeglasses only if they are billed directly by the
professional practitioner. If billed by a physician, they are reported as Physicians' Services. Otherwise, report
them under Other Care.
Other Licensed Practitioners' Services do not include prosthetic devices billed by physicians, laboratory or X-ray
services provided by other practitioners, or services of other practitioners that are included in inpatient or
outpatient hospital bills. These services are counted under the related type of service as appropriate. Devices
billed by providers not included under the listed types of service are counted under Other Care.
Report Other Licensed Practitioners' Services that are billed by a hospital as inpatient or outpatient services, as
appropriate.
Speech therapists, audiologists, opticians, physical therapists, and occupational therapists are not included
within Other Licensed Practitioners' Services.
Chiropractors' services include only services that are provided by a chiropractor (who is licensed by the State)
and consist of treatment by means of manual manipulation of the spine that the chiropractor is legally authorized
by the State to perform.

11. Clinic Services (MSIS Code=12)(See 42 CFR 440.90).--Clinic services include preventive, diagnostic,
therapeutic, rehabilitative, or palliative items or services that are provided:
o

To outpatients;

o

By a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients
including services furnished outside the clinic by clinic personnel to individuals without a fixed home or
mailing address. For reporting purposes, consider a group of physicians who share, only for mutual
convenience, space, services of support staff, etc., as physicians, rather than a clinic, even though they
practice under the name of the clinic; and

o

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

NOTE: Place dental clinic services under dental services. Report any services not included above under other
care. A clinic staff may include practitioners with different specialties.

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12. Laboratory and X-Ray Services(MSIS Code=15)(See 42 CFR 440.30).--These are professional or technical
laboratory and radiological services that are:
o

Ordered and provided by or under the direction of a physician or other licensed practitioner of the healing
arts within the scope of his or her practice as defined by State law or ordered and billed by a physician but
provided by referral laboratory;

o

Provided in an office or similar facility other than a hospital inpatient or outpatient department or clinic; and

o

Provided by a laboratory that meets the requirements for participation in Medicare.

Laboratory and X-ray services provided by dentists are reported under dental services.

13. Sterilizations (MSIS Code=24)(See 42 CFR 441, Subpart F).--These are medical procedures, treatment or
operations for the purpose of rendering an individual permanently incapable of reproducing.

14. Home Health Services (MSIS Code=13) (See 42 CFR 440.70).--These are services provided at the patient's
place of residence, in compliance with a physician's written plan of care that is reviewed every 62 days. The
following items and services are mandatory.
o

Nursing services, as defined in the State Nurse Practice Act, that is provided on a part-time or intermittent
basis by a home health agency (a public or private agency or organization, or part of any agency or
organization, that meets the requirements for participation in Medicare). If there is no agency in the area, a
registered nurse who:
-

Is licensed to practice in the State;

-

Receives written orders from the patient's physician;

-

Documents the care and services provided; and

-

Has had orientation to acceptable clinical and administrative record keeping from a health department
nurse;

o

Home health aide services provided by a home health agency; and

o

Medical supplies, equipment, and appliances suitable for use in the home.

The following therapy services are optional: physical therapy, occupational therapy, or speech pathology and
audiology services provided by a home health agency or by a facility licensed by the State to provide these
medical rehabilitation services. (See 42 CFR 441.15.)
Place of residence is normally interpreted to mean the patient's home and does not apply to hospitals or NFs.
Services received in a NF that are different from those normally provided as part of the institution's care may
qualify as home health services. For example, a registered nurse may provide short-term care for a recipient in a
NF during an acute illness to avoid the recipient's transfer to another NF.

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15. Personal Support Services.--Report total unduplicated recipients and payments for services defined in 15a through
15i.

15a. Personal Care Services (MSIS Code=30)(See 42 CFR 440.167).--These are services furnished to an individual who
is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or
institution for mental disease that are:
o

Authorized for the individual by a physician in accordance with a plan of treatment or (at the option of the
State) otherwise authorized for the individual in accordance with a service plan approved by the State; and

o

Provided by an individual who is qualified to provide such services and who is not a member of the
individual’s family.

15b. Targeted Case Management Services (MSIS Code=31)(See §1915(g)(2) of the Act).--These are services that are
furnished to individuals eligible under the plan to gain access to needed medical, social, educational, and other
services. The agency may make available case management services to:
o

Specific geographic areas within a State, without regard to statewide requirement in 42 CFR 431.50; and

o

Specific groups of individuals eligible for Medicaid, without regard to the comparability requirements in 42
CFR 440.240.

The agency must permit individuals to freely choose any qualified Medicaid provider except when obtaining case
management services in accordance with 42 CFR 431.51.

