Transformed - Medicaid Statistical Information System (T-MSIS)

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

3-TMSIS_V2.1_Record_SegmentRelationships (2019 version 2)

Transformed - Medicaid Statistical Information System (T-MSIS)

OMB: 0938-0345

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T-MSIS Record Segment Definitions and Relationships

This document contains definitions and diagrams that depict TMSIS Record Segment Relationships. On all joins, the effective date of the child must fall completely with the set of effective date span of the active parent records. There shall be no dates where a child is active without a corresponding active parent.

Table 1: T-MSIS Record Segment Definitions

File Name

Record Segment Name

Record Identifier

Record Segment Definition

Record Segment Length

Claim Inpatient File

FILE-HEADER-RECORD-IP

CIP00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

2,100

Claim Inpatient File

CLAIM-HEADER-RECORD-IP

CIP00002

A record to capture data about an inpatient claim or encounter that applies to the claim in its totality.

2,100

Claim Inpatient File

CLAIM-LINE-RECORD-IP

CIP00003

A record to capture data about specific goods or services rendered to a Medicaid/CHIP enrollee during the hospital stay.

2,100

Claim Long-term Care File

FILE-HEADER-RECORD-LT

CLT00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

1,900

Claim Long-term Care File

CLAIM-HEADER-RECORD-LT

CLT00002

A record to capture data about a long-term care claim or encounter that applies to the claim in its totality.

1,900

Claim Long-term Care File

CLAIM-LINE-RECORD-LT

CLT00003

A record to capture data about specific goods or services rendered to a Medicaid/CHIP enrollee during a long-term care stay.

1,900

Claim Other File

FILE-HEADER-RECORD-OT

COT00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

1,750

Claim Other File

CLAIM-HEADER-RECORD-OT

COT00002

A record to capture data about another type of claim or encounter (besides IP, LT, and RX) that applies to the claim in its totality.

1,750

Claim Other File

CLAIM-LINE-RECORD-OT

COT00003

A record to capture data about specific goods or services rendered to a Medicaid/CHIP enrollee during an outpatient visit.

1,750

Claim Prescription File

FILE-HEADER-RECORD-RX

CRX00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

1,450

Claim Prescription File

CLAIM-HEADER-RECORD-RX

CRX00002

A record to capture data about a pharmacy claim or encounter that applies to the claim in its totality.

1,450

Claim Prescription File

CLAIM-LINE-RECORD-RX

CRX00003

A record to capture data about specific prescription goods or services rendered to a Medicaid/CHIP enrollee.

1,450

Eligible File

FILE-HEADER-RECORD-ELIGIBILITY

ELG00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

1,000

Eligible File

PRIMARY-DEMOGRAPHICS-ELIGIBILITY

ELG00002

A record to capture basic demographic information about the individual.

1,000

Eligible File

VARIABLE-DEMOGRAPHICS-ELIGIBILITY

ELG00003

A record to capture additional demographic information that is more prone to periodic changes than primary demographics.

1,000

Eligible File

ELIGIBLE-CONTACT-INFORMATION

ELG00004

A record to capture addresses and phone numbers of the individual.

1,000

Eligible File

ELIGIBILITY-DETERMINANTS

ELG00005

A record to capture factors that influence an individual’s eligibility for basic Medicaid/CHIP, as well as the various waivers and demonstrations.

1,000

Eligible File

HEALTH-HOME-SPA-PARTICIPATION-INFORMATION

ELG00006

A record to capture the eligible person's participation in the state's health home initiative.

1,000

Eligible File

HEALTH-HOME-SPA-PROVIDERS

ELG00007

A record to capture the identity of the health home entity in which the eligible person is enrolled, as well as the identity of the provider with primary responsibility for coordinating the delivery of health home services.

1,000

Eligible File

HEALTH-HOME-CHRONIC-CONDITIONS

ELG00008

A record to capture an eligible person's chronic conditions that qualified him/her for participation in the health home initiative.

