Transformed - Medicaid Statistical Information System (T-MSIS)
Transformed - Medicaid Statistical Information System (T-MSIS) (CMS-R-284)
1-T-MSIS_V2.4.0_DataDictionary.xlsx
Transformed - Medicaid Statistical Information System (T-MSIS)
OMB: 0938-0345
Document [xlsx]
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Data Element Definitions v2.4.0
Summ - Req Action Code Metrics
RecSegment Keys & Constraints
Overview
Cover SheetData Element Definitions v2.4.0
Summ - Req Action Code Metrics
RecSegment Keys & Constraints
Sheet 1: Cover Sheet
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| Centers for Medicaid and CHIP Services (CMCS) | |||||||||||||||
| Transformed Medicaid Statistical Information System (T-MSIS) | |||||||||||||||
| Data Dictionary | |||||||||||||||
| Version: v2.4.0 | |||||||||||||||
| Last Modified: 12/04/2020 | |||||||||||||||
| End of Sheet | |||||||||||||||
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Sheet 2: Data Element Definitions v2.4.0
| DD V2.4.0 - Data Element | |||||||||||
| ACTION CODE | NEW ROW NBR |
DE NO | DE NO EXTENDED | DATA ELEMENT NAME COMPUTING |
DATA ELEMENT NAME TEXT |
DATA ELEMENT LEVEL NECESSITY | DEFINITION | CODING REQUIREMENT | LAST UPDATE DATE |
FILENAME | FILE SEGMENT NAME WITH RECORD ID COMPUTING |
| X1 | 1 | CIP001 | CIP.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 2 | CIP001 | CIP.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CIP00001" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 3 | CIP002 | CIP.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 4 | CIP002 | CIP.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 5 | CIP002 | CIP.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 6 | CIP003 | CIP.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 7 | CIP003 | CIP.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 8 | CIP003 | CIP.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 9 | CIP004 | CIP.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 10 | CIP004 | CIP.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 11 | CIP004 | CIP.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 12 | CIP005 | CIP.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 13 | CIP005 | CIP.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 14 | CIP006 | CIP.001.006 | FILE-NAME | File Name | Mandatory | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'CLAIM-IP' | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 15 | CIP006 | CIP.001.006 | FILE-NAME | File Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| D1 | 16 | CIP006 | CIP.001.006 | FILE-NAME | Not Applicable | Not Applicable | [No longer essential - This requirement only] | For TYPE-OF-SERVICE = 001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132, or 135, FILE-NAME must be CLAIM-IP. | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 17 | CIP007 | CIP.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 18 | CIP007 | CIP.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 19 | CIP007 | CIP.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 20 | CIP008 | CIP.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 21 | CIP008 | CIP.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 22 | CIP008 | CIP.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 23 | CIP008 | CIP.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 24 | CIP008 | CIP.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 25 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 26 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 27 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 28 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 29 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 30 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 31 | CIP009 | CIP.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 32 | CIP010 | CIP.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 33 | CIP010 | CIP.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 34 | CIP010 | CIP.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 35 | CIP010 | CIP.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 36 | CIP010 | CIP.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 37 | CIP010 | CIP.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 38 | CIP011 | CIP.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 39 | CIP011 | CIP.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 40 | CIP011 | CIP.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 41 | CIP012 | CIP.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability _x000D_ files. |
Value must be in SSN Indicator List (VVL) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 42 | CIP012 | CIP.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 43 | CIP012 | CIP.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 44 | CIP013 | CIP.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 45 | CIP013 | CIP.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 46 | CIP013 | CIP.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 47 | CIP013 | CIP.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 48 | CIP013 | CIP.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| A2 | 49 | CIP014 | CIP.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 50 | CIP014 | CIP.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 51 | CIP014 | CIP.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| D1 | 52 | CIP015 | CIP.001.015 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 53 | CIP275 | CIP.001.275 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the _x000D_ original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject _x000D_ area). |
Value must between 1 and 9999 | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 54 | CIP275 | CIP.001.275 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 55 | CIP275 | CIP.001.275 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| C2 | 56 | CIP275 | CIP.001.275 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 57 | CIP275 | CIP.001.275 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 |
| X1 | 58 | CIP016 | CIP.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 59 | CIP016 | CIP.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CIP00002" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 60 | CIP017 | CIP.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 61 | CIP017 | CIP.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 62 | CIP017 | CIP.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 63 | CIP017 | CIP.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (CIP.001.007) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 64 | CIP018 | CIP.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 65 | CIP018 | CIP.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 66 | CIP018 | CIP.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 67 | CIP018 | CIP.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 68 | CIP019 | CIP.002.019 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 69 | CIP019 | CIP.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 70 | CIP019 | CIP.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 71 | CIP020 | CIP.002.020 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 72 | CIP020 | CIP.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 73 | CIP020 | CIP.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 74 | CIP020 | CIP.