15c. Rehabilitative Services (MSIS Code=33)(See 42 CFR 440.130(d)).--These include any medical or remedial
services recommended by a physician or other licensed practitioner of the healing arts within the scope of his/her
practice under State law for maximum reduction of physical or mental disability and restoration of a recipient to
his/her best possible functional level.

15d. Physical Therapy, Occupational Therapy, and Services For Individuals With Speech, Hearing, and Language
Disorders (MSIS Code=34)(See 42 CFR 440.110).--These are services prescribed by a physician or other licensed
practitioner within the scope of his or her practice under State law and provided to a recipient by, or under the direction
of, a qualified physical therapist, occupational therapist, speech pathologist, or audiologist. It includes any necessary
supplies and equipment.

15e. Hospice Services (MSIS Code=35)(See 42 CFR 418.202).--Whether received in a hospice facility or elsewhere,
these are services that are:
o

Furnished to a terminally ill individual, as defined in 42 CFR 418.3;

o

Furnished by a hospice, as defined in 42 CFR 418.3, that meets the requirements for participation in
Medicare specified in 42 CFR 418, Subpart C or by others under an arrangement made by a hospice
program that meets those requirements and is a participating Medicaid provider; and

o

Furnished under a written plan that is established and periodically reviewed by:
-

The attending physician;

-

The medical director or physician designee of the program, as described in 42 CFR 418.54; and

-

The interdisciplinary group described in 42 CFR 418.68.

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15f. Nurse Midwife (MSIS Code=36)(See 42 CFR 440.165 and 441.21).--These are services that are concerned with
management and the care of mothers and newborns throughout the maternity cycle and are furnished within the
scope of practice authorized by State law or regulation.

15g. Nurse Practitioner (MSIS Code=37)(See 42 CFR 440.166 and 441.22).--These are services furnished by a
registered professional nurse who meets State’s advanced educational and clinical practice requirements, if any,
beyond the 2 to 4 years of basic nursing education required of all registered nurses.

15h. Private Duty Nursing (MSIS Code=38)(See 42 CFR 440.80).--When covered in the State plan, these are services
of registered nurses or licensed practical nurses provided under direction of a physician to recipients in their own
homes, hospitals or nursing facilities (as specified by the State).

15i. Religious Non-Medical Health Care Institutions (MSIS Code=39)(See 42 CFR 440.170(b)(c)).--These are nonmedical health care services equivalent to a hospital or extended care level of care provided in facilities that
meet the requirements of Section 1861(ss)(1) of the Act.

16.

Other Care (See 42 CFR 440.120(b), (c), and (d), and 440.170(a)).--Report total unduplicated recipients and
payments for services in sections 16a, 16b, and 16c. Such services do not meet the definition of, and are not
classified under, any of the previously described categories.

16a. Transportation (MSIS Code=26)(See 42 CFR 440.170(a)).--Report totals for services provided under this title to
include transportation and other related travel services determined necessary by you to secure medical
examinations and treatment for a recipient.
NOTE: Transportation, as defined above, is furnished only by a provider to whom a direct vendor payment can
appropriately be made. If other arrangements are made to assure transportation under 42 CFR 431.53,
FFP is available as an administrative cost.

16b. Abortions (MSIS Code=25)(See 42 CFR 441, Subpart E).--In accordance with the terms of the DHHS
Appropriations Bill and 42 CFR 441, Subpart E, FFP is available for abortions:
o

When a physician has certified in writing to the Medicaid agency that, on the basis of his or her professional
judgment, the life of the mother would be endangered if the fetus were carried to term; or

o

When the abortion is performed to terminate a pregnancy resulting from an act of rape of incest. FFP is not
available for an abortion under any other circumstances.

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16c. Other Services (MSIS Code=19).--These services do not meet the definitions of any of the previously described
service categories. They may include, but are not limited to:
o

17.

Prosthetic devices (see 42 CFR 440.120(c)) which are replacement, corrective, or supportive devices
prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as
defined by State law to:
-

Artificially replace a missing portion of the body;

-

Prevent or correct physical deformity or malfunctions; or

-

Support a weak or deformed portion of the body.

o

Eyeglasses (see 42 CFR 440.120 (d)). Eyeglasses mean lenses, including frames, and other aids to vision
prescribed by a physician skilled in diseases of the eye or an optician. It includes optician fees for services.

o

Home and Community-Based Waiver services (See §1915(c) of the Act and 42 CFR 440.180) that cannot
be associated with other TYPE-OF-SERVICE codes (e.g., community homes for the disabled and adult day
care.)

Capitated Care (See 42 CFR Part 434).--This includes enrollees and capitated payments for the plan types
defined in 17 a and b below. Report unduplicated enrolled eligibles and payments for 17 a and b.