1,000

Eligible File

LOCK-IN-INFORMATION

ELG00009

A record to capture the provider, or providers, to whom the eligible person is restricted, as well as the time periods during which the lock-in provisions are in force.

1,000

Eligible File

MFP-INFORMATION

ELG00010

A record to capture information about an eligible person's participation in the Money Follows the Person demonstration program.

1,000

Eligible File

STATE-PLAN-OPTION-PARTICIPATION

ELG00011

A record to capture the identity of the State Plan Options in which an eligible person is enrolled.

1,000

Eligible File

WAIVER-PARTICIPATION

ELG00012

A record to capture the identity of the waivers in which an eligible person is enrolled.

1,000

Eligible File

LTSS-PARTICIPATION

ELG00013

A record to capture the level of care an eligible person receives at various points in time while in a long-term care facility.

1,000

Eligible File

MANAGED-CARE-PARTICIPATION

ELG00014

A record to capture information about an eligible person's enrollment in a managed care plan.

1,000

Eligible File

ETHNICITY-INFORMATION

ELG00015

A record to capture information about an eligible person's ethnicity.

1,000

Eligible File

RACE-INFORMATION

ELG00016

A record to capture information about an eligible person's race.

1,000

Eligible File

DISABILITY-INFORMATION

ELG00017

A record to capture information about an eligible person's disabilities.

1,000

Eligible File

1115A-DEMONSTRATION-INFORMATION

ELG00018

A record to capture an eligible person's 1115A participation.

1,000

Eligible File

HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME

ELG00020

A record to capture an eligible person's chronic conditions for which an eligible person is receiving home and community-based care.

1,000

Eligible File

ENROLLMENT-TIME-SPAN-SEGMENT

ELG00021

A record to capture the eligible person's type of enrollment and time spans of enrollment.

1,000

Managed Care Plan Information File

FILE-HEADER-RECORD-MANAGED-CARE

MCR00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

1,000

Managed Care Plan Information File

MANAGED-CARE-MAIN

MCR00002

A record to capture basic, generally static information about a managed care entity.

1,000

Managed Care Plan Information File

MANAGED-CARE-LOCATION-AND-CONTACT-INFO

MCR00003

A record to capture addresses, phone numbers, fax numbers, and email addresses of the managed care organization.

1,000

Managed Care Plan Information File

MANAGED-CARE-SERVICE-AREA

MCR00004

A record to capture the zip codes, counties, or other geographic descriptors that define the managed care entity’s service area.

1,000

Managed Care Plan Information File

MANAGED-CARE-OPERATING-AUTHORITY

MCR00005

A record to capture information about the operating authority, waivers and demonstrations under which a managed care entity is contracted with the state.

1,000

Managed Care Plan Information File

MANAGED-CARE-PLAN-POPULATION-ENROLLED

MCR00006

A record to capture the identity of the Medicaid/CHIP eligibility groups that the managed care entity is authorized to enroll.

1,000

Managed Care Plan Information File

MANAGED- CARE-ACCREDITATION-ORGANIZATION

MCR00007

A record to capture information concerning the accreditations that the managed care entity has.

1,000

Managed Care Plan Information File

NATIONAL-HEALTH-CARE-ENTITY-ID-INFO

MCR00008

A record to capture the national health plan identifiers associated with the managed care entity.

1,000

Managed Care Plan Information File

CHPID-SHPID-RELATIONSHIPS

MCR00009

A record to link a managed care entity Sub-Health Plan IDs with the appropriate Controlling Health Plan IDs.

1,000

Provider File

FILE-HEADER-RECORD-PROVIDER

PRV00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

1,100

Provider File

PROV-ATTRIBUTES-MAIN

PRV00002

A record to capture basic, generally static information about each provider.