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 75 | CIP021 | CIP.002.021 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 76 | CIP021 | CIP.002.021 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 77 | CIP022 | CIP.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 78 | CIP022 | CIP.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 79 | CIP022 | CIP.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 80 | CIP022 | CIP.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 81 | CIP022 | CIP.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 82 | CIP022 | CIP.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 83 | CIP023 | CIP.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Conditional | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Value must be in Crossover Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 84 | CIP023 | CIP.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 85 | CIP023 | CIP.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 86 | CIP023 | CIP.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 87 | CIP023 | CIP.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If the TYPE-OF-CLAIM value is in ["1", "3", "A", "C"], then value is mandatory and must be reported. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 88 | CIP024 | CIP.002.024 | TYPE-OF-HOSPITAL | Type of Hospital | Mandatory | This code denotes the type of hospital on the claim (servicing facility). | Value must be in Type of Hospital List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 89 | CIP024 | CIP.002.024 | TYPE-OF-HOSPITAL | Type of Hospital | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 90 | CIP024 | CIP.002.024 | TYPE-OF-HOSPITAL | Type of Hospital | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 91 | CIP025 | CIP.002.025 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration. | Value must be in 1115A Demonstration Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 92 | CIP025 | CIP.002.025 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 93 | CIP025 | CIP.002.025 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 94 | CIP025 | CIP.002.025 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 95 | CIP026 | CIP.002.026 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | Value must be in Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 96 | CIP026 | CIP.002.026 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 97 | CIP026 | CIP.002.026 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 98 | CIP026 | CIP.002.026 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 99 | CIP026 | CIP.002.026 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 100 | CIP027 | CIP.002.027 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. If the amount paid is different from the amount billed you need an adjustment reason code. | Value must be in Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 101 | CIP027 | CIP.002.027 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 102 | CIP027 | CIP.002.027 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 103 | CIP027 | CIP.002.027 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must not be populated when associated Adjustment Indicator equals "0" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 104 | CIP028 | CIP.002.028 | ADMISSION-TYPE | Admission Type | Mandatory | The basic types of admission for Inpatient hospital stays and a code indicating the priority of this admission. | Value must be in Admission Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 105 | CIP028 | CIP.002.028 | ADMISSION-TYPE | Admission Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 106 | CIP028 | CIP.002.028 | ADMISSION-TYPE | Admission Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 107 | CIP029 | CIP.002.029 | DRG-DESCRIPTION | DRG Description | Conditional | Description of the associated state-specific DRG code. If using standard MS-DRG classification system, a DRG Description is not required. | Value must be 20 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 108 | CIP029 | CIP.002.029 | DRG-DESCRIPTION | DRG Description | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 109 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 110 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 111 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 112 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 113 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 114 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 115 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 116 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 117 | CIP030 | CIP.002.030 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 118 | CIP031 | CIP.002.031 | ADMITTING-DIAGNOSIS-CODE-FLAG | Admitting Diagnosis Code Flag | Mandatory | A flag that identifies the coding system used for the Admitting Diagnosis Code. | Value must be in Diagnosis Code Flag(VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 119 | CIP031 | CIP.002.031 | ADMITTING-DIAGNOSIS-CODE-FLAG | Admitting Diagnosis Code Flag | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 120 | CIP031 | CIP.002.031 | ADMITTING-DIAGNOSIS-CODE-FLAG | Admitting Diagnosis Code Flag | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 121 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Conditional | The primary/principal ICD-9/10-CM diagnosis code as reported on the claim. | When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 122 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 123 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 124 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 125 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 126 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 127 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 128 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 129 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 130 | CIP032 | CIP.002.032 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If Type of Claim (CIP.002.100) in ("1", "3", "A", "C", "U", "W") then value must be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 131 | CIP033 | CIP.002.033 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 132 | CIP033 | CIP.002.033 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 133 | CIP033 | CIP.002.033 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 134 | CIP033 | CIP.002.033 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 135 | CIP034 | CIP.002.034 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 136 | CIP034 | CIP.002.034 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 137 | CIP034 | CIP.002.034 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 138 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 139 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 140 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 141 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 142 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 143 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 144 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 145 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 146 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 147 | CIP035 | CIP.002.035 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 1 (CIP.002.032) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 148 | CIP036 | CIP.002.036 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 149 | CIP036 | CIP.002.036 