17a. Health Maintenance Organization (HMO) and Health Insuring Organization (HIO) (MSIS Code=20).--These
include plans contracted to provide capitated comprehensive services. An HMO is a public or private
organization that contracts on a prepaid capitated risk basis to provide a comprehensive set of services and is
federally qualified or State-plan defined. An HIO is an entity that provides for or arranges for the provision of care
and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

17b. Prepaid Health Plans (PHP) (MSIS Code=21).--These include plans that are contracted to provide less than
comprehensive services. Under a non-risk or risk arrangement, the State may contract with (but not limited to
these entities) a physician, physician group, or clinic for a limited range of services under capitation. A PHP is an
entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis or the entity
provides comprehensive services on a non-risk basis.
NOTE: Include dental, mental health, and other plans covering limited services under PHP.

17c. Private Health Insurance (MSIS Code=23) --These include plans marketed by private health insurance
companies and enrolled in by individual enrollees on their own choosing.
18.

Primary Care Case Management (PCCM) (MSIS Code=22)(See §1915(b)(1) of the Act).--The State contracts
directly with primary care providers who agree to be responsible for the provision and/or coordination of medical
services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care
physician a monthly case management fee. Report these recipients and associated PCCM fees in this section.
NOTE: Where the fee includes services beyond case management, report the enrollees and fees under prepaid
health plans (17b).

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SERVICE HIERARCHY

Experience has demonstrated there can be instances when more than one service area category could be applicable
for a provided service. The following rules apply to these instances:
o

The specific service categories of sterilizations and abortions take precedence over provider categories, such as
inpatient hospital or outpatient hospital.

o

Services of a physician employed by a clinic are reported under clinic services if the clinic is the billing entity. Xrays 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.

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Medicaid and CHIP Statistical Information System (MSIS) File Specs & Data Dictionary

MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary Attachments

ATTACHMENT 4 - Program Type Reference

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DEFINITIONS OF PROGRAM TYPES

The following definitions describe special Medicaid programs that are coded independently of type of service for MSIS
purposes. These programs tend to cover bands of services that cut across many types of service.
Program Type 1.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (See 42 CFR 440.40(b)).--This
includes either general health screening services and vision, dental, and hearing services furnished
to Medicaid eligibles under age 21 to fulfill the requirements of the EPSDT program or services
rendered based on referrals from EPSDT visits. The Act specifies two sets of EPSDT screenings:
o

o

Program Type 2.

Periodic screenings, which are provided at distinct intervals determined by the State, and
which must include the following services:
-

A comprehensive health and developmental history assessment (including assessment of
both physical and mental health development);

-

A comprehensive unclothed physical exam;

-

Appropriate immunizations according to the Advisory Committee on Immunization
Practices schedule;

-

Laboratory tests (including blood lead level assessment); and

-

Health education (including anticipatory guidance); and

Interperiodic screenings, which are provided when medically necessary to determine the
existence of suspected physical or mental illness or conditions.

Family Planning (See 42 CFR 440.40(c)).-- Only items and procedures clearly provided or
performed for family planning purposes and matched at the 90 percent FFP rate should be included
as Family Planning. Services covered under this program include, but are not limited to:
o

Counseling and patient education and treatment furnished by medical professionals in
accordance with State law;

o

Laboratory and X-ray services;

o

Medically approved methods, procedures, pharmaceutical supplies, and devices to prevent
conception;

o

Natural family planning methods; and

o

Diagnosis and treatment for infertility.

NOTE: CMS’s Revised Financial Management Review Guide for Family Planning Services
describes items and procedures eligible for the enhanced match as family planning
services.

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Program Type 3.

February 2014

Rural Health Clinics (RHC)(See 42 CFR 440.20(b)).--These include services (as allowed by State
law) furnished by a rural health clinic which has been certified in accordance with the conditions of
42 CFR Part 491 (certification of certain health facilities). Services performed in RHCs include, but
are not limited to:
o

Services furnished by a physician within the scope of his or her profession as defined by State
law. The physician performs these services in or away from the clinic and has an agreement
with the clinic providing that he or she will be paid for these services;

o

Services furnished by a physician assistant, nurse practitioner, nurse midwife, or other
specialized nurse practitioner (as defined in 42 CFR 405.2401 and 491.2) if the services are
furnished in accordance with the requirements specified in 42 CFR 405.2412(a);

o

Services and supplies provided in conjunction with professional services furnished by a
physician, physician assistant, nurse practitioner, nurse midwife, or specialized nurse
practitioner. (See 42 CFR 405.2413 and 405.2415 for the criteria determining whether
services and supplies are included here.); or

o

Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and
biologicals) if:
-

The clinic is located in an area in which the Secretary has determined that there is a
shortage of home health agencies (see 42 CFR 405.2417);

-

The services are furnished by a registered nurse or licensed practical or vocational nurse
employed, or otherwise compensated for the services, by the clinic;

-

The services are furnished under a written plan of treatment that is either established and
reviewed at least every 60 days by a supervising physician of the clinic, or that is
established by a physician, physician's assistant, nurse practitioner, nurse midwife, or
specialized nurse practitioner and reviewed and approved at least every 60 days by a
supervising physician of the clinic; and

-

The services are furnished to a homebound patient. For purposes of visiting nurse
services, a homebound recipient means one who is permanently or temporarily confined
to a place of residence because of a medical or health condition and leaves the place of
residence infrequently. For this purpose, a place of residence does not include a hospital
or nursing facility.