1,100

Provider File

PROV-ATTRIBUTES-MAIN

PRV00002

A provider is an individual person (medical or non-medical), a group of individuals, or an organization (e.g. institution, facility, agency, hospital, nursing facility, home health agency, school, or transportation organization) that delivers or facilitates health-related treatments, health care services, or living supports.

1,100

Provider File

PROV-LOCATION-AND-CONTACT-INFO

PRV00003

A record to capture addresses, phone numbers, and email addresses of the provider.

1,100

Provider File

PROV-LOCATION-AND-CONTACT-INFO

PRV00003

Each PROV-LOCATION-AND-CONTACT-INFO record segment represents the set of contact information for a single provider location.

1,100

Provider File

PROV-LOCATION-AND-CONTACT-INFO

PRV00003

The state can enter as many sets of contact information (i.e., multiple PROV-LOCATION-AND-CONTACT-INFO record segments) as it considers necessary. The value selected for the ADDR-TYPE field describes the type of contact information on that particular record (e.g., provider service location, provider billing address, etc.). The PROV-LOCATION-ID differentiates one PROV-LOCATION-AND-CONTACT-INFO record segment from another when the ADDR-TYPE value on both records is the same.

1,100

Provider File

PROV-LICENSING-INFO

PRV00004

A record to capture licensing and accreditation information relevant to the provider.

1,100

Provider File

PROV-IDENTIFIERS

PRV00005

A record to capture the identifiers assigned to the provider entity by various governmental, professional, and payer entities.

1,100

Provider File

PROV-TAXONOMY-CLASSIFICATION

PRV00006

A record to classify the provider into areas of specialty, as well as the authorized categories of service for which the provider entity has been authorized by the state to render to Medicaid/CHIP eligibles.

1,100

Provider File

PROV-MEDICAID-ENROLLMENT

PRV00007

A record to capture the provider’s periods of participation in the state's Medicaid/CHIP programs, and the reason for a change in enrollment status.

1,100

Provider File

PROV-AFFILIATED-GROUPS

PRV00008

A record to capture a provider’s relationship(s) with other provider(s).

1,100

Provider File

PROV-AFFILIATED-PROGRAMS

PRV00009

A record to capture the Medicaid/CHIP health plans, waivers, health home entities, etc. that the provider entity is associated with.

1,100

Provider File

PROV-BED-TYPE-INFO

PRV00010

A record to capture the number on beds available for various categories of bed at provider entities that are facilities.

1,100

Third-party Liability File

FILE-HEADER-RECORD-TPL

TPL00001

A record containing metadata necessary to identify the file itself, when it was created and the number of records it contains.

900

Third-party Liability File

TPL-MEDICAID-ELIGIBLE-PERSON-MAIN

TPL00002

A record to capture basic, generally static information to identify Medicaid/CHIP enrollees for whom third party funds may be available to offset some or all of their Medicaid/CHIP costs.

900

Third-party Liability File

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

TPL00003

A record to capture insurance policy information needed to facilitate pursuit of the third party liability.

900

Third-party Liability File

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

TPL00004

A record to capture TPL insurance coverage information to support the applicability assessment of the third party insurance coverage to the Medicaid/CHIP costs incurred on behalf of the Medicaid/CHIP enrollee.

900

Third-party Liability File

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

TPL00005

A record to flag Medicaid/CHIP enrollees who potentially have non-insurance sources of funds that could be used to offset Medicaid/CHIP expenditures.

900

Third-party Liability File

TPL-ENTITY-CONTACT-INFORMATION

TPL00006

A record to capture addresses and phone numbers of the entity providing TPL insurance coverage.