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 150 | CIP036 | CIP.002.036 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 151 | CIP036 | CIP.002.036 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 152 | CIP037 | CIP.002.037 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 153 | CIP037 | CIP.002.037 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 154 | CIP037 | CIP.002.037 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 155 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 156 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 157 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 158 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 159 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 160 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 161 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 162 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 163 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 164 | CIP038 | CIP.002.038 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 2 (CIP.002.035) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 165 | CIP039 | CIP.002.039 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 166 | CIP039 | CIP.002.039 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 167 | CIP039 | CIP.002.039 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 168 | CIP039 | CIP.002.039 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 169 | CIP040 | CIP.002.040 | DIAGNOSIS-POA-FLAG-3 | Diagnosis POA Flag 3 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 170 | CIP040 | CIP.002.040 | DIAGNOSIS-POA-FLAG-3 | Diagnosis POA Flag 3 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 171 | CIP040 | CIP.002.040 | DIAGNOSIS-POA-FLAG-3 | Diagnosis POA Flag 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 172 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 173 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 174 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 175 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 176 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 177 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 178 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 179 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 180 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 181 | CIP041 | CIP.002.041 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 3 (CIP.002.038) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 182 | CIP042 | CIP.002.042 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 183 | CIP042 | CIP.002.042 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 184 | CIP042 | CIP.002.042 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 185 | CIP042 | CIP.002.042 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 186 | CIP043 | CIP.002.043 | DIAGNOSIS-POA-FLAG-4 | Diagnosis POA Flag 4 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 187 | CIP043 | CIP.002.043 | DIAGNOSIS-POA-FLAG-4 | Diagnosis POA Flag 4 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 188 | CIP043 | CIP.002.043 | DIAGNOSIS-POA-FLAG-4 | Diagnosis POA Flag 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 189 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 190 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 191 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 192 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 193 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 194 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 195 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 196 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 197 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 198 | CIP044 | CIP.002.044 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 4 (CIP.002.041) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 199 | CIP045 | CIP.002.045 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 200 | CIP045 | CIP.002.045 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 201 | CIP045 | CIP.002.045 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A1 | 202 | CIP045 | CIP.002.045 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 203 | CIP046 | CIP.002.046 | DIAGNOSIS-POA-FLAG-5 | Diagnosis POA Flag 5 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 204 | CIP046 | CIP.002.046 | DIAGNOSIS-POA-FLAG-5 | Diagnosis POA Flag 5 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 205 | CIP046 | CIP.002.046 | DIAGNOSIS-POA-FLAG-5 | Diagnosis POA Flag 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 206 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 207 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 208 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 209 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 210 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 211 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 212 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 213 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 214 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 215 | CIP047 | CIP.002.047 | DIAGNOSIS-CODE-6 | Diagnosis Code 6 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 5 (CIP.002.044) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 216 | CIP048 | CIP.002.048 | DIAGNOSIS-CODE-FLAG-6 | Diagnosis Code Flag 6 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 217 | CIP048 | CIP.002.048 | DIAGNOSIS-CODE-FLAG-6 | Diagnosis Code Flag 6 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 218 | CIP048 | CIP.002.048 | DIAGNOSIS-CODE-FLAG-6 | Diagnosis Code Flag 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 219 | CIP048 | CIP.002.048 | DIAGNOSIS-CODE-FLAG-6 | Diagnosis Code Flag 6 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 220 | CIP049 | CIP.002.049 | DIAGNOSIS-POA-FLAG-6 | Diagnosis POA Flag 6 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 221 | CIP049 | CIP.002.049 | DIAGNOSIS-POA-FLAG-6 | Diagnosis POA Flag 6 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 222 | CIP049 | CIP.002.049 | DIAGNOSIS-POA-FLAG-6 | Diagnosis POA Flag 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 223 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 224 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 225 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 226 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 227 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 228 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 229 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 230 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 231 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 232 | CIP050 | CIP.002.050 | DIAGNOSIS-CODE-7 | Diagnosis Code 7 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 6 (CIP.002.047) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 233 | CIP051 | CIP.002.051 | DIAGNOSIS-CODE-FLAG-7 | Diagnosis Code Flag 7 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 234 | CIP051 | CIP.002.051 | DIAGNOSIS-CODE-FLAG-7 | Diagnosis Code Flag 7 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 235 | CIP051 | CIP.002.051 | DIAGNOSIS-CODE-FLAG-7 | Diagnosis Code Flag 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 236 | CIP051 | CIP.002.051 | DIAGNOSIS-CODE-FLAG-7 | Diagnosis Code Flag 7 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 237 | CIP052 | CIP.002.052 | DIAGNOSIS-POA-FLAG-7 | Diagnosis POA Flag 