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Program Type 4.

Federally Qualified Health Center (FQHC) (See §1905(a)(2) of the Act).--FQHCs are facilities or
programs more commonly known as community health centers, migrant health centers, and health
care for the homeless programs. A facility or program qualifies as a FQHC providing services
covered under Medicaid if:
o

They receive grants under §§329, 330, or 340 of the Public Health Service Act (PHS);

o

The Health Resources and Services Administration, PHS, certifies the center as meeting
FQHC requirements; or

o

The Secretary determines that the center qualifies through waiver of the requirements.

Services performed in FHQCs are defined the same as the services provided by rural health clinics.
They may include physician services, services provided by physician assistants, nurse
practitioners, clinical psychologists, clinical social workers, and services and supplies incident to
such services as are otherwise covered if furnished by a physician or as incident to a physician's
services. In certain cases, services to a homebound Medicaid patient may be provided. Any other
ambulatory service included in the State's Medicaid plan is considered covered by a FQHC
program if the center offers it.

Program Type 5.

Indian Health Services (See §1911 of the Act) (See 42 CFR 431.110).--These are services
provided by the Indian Health Services (IHS), an agency charged with providing the primary source
of health care for American Indian and Alaska Native people who are members of federally
recognized tribes and organizations. A State plan must provide that an IHS facility, meeting State
plan requirements for Medicaid participants, must be accepted as a Medicaid provider on the same
basis as any other qualified provider.

Program Type 6.

Home and Community-Based Care for Functionally Disabled Elderly (See §1929 of the Act) and for
Individuals Age 65 and Older(MSIS (See 42 CFR 441, Subpart H).--This program is for §1915(d)
recipients of home and community-based services for individuals age 65 or older. This is an option
within the Medicaid program to provide home and community-based care to functionally disabled
individuals age 65 or older who are otherwise eligible for Medicaid or for non-disabled elderly
individuals.

Program Type 7.

Home and Community-Based Waivers (See §1915(c) of the Act and 42 CFR 440.180).--This
program includes services furnished under a waiver approved under the provisions in 42 CFR Part
441, Subpart G (home and community-based services; waiver requirements).

PROGRAM HIERARCHY

If more than one program type could be applicable for a particular claim, the following hierarchy should be
applied:
Family Planning
Waiver Services
EPSDT
Indian Health
RHC
FQHC

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MEDICAID AND CHIP STATISTICAL INFORMATION SYSTEM
(MSIS)
File Specifications and Data Dictionary Attachments

ATTACHMENT 5 – T-MSIS Eligibility Group Valid Values Table

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DEFINITIONS OF NEW FIELD – T-MSIS ELIGIBILITY-GROUP CAN BE FOUND AS #’S 72-75 IN THE TABLE
BELOW
This section is located in the T-MSIS Data Dictionary documentation as ‘Appendix F: Eligibility Group Table.’

Code

Eligibility Group

01

Parents and Other
Caretaker Relatives

02

Transitional Medical
Assistance

03

Short Description
Citation
MEDICAID MANDATORY COVERAGE

Type

Category

Parents and other caretaker
relatives of dependent
children with household
income at or below a
standard established by the
state.
Families with Medicaid
eligibility extended for up to
12 months because of
earnings.

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

Family/Adult

Mandatory
Coverage

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

Family/Adult

Mandatory
Coverage

Extended Medicaid
due to Earnings

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

Family/Adult

Mandatory
Coverage

04

Extended Medicaid
due to Spousal
Support Collections

Family/Adult

Mandatory
Coverage

05

Pregnant Women

Families with Medicaid
eligibility extended for 4
months as the result of the
collection of spousal
support.
Women who are pregnant or
post-partum, with household
income at or below a
standard established by the
state.

42 CFR
435.112;
408(a)(11)(A);
1902 (e)(1)(A);
1931 (c)(2)
42 CFR
435.115;
408(a)(11)(B);
1931 (c)(1)
42 CFR
435.116;
1902(a)(10)(A)(i
)(III) and (IV);
1902(a)(10)(A)(i
i)(I), (IV) and
(IX);
1931(b) and (d);

Family/Adult

Mandatory
Coverage

06

Deemed Newborns

42 CFR
435.117;
1902(e)(4) and
2112€

Family/Adult

Mandatory
Coverage

07

Infants and Children
under Age 19

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

Family/Adult

Mandatory
Coverage

February 2014

Children born to women
covered under Medicaid or a
separate CHIP for the date
of the child's birth, who are
deemed eligible for Medicaid
until the child turns age 1
Infants and children under
age 19 with household
income at or below
standards established by the
state based on age group.