900



Diagram 1: Claim IP File – Claim Record Segment Relationships

Claim Inpatient Fle

Description of Diagram 1:

Each claim record in the T-MSIS inpatient claims file is composed of two types of record segments: One claim header segment and multiple claim line segments. Each claim line segment joins to its claim header segment on the following four data elements:

  1. SUBMITTING-STATE

  2. ICN-ORIG

  3. ICN-ADJ

  4. ADJUDICATION-DATE

Diagram 2: Claim LT File – Claim Record Segment Relationships

Claim Long Term

Description of Diagram 2:

Each claim record in the T-MSIS long-term care claims file is composed of two types of record segments: One claim header segment and multiple claim line segments. Each claim line segment joins to its claim header segment on the following four data elements:

  1. SUBMITTING-STATE

  2. ICN-ORIG

  3. ICN-ADJ

  4. ADJUDICATION-DATE


Diagram 3: Claim OT File – Claim Record Segment Relationships

Claim Other File

Description of Diagram 3:

Each claim record in the T-MSIS other claims file is composed of two types of record segments: One claim header segment and multiple claim line segments. Each claim line segment joins to its claim header segment on the following four data elements:

  1. SUBMITTING-STATE

  2. ICN-ORIG

  3. ICN-ADJ

  4. ADJUDICATION-DATE


Diagram 4: Claim Rx File – Claim Record Segment Relationships

Claim Rx File

Description of Diagram 4:

Each claim record in the T-MSIS prescription drug (Rx) claims file is composed of two types of record segments: One claim header segment and multiple claim line segments. Each claim line segment joins to its claim header segment on the following four data elements:

  1. SUBMITTING-STATE

  2. ICN-ORIG

  3. ICN-ADJ

  4. ADJUDICATION-DATE



Diagram 5: Eligibles File – Eligible Person Record Segment Relationships

Eligibile Person Record Segment

Description of Diagram 5:

Each eligible person in T-MSIS has a record in the T-MSIS eligibility file. Each of these records is comprised of up to eighteen different types of record segments. The PRIMARY-DEMOGRAPHICS-ELIGIBILITY (ELG00002) segment is the parent segment and all other segments, except for the HEALTH-HOME-SPA-PROVIDERS (ELG00007) segment, join to it on the following two data elements:

  1. SUBMITTING-STATE

  2. MSIS-IDENTIFICATION-NUM

The exception (the HEALTH-HOME-SPA-PROVIDERS (ELG00007) segment) is a child of the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION (ELG00006) segment and joins to it on:

  1. SUBMITTING-STATE

  2. MSIS-IDENTIFICATION-NUM

  3. HEALTH-HOME-SPA-ID

  4. HEALTH-HOME ENTITY-NAME



Diagram 6: Providers File – Provider Record Segment Relationships

Provider Record Segment Relationship

Description of Diagram 6:

Each provider in T-MSIS (regardless of whether the provider is a single individual, a group of practitioners, a facility, or a group of facilities) must have a record in the T-MSIS providers file. Each provider record is comprised of up to nine different types of record segments. The PROV-ATTRIBUTES-MAIN (PRV00002) segment is the parent segment to five segments: PROV-TAXONOMY-CLASSIFICATION (PRV00006), PROV-MEDICAID-ENROLLMENT (PRV00007), PROV-AFFILIATED-GROUPS (PRV00008), PROV-AFFILIATED-PROGRAMS (PRV00009), and PROV-LOCATION-AND-CONTACT-INFO (PRV00003), all of which join to PROV-ATTRIBUTES-MAIN on the following two data elements:

  1. SUBMITTING-STATE

  2. SUBMITTING-STATE-PROV-ID.

In addition, the PROV-LOCATION-AND-CONTACT-INFO (PRV00003) segment is a parent segment in its own right to three additional subordinate segments: PROV-IDENTIFIERS (PRV00005), PROV-LICENSING-INFO (PRV00004), PROV-BED-TYPE-INFO (PRV00010). These three segments join to the PROV-LOCATION-AND-CONTACT-INFO segment on:

  1. SUBMITTING-STATE

  2. SUBMITTING-STATE-PROV-ID

  3. PROV-LOCATION-ID.



Diagram 7: Managed Care File – Managed Care Entity Record Segment Relationships

Description of Diagram 7:

Each managed care entity in T-MSIS must have a record in the T-MSIS managed care file. Each managed care record is comprised of up to eight different types of record segments. The MANAGED-CARE-MAIN (MCR00002) segment is the parent segment to six segments: MANAGED-CARE-LOCATION-AND-CONTACT-INFO (MCR00003), MANAGED-CARE-SERVICE-AREA (MCR00004), MANAGED-CARE-OPERATING-AUTHORITY (MCR00005), MANAGED-CARE-PLAN-POPULATION-ENROLLED (MCR00006), MANAGED- CARE-ACCREDITATION-ORGANIZATION (MCR00007), and NATIONAL-HEALTH-CARE-ENTITY-ID-INFO (MCR00008), all of which join to PROV-ATTRIBUTES-MAIN on the following two data elements:

  1. SUBMITTING-STATE

  2. STATE-PLAN-ID-NUM

In addition, the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO (MCR00008) segment is a parent segment in its own right to the CHPID-SHPID-RELATIONSHIPS (MCR00009) segment, which joins to the NATIONAL-HEALTH-CARE-ENTITY-ID-INFO segment on:

  1. SUBMITTING-STATE

  2. STATE-PLAN-ID-NUM

  3. NATIONAL-HEALTH-CARE-ENTITY-ID*

  4. NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE*.

* = MCR00008.NATIONAL-HEALTH-CARE-ENTITY-ID would join to either MCR00009.CHPID or MCR00009.SHPID based on the value in MCR00008.NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE.



Diagram 8: Third-Party Liability (TPL) File – TPL Record Segment Relationships

Third-Party Liability File Segment Relationships

Description of Diagram 8:

Each instance of potential third-party liability for T-MSIS eligibles must have a record in the T-MSIS TPL file. There are actually two sets of information captured (called “subject areas”) in the TPL file: One set of records captures general information about non-Medicaid, non-Medicare health insurers, while the other set of records captures information about third party sources of funds that individual Medicaid/CHIP eligibles have.

TPL Health Insurance Entity Subject Area

Two types of record segments comprise the “TPL health insurance entity subject area:” the TPL-ENTITY-CONTACT-INFORMATION (TPL00006) and TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES (TPL00004) segments. There is a one-to-many relationship between these segment types (one TPL-ENTITY-CONTACT-INFORMATION segment type to many TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES segments). The TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES segment joins to the TPL-ENTITY-CONTACT-INFORMATION segment on two fields:

  1. SUBMITTING-STATE

  2. INSURANCE-CARRIER-ID-NUM

Medicaid/CHIP Enrollees with TPL Funding Subject Area

Three types of segments make up the “Medicaid/CHIP Enrollees with TPL Funding Subject Area.” The TPL-MEDICAID-ELIGIBLE-PERSON-MAIN

(TPL00002) segment type is the parent segment, with TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO

(TPL00003) and TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION (TPL00005) being the subordinate segments. The two subordinate segments join to TPL-MEDICAID-ELIGIBLE-PERSON-MAIN (TPL00002) segment on:

  1. SUBMITTING-STATE

  2. MSIS-IDENTIFICATION-NUM



PRA Disclosure Statement The Transformed Medicaid Statistical Information System (T-MSIS) is used to assist the Centers for Medicare & Medicaid Services (CMS) with monitoring and oversight of Medicaid and CHIP programs, to enable evaluation of demonstrations under section 1115 of the Social Security Act and to calculate quality measures and other metrics, including those reported through the new Medicaid and CHIP Scoreboard. Section 4735 of the Balanced Budget Act of 1997 included a statutory requirement for states to submit claims data, enrollee encounter data, and supporting information. Section 6504 of the Affordable Care Act strengthened this provision by requiring states to include data elements the Secretary determines necessary for program integrity, program oversight, and administration. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0345 (Expires: 07/31/2019). The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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