7 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 238 | CIP052 | CIP.002.052 | DIAGNOSIS-POA-FLAG-7 | Diagnosis POA Flag 7 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 239 | CIP052 | CIP.002.052 | DIAGNOSIS-POA-FLAG-7 | Diagnosis POA Flag 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 240 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 241 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 242 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 243 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 244 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 245 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 246 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 247 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 248 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 249 | CIP053 | CIP.002.053 | DIAGNOSIS-CODE-8 | Diagnosis Code 8 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 7 (CIP.002.050) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 250 | CIP054 | CIP.002.054 | DIAGNOSIS-CODE-FLAG-8 | Diagnosis Code Flag 8 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 251 | CIP054 | CIP.002.054 | DIAGNOSIS-CODE-FLAG-8 | Diagnosis Code Flag 8 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 252 | CIP054 | CIP.002.054 | DIAGNOSIS-CODE-FLAG-8 | Diagnosis Code Flag 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 253 | CIP054 | CIP.002.054 | DIAGNOSIS-CODE-FLAG-8 | Diagnosis Code Flag 8 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 254 | CIP055 | CIP.002.055 | DIAGNOSIS-POA-FLAG-8 | Diagnosis POA Flag 8 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 255 | CIP055 | CIP.002.055 | DIAGNOSIS-POA-FLAG-8 | Diagnosis POA Flag 8 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 256 | CIP055 | CIP.002.055 | DIAGNOSIS-POA-FLAG-8 | Diagnosis POA Flag 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 257 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 258 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 259 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 260 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 261 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 262 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 263 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 264 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 265 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 266 | CIP056 | CIP.002.056 | DIAGNOSIS-CODE-9 | Diagnosis Code 9 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 8 (CIP.002.053) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 267 | CIP057 | CIP.002.057 | DIAGNOSIS-CODE-FLAG-9 | Diagnosis Code Flag 9 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 268 | CIP057 | CIP.002.057 | DIAGNOSIS-CODE-FLAG-9 | Diagnosis Code Flag 9 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 269 | CIP057 | CIP.002.057 | DIAGNOSIS-CODE-FLAG-9 | Diagnosis Code Flag 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 270 | CIP057 | CIP.002.057 | DIAGNOSIS-CODE-FLAG-9 | Diagnosis Code Flag 9 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 271 | CIP058 | CIP.002.058 | DIAGNOSIS-POA-FLAG-9 | Diagnosis POA Flag 9 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 272 | CIP058 | CIP.002.058 | DIAGNOSIS-POA-FLAG-9 | Diagnosis POA Flag 9 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 273 | CIP058 | CIP.002.058 | DIAGNOSIS-POA-FLAG-9 | Diagnosis POA Flag 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 274 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 275 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 276 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 277 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 278 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 279 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 280 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 281 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 282 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 283 | CIP059 | CIP.002.059 | DIAGNOSIS-CODE-10 | Diagnosis Code 10 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 9 (CIP.002.056) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 284 | CIP060 | CIP.002.060 | DIAGNOSIS-CODE-FLAG-10 | Diagnosis Code Flag 10 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 285 | CIP060 | CIP.002.060 | DIAGNOSIS-CODE-FLAG-10 | Diagnosis Code Flag 10 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 286 | CIP060 | CIP.002.060 | DIAGNOSIS-CODE-FLAG-10 | Diagnosis Code Flag 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 287 | CIP060 | CIP.002.060 | DIAGNOSIS-CODE-FLAG-10 | Diagnosis Code Flag 10 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 288 | CIP061 | CIP.002.061 | DIAGNOSIS-POA-FLAG-10 | Diagnosis POA Flag 10 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 289 | CIP061 | CIP.002.061 | DIAGNOSIS-POA-FLAG-10 | Diagnosis POA Flag 10 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 290 | CIP061 | CIP.002.061 | DIAGNOSIS-POA-FLAG-10 | Diagnosis POA Flag 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 291 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 292 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 293 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 294 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 295 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 296 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 297 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 298 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 299 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 300 | CIP062 | CIP.002.062 | DIAGNOSIS-CODE-11 | Diagnosis Code 11 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 10 (CIP.002.059) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 301 | CIP063 | CIP.002.063 | DIAGNOSIS-CODE-FLAG-11 | Diagnosis Code Flag 11 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 302 | CIP063 | CIP.002.063 | DIAGNOSIS-CODE-FLAG-11 | Diagnosis Code Flag 11 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 303 | CIP063 | CIP.002.063 | DIAGNOSIS-CODE-FLAG-11 | Diagnosis Code Flag 11 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 304 | CIP063 | CIP.002.063 | DIAGNOSIS-CODE-FLAG-11 | Diagnosis Code Flag 11 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 305 | CIP064 | CIP.002.064 | DIAGNOSIS-POA-FLAG-11 | Diagnosis POA Flag 11 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 306 | CIP064 | CIP.002.064 | DIAGNOSIS-POA-FLAG-11 | Diagnosis POA Flag 11 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 307 | CIP064 | CIP.002.064 | DIAGNOSIS-POA-FLAG-11 | Diagnosis POA Flag 11 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 308 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 309 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 310 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 311 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 312 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 313 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 314 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 315 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 316 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 317 | CIP065 | CIP.002.065 | DIAGNOSIS-CODE-12 | Diagnosis Code 12 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 11 (CIP.002.062) is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 318 | CIP066 | CIP.002.066 | DIAGNOSIS-CODE-FLAG-12 | Diagnosis Code Flag 12 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 319 | CIP066 | CIP.002.066 | DIAGNOSIS-CODE-FLAG-12 | Diagnosis Code Flag 12 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 320 | CIP066 | CIP.002.066 | DIAGNOSIS-CODE-FLAG-12 | Diagnosis Code Flag 12 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 321 | CIP066 | CIP.002.066 | DIAGNOSIS-CODE-FLAG-12 | Diagnosis Code Flag 12 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 322 | CIP067 | CIP.002.067 | DIAGNOSIS-POA-FLAG-12 | Diagnosis POA Flag 12 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 323 | CIP067 | CIP.002.067 | DIAGNOSIS-POA-FLAG-12 | Diagnosis POA Flag 12 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 324 | CIP067 | CIP.002.067 | DIAGNOSIS-POA-FLAG-12 | Diagnosis POA Flag 12 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 325 | CIP068 | CIP.002.068 | DIAGNOSIS-RELATED-GROUP | Diagnosis Related Group | Conditional | A code representing the Diagnosis Related Group (DRG) that is applicable for the inpatient services being rendered. This field is required on FFS claims and encounters records in _x000D_ which diagnosis related groups are used to determine paid amounts. |
Value must be 4 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 326 | CIP068 | CIP.002.068 | DIAGNOSIS-RELATED-GROUP | Diagnosis Related Group | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 327 | CIP069 | CIP.002.069 | DIAGNOSIS-RELATED-GROUP-IND | Diagnosis Related Group Indicator | Conditional | An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values. | Value must be 4 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 328 | CIP069 | CIP.002.069 | DIAGNOSIS-RELATED-GROUP-IND | Diagnosis Related Group Indicator | Not Applicable | Not Applicable | The right-most 2 positions must be found in 01-99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 329 | CIP069 | CIP.002.069 | DIAGNOSIS-RELATED-GROUP-IND | Diagnosis Related Group Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 330 | CIP069 | CIP.002.069 | DIAGNOSIS-RELATED-GROUP-IND | Diagnosis Related Group Indicator | Not Applicable | Not Applicable | Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 331 | CIP070 | CIP.002.070 | PROCEDURE-CODE-1 | Procedure Code 1 | Conditional | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-DATE-1, and _x000D_ PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through _x000D_ PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 332 | CIP070 | CIP.002.070 | PROCEDURE-CODE-1 | Procedure Code 1 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 333 | CIP070 | CIP.002.070 | PROCEDURE-CODE-1 | Procedure Code 1 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 334 | CIP070 | CIP.002.070 | PROCEDURE-CODE-1 | Procedure Code 1 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 335 | CIP070 | CIP.002.070 | PROCEDURE-CODE-1 | Procedure Code 1 | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 336 | CIP070 | CIP.002.070 | PROCEDURE-CODE-1 | Procedure Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 337 | CIP071 | CIP.002.071 | PROCEDURE-CODE-MOD-1 | Procedure Code Modifier 1 | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 338 | CIP072 | CIP.002.072 | PROCEDURE-CODE-FLAG-1 | Procedure Code Flag 1 | Conditional | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 339 | CIP072 | CIP.002.072 | PROCEDURE-CODE-FLAG-1 | Procedure Code Flag 1 | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 340 | CIP072 | CIP.002.072 | PROCEDURE-CODE-FLAG-1 | Procedure Code Flag 1 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 341 | CIP072 | CIP.002.072 | PROCEDURE-CODE-FLAG-1 | Procedure Code Flag 1 | Not Applicable | Not Applicable | If Procedure Code 1 (CIP.002.070) is populated, Procedure Code Flag 1 (CIP.002.072) must be '02' (ICD-9 CM) or '07' (ICD-10 - CM PCS). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 342 | CIP072 | CIP.002.072 | PROCEDURE-CODE-FLAG-1 | Procedure Code Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 343 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Conditional | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 344 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 345 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 346 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 347 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 348 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 349 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 350 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 351 | CIP074 | CIP.002.074 | PROCEDURE-CODE-2 | Procedure Code 2 | Conditional | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, PROCEDURE-CODE-DATE-1, and _x000D_ PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through _x000D_ PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 352 | CIP074 | CIP.002.074 | PROCEDURE-CODE-2 | Procedure Code 2 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 353 | CIP074 | CIP.002.074 | PROCEDURE-CODE-2 | Procedure Code 2 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 354 | CIP074 | CIP.002.074 | PROCEDURE-CODE-2 | Procedure Code 2 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 355 | CIP074 | CIP.002.074 | PROCEDURE-CODE-2 | Procedure Code 2 | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 356 | CIP074 | CIP.002.074 | PROCEDURE-CODE-2 | Procedure Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 357 | CIP075 | CIP.002.075 | PROCEDURE-CODE-MOD-2 | Procedure Code Modifier 2 | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 358 | CIP076 | CIP.002.076 | PROCEDURE-CODE-FLAG-2 | Procedure Code Flag 2 | Conditional | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 359 | CIP076 | CIP.002.076 | PROCEDURE-CODE-FLAG-2 | Procedure Code Flag 2 | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 360 | CIP076 | CIP.002.076 | PROCEDURE-CODE-FLAG-2 | Procedure Code Flag 2 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 361 | CIP076 | CIP.002.076 | PROCEDURE-CODE-FLAG-2 | Procedure Code Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 362 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Conditional | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 363 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 364 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 365 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 366 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 367 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 368 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 369 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A1 | 370 | CIP078 | CIP.002.078 | PROCEDURE-CODE-3 | Procedure Code 3 | Conditional | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-DATE-1, and _x000D_ PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through _x000D_ PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A1 | 371 | CIP078 | CIP.002.078 | PROCEDURE-CODE-3 | Procedure Code 3 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 372 | CIP078 | CIP.002.078 | PROCEDURE-CODE-3 | Procedure Code 3 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 373 | CIP078 | CIP.002.078 | PROCEDURE-CODE-3 | Procedure Code 3 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 374 | CIP078 | CIP.002.078 | PROCEDURE-CODE-3 | Procedure Code 3 | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 375 | CIP078 | CIP.002.078 | PROCEDURE-CODE-3 | Procedure Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 376 | CIP079 | CIP.002.079 | PROCEDURE-CODE-MOD-3 | Procedure Code Modifier 3 | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 377 | CIP080 | CIP.002.080 | PROCEDURE-CODE-FLAG-3 | Procedure Code Flag 3 | Conditional | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 378 | CIP080 | CIP.002.080 | PROCEDURE-CODE-FLAG-3 | Procedure Code Flag 3 | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 379 | CIP080 | CIP.002.080 | PROCEDURE-CODE-FLAG-3 | Procedure Code Flag 3 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 380 | CIP080 | CIP.002.080 | PROCEDURE-CODE-FLAG-3 | Procedure Code Flag 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 381 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Conditional | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 382 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 383 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 384 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 385 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 386 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 387 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 388 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 389 | CIP082 | CIP.002.082 | PROCEDURE-CODE-4 | Procedure Code 4 | Conditional | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-DATE-1, and _x000D_ PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through _x000D_ PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 390 | CIP082 | CIP.002.082 | PROCEDURE-CODE-4 | Procedure Code 4 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 391 | CIP082 | CIP.002.082 | PROCEDURE-CODE-4 | Procedure Code 4 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 392 | CIP082 | CIP.002.082 | PROCEDURE-CODE-4 | Procedure Code 4 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 393 | CIP082 | CIP.002.082 | PROCEDURE-CODE-4 | Procedure Code 4 | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 394 | CIP082 | CIP.002.082 | PROCEDURE-CODE-4 | Procedure Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 395 | CIP083 | CIP.002.083 | PROCEDURE-CODE-MOD-4 | Procedure Code Modifier 4 | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 396 | CIP084 | CIP.002.084 | PROCEDURE-CODE-FLAG-4 | Procedure Code Flag 4 | Conditional | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 397 | CIP084 | CIP.002.084 | PROCEDURE-CODE-FLAG-4 | Procedure Code Flag 4 | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 398 | CIP084 | CIP.002.084 | PROCEDURE-CODE-FLAG-4 | Procedure Code Flag 4 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 399 | CIP084 | CIP.002.084 | PROCEDURE-CODE-FLAG-4 | Procedure Code Flag 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 400 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Conditional | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 401 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 402 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 403 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 404 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 405 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 406 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 407 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 408 | CIP086 | CIP.002.086 | PROCEDURE-CODE-5 | Procedure Code 5 | Conditional | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in PROCEDURE-CODE-1, PROCEDURE-CODE-DATE-1, and _x000D_ PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through _x000D_ PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 409 | CIP086 | CIP.002.086 | PROCEDURE-CODE-5 | Procedure Code 5 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 410 | CIP086 | CIP.002.086 | PROCEDURE-CODE-5 | Procedure Code 5 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 411 | CIP086 | CIP.002.086 | PROCEDURE-CODE-5 | Procedure Code 5 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 412 | CIP086 | CIP.002.086 | PROCEDURE-CODE-5 | Procedure Code 5 | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 413 | CIP086 | CIP.002.086 | PROCEDURE-CODE-5 | Procedure Code 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 414 | CIP087 | CIP.002.087 | PROCEDURE-CODE-MOD-5 | Procedure Code Modifier 5 | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 415 | CIP088 | CIP.002.088 | PROCEDURE-CODE-FLAG-5 | Procedure Code Flag 5 | Not Applicable | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 416 | CIP088 | CIP.002.088 | PROCEDURE-CODE-FLAG-5 | Procedure Code Flag 5 | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 417 | CIP088 | CIP.002.088 | PROCEDURE-CODE-FLAG-5 | Procedure Code Flag 5 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 418 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Conditional | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 419 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 420 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 421 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 422 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 423 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 424 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 425 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 426 | CIP090 | CIP.002.090 | PROCEDURE-CODE-6 | Procedure Code 6 | Conditional | A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, PROCEDURE-CODE-DATE-1, and _x000D_ PROCEDURE-CODE-FLAG-1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use PROCEDURE-CODE-2 through _x000D_ PROCEDURE-CODE-6 (and related data elements) to record secondary, tertiary, etc. procedures. |
When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 427 | CIP090 | CIP.002.090 | PROCEDURE-CODE-6 | Procedure Code 6 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 428 | CIP090 | CIP.002.090 | PROCEDURE-CODE-6 | Procedure Code 6 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 429 | CIP090 | CIP.002.090 | PROCEDURE-CODE-6 | Procedure Code 6 | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 430 | CIP090 | CIP.002.090 | PROCEDURE-CODE-6 | Procedure Code 6 | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 431 | CIP090 | CIP.002.090 | PROCEDURE-CODE-6 | Procedure Code 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 432 | CIP091 | CIP.002.091 | PROCEDURE-CODE-MOD-6 | Procedure Code Modifier 6 | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 433 | CIP092 | CIP.002.092 | PROCEDURE-CODE-FLAG-6 | Procedure Code Flag 6 | Conditional | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 434 | CIP092 | CIP.002.092 | PROCEDURE-CODE-FLAG-6 | Procedure Code Flag 6 | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 435 | CIP092 | CIP.002.092 | PROCEDURE-CODE-FLAG-6 | Procedure Code Flag 6 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 436 | CIP092 | CIP.002.092 | PROCEDURE-CODE-FLAG-6 | Procedure Code Flag 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 437 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 438 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 439 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 440 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 441 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 442 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 443 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 444 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Mandatory | The date on which the recipient was admitted to a hospital. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 445 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 446 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be less than or equal to associated Discharge Date value in the claim header. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 447 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated eligible Date of Birth value. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 448 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be less than or equal to associated eligible Date of Death value. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 449 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 450 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 451 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 452 | CIP095 | CIP.002.095 | ADMISSION-HOUR | Admission Hour | Conditional | The hour of admission to a hospital. | Value must be in Hour List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 453 | CIP095 | CIP.002.095 | ADMISSION-HOUR | Admission Hour | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 454 | CIP095 | CIP.002.095 | ADMISSION-HOUR | Admission Hour | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 455 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Conditional | The date on which the recipient was discharged from a hospital. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 456 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 457 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be less than or equal to associated Adjudication Date value. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 458 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Admission Date value. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 459 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated eligible Date of Birth value. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 460 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be less than or equal to associated eligible Date of Death value. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 461 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 462 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 463 | CIP097 | CIP.002.097 | DISCHARGE-HOUR | Discharge Hour | Conditional | The hour of discharge from a hospital. | Value must be in Hour List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 464 | CIP097 | CIP.002.097 | DISCHARGE-HOUR | Discharge Hour | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 465 | CIP097 | CIP.002.097 | DISCHARGE-HOUR | Discharge Hour | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 466 | CIP097 | CIP.002.097 | DISCHARGE-HOUR | Discharge Hour | Not Applicable | Not Applicable | When populated, Discharge Date (CIP.002.096) must be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 467 | CIP098 | CIP.002.098 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 468 | CIP098 | CIP.002.098 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 469 | CIP098 | CIP.002.098 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 470 | CIP098 | CIP.002.098 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 471 | CIP098 | CIP.002.098 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or after associated Admission Date value | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 472 | CIP099 | CIP.002.099 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 473 | CIP099 | CIP.002.099 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 474 | CIP099 | CIP.002.099 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Must have an associated Total Medicaid Paid Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 475 | CIP099 | CIP.002.099 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 476 | CIP100 | CIP.002.100 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. | Value must be in Type of Claim List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 477 | CIP100 | CIP.002.100 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 478 | CIP100 | CIP.002.100 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 479 | CIP100 | CIP.002.100 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | When value equals 'Z', claim denied indicator must equal '0' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 480 | CIP101 | CIP.002.101 | TYPE-OF-BILL | Type of Bill | Mandatory | A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) | Value must be in Type of Bill List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 481 | CIP101 | CIP.002.101 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | Value must be 4 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 482 | CIP101 | CIP.002.101 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | First character must be a '0' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 483 | CIP101 | CIP.002.101 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 484 | CIP102 | CIP.002.102 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 485 | CIP102 | CIP.002.102 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 486 | CIP102 | CIP.002.102 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 487 | CIP102 | CIP.002.102 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | If value in [ 26, 87, 542, 585, 654 ], Claim Denied Indicator must be '0' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 488 | CIP103 | CIP.002.103 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.), which is then further detailed in the companion data element CLAIM-STATUS | Value must be in Claim Status Category List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 489 | CIP103 | CIP.002.103 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 490 | CIP103 | CIP.002.103 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 491 | CIP103 | CIP.002.103 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 492 | CIP103 | CIP.002.103 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 493 | CIP104 | CIP.002.104 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. | Value must be in Source Location List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 494 | CIP104 | CIP.002.104 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 495 | CIP104 | CIP.002.104 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 496 | CIP105 | CIP.002.105 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | Value must be 15 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 497 | CIP105 | CIP.002.105 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must have an associated Check Effective Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 498 | CIP105 | CIP.002.105 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 499 | CIP105 | CIP.002.105 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 500 | CIP106 | CIP.002.106 | CHECK-EFF-DATE | Check Effective Date | Conditional | The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 501 | CIP106 | CIP.002.106 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 502 | CIP106 | CIP.002.106 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Value may be the same as associated Remittance Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 503 | CIP106 | CIP.002.106 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Must have an associated Check Number | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 504 | CIP106 | CIP.002.106 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 