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Code
08

Eligibility Group
Children with Title IVE Adoption
Assistance, Foster
Care or Guardianship
Care

Short Description
Citation
Type
Category
Individuals for whom an
42 CFR
Family/Adult
Mandatory
adoption assistance
435.145;
Coverage
agreement is in effect or
473(b)(3);
foster care or kinship
1902(a)(10)(A)(i
guardianship assistance
)(I)
maintenance payments are
made under Title IV-E of the
Act.
09
Former Foster Care
Individuals under the age of
42 CFR
Family/Adult
Mandatory
Children
26, not otherwise
435.150;
Coverage
mandatorily eligible, who
1902(a)(10)(A)(i
were in foster care and on
)(IX)
Medicaid either when they
turned age 18 or aged out of
foster care.
10
Individuals at or
Non-pregnant individuals
42 CFR
Family/Adult
Mandatory
below 133% FPL
aged 19 through 64, not
435.119;
Coverage
Age 19 through 64
otherwise mandatorily
1902(a)(10)(A)(i
eligible, with income at or
)(VIII)
below 133% FPL.
Please note that T-MSIS eligibility grouping # 10 “Individuals at or below 133% FPL Age 19 through 64” has been
removed and replaced with expanded groupings 72-75 (see below).
72

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

73

74

75

February 2014

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

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

Family/Adult

Mandatory
Coverage

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

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

Family/Adult

Mandatory
Coverage

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

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

Family/Adult

Mandatory
Coverage

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

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

Family/Adult

Mandatory
Coverage

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Code
11

Eligibility Group
Individuals Receiving
SSI

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

12

Aged, Blind and
Disabled Individuals
in 209(b) States

13

Individuals Receiving
Mandatory State
Supplements

14

Individuals Who Are
Essential Spouses

15

Institutionalized
Individuals
Continuously Eligible
Since 1973

16

Blind or Disabled
Individuals Eligible in
1973

17

Individuals Who Lost
Eligibility for SSI/SSP
Due to an Increase in
OASDI Benefits in
1972

18

Individuals Who
Would be Eligible for
SSI/SSP but for
OASDI COLA
increases since April,
1977

19

Disabled Widows
and Widowers
Ineligible for SSI due

In 209(b) states, aged, blind
and disabled individuals who
meet more restrictive criteria
than used in SSI.
Individuals receiving
mandatory State
Supplements to SSI
benefits.
Individuals who were eligible
as essential spouses in
1973 and who continue be
essential to the well-being of
a recipient of cash
assistance.
Institutionalized individuals
who were eligible for
Medicaid in 1973 as
inpatients of Title XIX
medical institutions or
intermediate care facilities,
and who continue to meet
the 1973 requirements.
Blind or disabled individuals
who were eligible for
Medicaid in 1973 who meet
all current requirements for
Medicaid except for the
blindness or disability
criteria.
Individuals who would be
eligible for SSI/SSP except
for the increase in OASDI
benefits in 1972, who were
entitled to and receiving
cash assistance in August,
1972.
Individuals who are
receiving OASDI and
became ineligible for
SSI/SSP after April, 1977,
who would continue to be
eligible if the cost of living
increases in OASDI since
their last month of eligibility
for SSI/SSP/OASDI were
deducted from income.
Disabled widows and
widowers who would be
eligible for SSI /SSP, except

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Citation
42 CFR
435.120;
1902(a)(10)(A)(i
)(II)(aa)
42 CFR
435.121;
1902(f)

Type
ABD

Category
Mandatory
Coverage

ABD

Mandatory
Coverage

42 CFR
435.130

ABD

Mandatory
Coverage

42 CFR
435.131;
1905(a)

ABD

Mandatory
Coverage

42 CFR
435.132

ABD

Mandatory
Coverage

42 CFR
435.133

ABD

Mandatory
Coverage

42 CFR
435.134

ABD

Mandatory
Coverage

42 CFR
435.135;

ABD

Mandatory
Coverage

42 CFR
435.137;
1634(b)

ABD

Mandatory
Coverage

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Code

Eligibility Group
to Increase in OASDI

20

Disabled Widows
and Widowers
Ineligible for SSI due
to Early Receipt of
Social Security

21

Working Disabled
under 1619(b)

22

Disabled Adult
Children

23

Qualified Medicare
Beneficiaries

24

Qualified Disabled
and Working
Individuals

25

Specified Low
Income Medicare
Beneficiaries

26

Qualifying Individuals

February 2014

Short Description
for the increase in OASDI
benefits due to the
elimination of the reduction
factor in P.L. 98-21, who
therefore are deemed to be
SSI or SSP recipients.
Disabled widows and
widowers who would be
eligible for SSI/SSP, except
for the early receipt of
OASDI benefits, who are not
entitled to Medicare Part A,
who therefore are deemed
to be SSI recipients.
Blind or disabled individuals
who participated in Medicaid
as SSI cash recipients or
who were considered to be
receiving SSI, who would
still qualify for SSI except for
earnings.
Individuals who lose
eligibility for SSI at age 18 or
older due to receipt of or
increase in Title II OASDI
child benefits.
Individuals with income
equal to or less than 100%
of the FPL who are entitled
to Medicare Part A, who
qualify for Medicare costsharing.
Working, disabled
individuals with income
equal to or less than 200%
of the FPL, who are entitled
to Medicare Part A under
section 1818A, who qualify
for payment of Medicare
Part A premiums.
Individuals with income
between 100% and 120% of
the FPL who are entitled to
Medicare Part A, who qualify
for payment of Medicare
Part B premiums.
Individuals with income
between 120% and 135% of
the FPL who are entitled to
Medicare Part A, who qualify
for payment of Medicare
Part B premiums.

177

Citation

Type

Category

42 CFR
435.138;
1634(d)

ABD

Mandatory
Coverage

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

ABD

Mandatory
Coverage

1634(c)

ABD

Mandatory
Coverage

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

ABD

Mandatory
Coverage

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

ABD

Mandatory
Coverage

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

ABD

Mandatory
Coverage

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

ABD

Mandatory
Coverage

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Code

Eligibility Group

27

Optional Coverage of
Parents and Other
Caretaker Relatives

28

Reasonable
Classifications of
Individuals under
Age 21

29

Children with Non-IVE Adoption
Assistance

30

Independent Foster
Care Adolescents

31

Optional Targeted
Low Income Children

32

33

Short Description
Citation
MEDICAID OPTIONS FOR COVERAGE

Type

Category

Individuals qualifying as
parents or caretaker
relatives who are not
mandatorily eligible and who
have income at or below a
standard established by the
State.
Individuals under age 21
who are not mandatorily
eligible and who have
income at or below a
standard established by the
State.
Children with special needs
for whom there is a non-IV-E
adoption assistance
agreement in effect with a
state, who either were
eligible for Medicaid or had
income at or below a
standard established by the
state.
Individuals under an age
specified by the State, less
than age 21, who were in
State-sponsored foster care
on their 18th birthday and
who meet the income
standard established by the
State.
Uninsured children who
meet the definition of
optional targeted low income
children at 42 CFR 435.4,
who have household income
at or below a standard
established by the State.

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

Family/Adult

Options for
Coverage

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

Family/Adult

Options for
Coverage

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

Family/Adult

Options for
Coverage

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

Family/Adult

Options for
Coverage

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

Family/Adult

Options for
Coverage

Individuals Electing
COBRA Continuation
Coverage

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

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

Family/Adult

Options for
Coverage

Individuals above
133% FPL under Age
65

Individuals under 65, not
otherwise mandatorily or
optionally eligible, with
income above 133% FPL
and at or below a standard
established by the State.

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

Family/Adult

Options for
Coverage

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Code
34

Eligibility Group
Certain Individuals
Needing Treatment
for Breast or Cervical
Cancer

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

35

Individuals Eligible
for Family Planning
Services

36

Individuals with
Tuberculosis

37

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

Individuals who are not
pregnant, with income equal
to or below the highest
standard for pregnant
women, as specified by the
State, limited to family
planning and related
services.
Individuals infected with
tuberculosis whose income
does not exceed established
standards, limited to
tuberculosis-related
services.
Individuals who meet the
requirements of SSI or
Optional State Supplement,
but who do not receive cash.

38

Individuals Eligible
for Cash Assistance
except for
Institutionalization

39

Individuals Receiving
Home and
Community Based
Services under
Institutional Rules

40

Optional State
Supplement
Recipients - 1634
States, and SSI
Criteria States with
1616 Agreements

February 2014

Citation
42 CFR
435.213;
1902(a)(10)(A)(i
i)(XVIII);
1902(aa)
42 CFR
435.214;
1902(a)(10)(A)(i
i)(XXI)

Type
Family/Adult

Category
Options for
Coverage

Family/Adult

Options for
Coverage

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

Family/Adult

Options for
Coverage

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

ABD

Options for
Coverage

Individuals who meet the
requirements of AFDC, SSI
or Optional State
Supplement, and would be
eligible if they were not living
in a medical institution.
Individuals who would be
eligible for Medicaid under
the State Plan if in a medical
institution, who would live in
an institution if they did not
receive home and
community based services.

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

ABD

Options for
Coverage

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

ABD

Options for
Coverage

Individuals in 1634 States
and in SSI Criteria States
with agreements under
1616, who receive a state
supplementary payment (but
not SSI).

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

ABD

Options for
Coverage

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Code
41

Eligibility Group
Optional State
Supplement
Recipients - 209(b)
States, and SSI
Criteria States
without 1616
Agreements

Short Description
Individuals in 209(b) States
and in SSI Criteria States
without agreements under
1616, who receive a state
supplementary payment (but
not SSI).

Citation
42 CFR
435.234;
1902(a)(10)(A)(i
i)(XI)

42

Institutionalized
Individuals Eligible
under a Special
Income Level

Individuals who are in
institutions for at least 30
consecutive days who are
eligible under a special
income level.

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

ABD

Options for
Coverage

43

Individuals
participating in a
PACE Program
under Institutional
Rules

1934

ABD

Options for
Coverage

44

Individuals Receiving
Hospice Care

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

ABD

Options for
Coverage

45

Qualified Disabled
Children under Age
19

1902(e)(3)

ABD

Options for
Coverage

46

Poverty Level Aged
or Disabled

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

ABD

Options for
Coverage

47

Work Incentives
Eligibility Group

1902(a)(10)(A)(i
i)(XIII)

ABD

Options for
Coverage

48

Ticket to Work Basic
Group

Individuals who would be
eligible for Medicaid under
the State Plan if in a medical
institution, who would
require institutionalization if
they did not participate in the
PACE program.
Individuals who would be
eligible for Medicaid under
the State Plan if they were in
a medical institution, who
are terminally ill, and who
will receive hospice care.
Certain children under 19
living at home, who are
disabled and would be
eligible if they were living in
a medical institution.
Individuals who are aged or
disabled with income equal
to or less than a percentage
of the FPL, established by
the state (no higher than
100%).
Individuals with a disability
with income below 250% of
the FPL, who would qualify
for SSI except for earned
income.
Individuals with earned
income between ages 16
and 64 with a disability, with
income and resources equal
to or below a standard
specified by the State.

1902(a)(10)(A)(i
i)(XV)

ABD

Options for
Coverage

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Type
ABD

Category
Options for
Coverage

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Code
49

Eligibility Group
Ticket to Work
Medical
Improvements Group

50

Family Opportunity
Act Children with
Disabilities

51

Individuals Eligible
for Home and
Community-Based
Services

52

Individuals Eligible
for Home and
Community-Based
Services - Special
Income Level

Short Description
Individuals with earned
income between ages 16
and 64 who are no longer
disabled but still have a
medical impairment, with
income and resources equal
to or below a standard
specified by the State.
Children under 19 who are
disabled, with income equal
to or less than a standard
specified by the State (no
higher than 300% of the
FPL).
Individuals with income
equal to or below 150% of
the FPL, who qualify for
home and community based
services without a
determination that they
would otherwise live in an
institution.
Individuals with income
equal to or below 300% of
the SSI federal benefit rate,
who meet the eligibility
requirements for a waiver
approved for the State under
1915(c), (d) or (e), or 1115.

Citation
1902(a)(10)(A)(i
i)(XVI)

Type
ABD

Category
Options for
Coverage

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

ABD

Options for
Coverage

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

ABD

Options for
Coverage

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

ABD

Options for
Coverage

Family/Adult

Medically
Needy

Family/Adult

Medically
Needy

MEDICAID MEDICALLY NEEDY
53

Medically Needy
Pregnant Women

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

54

Medically Needy
Children under Age
18

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

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181

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

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Code
55

Eligibility Group
Medically Needy
Children Age 18
through 20

56

Medically Needy
Parents and Other
Caretakers

Short Description
Children over 18 and under
an age established by the
State (less than age 21),
who would qualify as
categorically needy, except
for income.
Parents and other caretaker
relatives of dependent
children, eligible as
categorically needy except
for income.

Citation
42 CFR
435.308;
1902(a)(10)(C)(i
i)(II)

Type
Family/Adult

Category
Medically
Needy

42 CFR
435.310

Family/Adult

Medically
Needy

Individuals who are age 65
42 CFR
or older, blind or disabled,
435.320,
who are not eligible as
435.322,
categorically needy, who
435.324,and
meet income and resource
435.330;
standards specified by the
1902(a)(10)(C)
State, or who meet the
income standard using
medical and remedial care
expenses to offset excess
income.
Blind or disabled individuals
42 CFR
who were eligible for
435.340
Medicaid as Medically
Needy in 1973 who meet all
current requirements for
Medicaid except for the
blindness or disability
criteria.
CHIP COVERAGE

ABD

Medically
Needy

ABD

Medically
Needy

Uninsured children under
age 19 who do not have
access to public employee
coverage and whose
household income is within
standards established by the
state.
Children born to targeted
low-income pregnant women
who are deemed eligible for
CHIP or Medicaid for one
year.

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

Children

Optional

2112(e)

Children

Optional

Removed – Do Not
Use
Removed – Do Not
Use
59

Medically Needy
Aged, Blind or
Disabled

60

Medically Needy
Blind or Disabled
Individuals Eligible in
1973

61

Targeted LowIncome Children

62

Deemed Newborn

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Code
63

Eligibility Group
Children Ineligible for
Medicaid Due to
Loss of Income
Disregards

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

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

Type
Children

Category
Mandatory

CHIP ADDITIONAL OPTIONS FOR COVERAGE
64

Coverage from
Conception to Birth

65

Children with Access
to Public Employee
Coverage

66

Children Eligible for
Dental Only
Supplemental
Coverage

67

Targeted LowIncome Pregnant
Women

68

Pregnant Women
with Access to Public
Employee Coverage

69

Individuals with
Mental Health
Conditions
(expansion group)

February 2014

Uninsured children from
conception to birth who do
not have access to public
employee coverage and
whose household income is
within standards established
by the state.
Uninsured children under
age 19 having access to
public employee coverage
and whose household
income is within standards
established by the state.
Children who are otherwise
eligible for CHIP but for the
fact that they are enrolled in
a group health plan or health
insurance offered through an
employer. Coverage is
limited to dental services.

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

Children

Option for
Coverage

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

Children

Option for
Coverage

2110(b)(5)

Children

Option for
Coverage

Pregnant Women

Option for
Coverage

Pregnant Women

Option for
Coverage

Uninsured pregnant women
2112
who do not have access to
public employee coverage
and whose household
income is within standards
established by the state.
Uninsured pregnant women
2110(b)(2)(B)
having access to public
and (b)(6)
employee coverage and
whose household income is
within standards established
by the state.
1115 EXPANSION ELIGIBILITY GROUPS
Individuals with mental
health conditions who do not
qualify for Medicaid due to
the severity or duration of
their disability or due to
other eligibility factors;
and/or those who are
otherwise eligible but require
benefits or services that are
not comparable to those
provided to other Medicaid
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Code

Eligibility Group

70

Family Planning
Participants
(expansion group)

71

Other expansion
group

February 2014

Short Description
beneficiaries.

Citation

Individuals of child bearing
age who require family
planning services and
supplies and for which the
state does not choose to, or
cannot provide, optional
eligibility coverage under the
Individuals Eligible for
Family Planning Services
eligibility group
(1902(a)(10)(A)(ii)(XXI)).
Individuals who do not
qualify for Medicaid or CHIP
under a mandatory eligibility
or coverage group and for
whom the state chooses to
provide eligibility and/or
benefits in a manner not
permitted by title XIX or XXI
of the Social Security Act.

184

Type

Category

1115 expansion

1115 expansion

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APPENDIX B – CODING SCHEME
ENROLLMENT OF INDIVIDUALS INTO THE NEW ADULT GROUP – (ACA MEDICAID EXPANSION)
USING T-MSIS ELIGIBILITY GROUP

For states engaging in Medicaid expansion for FFY2014Q1 (calendar
Oct-Dec 2013), with the “New Adult Group” (as defined as T-MSISELIGIBILTY-GROUP codes=72, 73, 74, or 75), enrollment can be
correctly captured for this quarter by coding each MSIS
eligibility file record as follows:
a) Correctly code the T-MSIS-ELIGIBILITY-GROUP for each
month; for non-eligible months, record spaces
b) DAYS-OF-ELIGIBILITY should be zeroes
c) ELIGIBILTY-GROUP should be zeroes for individuals who
were not eligible for at least one day during the month
d) MAINTENANCE-ASSIATANCE-STATUS should be zero
e) BASIS-OF-ELIGIBILITY should be zero
f) HEALTH-INSURANCE should be zero
g) TANF-CASH-FLAG should be zero
h) RESTRICTED-BENEFITS-FLAG should be zero
i) PLAN-TYPE-1 thru -4 should all be zeroes for individuals
who were not eligible for at least one day during the
month
j) PLAN-ID-1 thru -4 should all be zeroes for individuals
who were not eligible for at least one day during the
month
k) CHIP-CODE should be zero
l) WAIVER-TYPE-1 thru -3 should all be zero for individuals
who were not eligible for at least one day during the
month
m) WAIVER-ID-1 thru -3 should all be zeroes for individuals
who were not eligible for at least one day during the
month

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END OF DOCUMENT.

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