505 | CIP107 | CIP.002.107 | ALLOWED-CHARGE-SRC | Allowed Charge Source | Conditional | These codes indicate how each allowed charge was determined. Claims records for an eligible individual should not indicate Medicare as the source to indicate how an allowed charge was determined on the claim, if the eligible individual is not a dual eligible | Value must be in Allowed Charge Source List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 506 | CIP107 | CIP.002.107 | ALLOWED-CHARGE-SRC | Allowed Charge Source | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 507 | CIP107 | CIP.002.107 | ALLOWED-CHARGE-SRC | Allowed Charge Source | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 508 | CIP107 | CIP.002.107 | ALLOWED-CHARGE-SRC | Allowed Charge Source | Not Applicable | Not Applicable | (not a Medicare Beneficiary) if Dual Eligible (ELG.005.085) equals '00', then value must not be in ['1','I', 'K', 'M'] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 509 | CIP108 | CIP.002.108 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 510 | CIP108 | CIP.002.108 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 511 | CIP108 | CIP.002.108 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 512 | CIP108 | CIP.002.108 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 513 | CIP109 | CIP.002.109 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 514 | CIP109 | CIP.002.109 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 515 | CIP109 | CIP.002.109 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 516 | CIP109 | CIP.002.109 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 517 | CIP109 | CIP.002.109 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 1 is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 518 | CIP110 | CIP.002.110 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 519 | CIP110 | CIP.002.110 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 520 | CIP110 | CIP.002.110 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 521 | CIP110 | CIP.002.110 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 522 | CIP110 | CIP.002.110 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 2 is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 523 | CIP111 | CIP.002.111 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 524 | CIP111 | CIP.002.111 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 525 | CIP111 | CIP.002.111 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 526 | CIP111 | CIP.002.111 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 527 | CIP111 | CIP.002.111 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 3 is not populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 528 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Conditional | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial _x000D_ transactions. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 529 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 530 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must equal the sum of all Billed Amount instances for the associated claim | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 531 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 532 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 533 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 534 | CIP112 | CIP.002.112 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | If associated Type of Claim value is 2, 4, 5, B, D, or E, then value should not be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 535 | CIP113 | CIP.002.113 | TOT-ALLOWED-AMT | Total Allowed Amount | Conditional | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is _x000D_ determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 536 | CIP113 | CIP.002.113 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 537 | CIP113 | CIP.002.113 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 538 | CIP113 | CIP.002.113 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 539 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Conditional | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 540 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 541 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Must have an associated Medicaid Paid Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 542 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 543 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 544 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 545 | CIP114 | CIP.002.114 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must not be greater than Total Allowed Amount (CIP.002.113) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 546 | CIP115 | CIP.002.115 | TOT-COPAY-AMT | Total Copayment Amount | Conditional | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 547 | CIP115 | CIP.002.115 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 548 | CIP115 | CIP.002.115 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 549 | CIP115 | CIP.002.115 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 550 | CIP115 | CIP.002.115 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 551 | CIP115 | CIP.002.115 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 552 | CIP116 | CIP.002.116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Conditional | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and _x000D_ deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a "1" and leave Total Medicare Coinsurance Amount unpopulated. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 553 | CIP116 | CIP.002.116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 554 | CIP116 | CIP.002.116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 555 | CIP116 | CIP.002.116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 556 | CIP116 | CIP.002.116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 557 | CIP116 | CIP.002.116 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 558 | CIP117 | CIP.002.117 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Conditional | The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 559 | CIP117 | CIP.002.117 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 560 | CIP117 | CIP.002.117 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 561 | CIP117 | CIP.002.117 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 562 | CIP117 | CIP.002.117 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Medicare Combined Deductible Indicator is '1', then value must not be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 563 | CIP117 | CIP.002.117 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 564 | CIP118 | CIP.002.118 | TOT-TPL-AMT | Total Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 565 | CIP118 | CIP.002.118 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 566 | CIP118 | CIP.002.118 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 567 | CIP118 | CIP.002.118 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 568 | CIP119 | CIP.002.119 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 569 | CIP119 | CIP.002.119 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 570 | CIP119 | CIP.002.119 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 571 | CIP121 | CIP.002.121 | OTHER-INSURANCE-IND | Other Insurance Indicator | Conditional | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Value must be in Other Insurance Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 572 | CIP121 | CIP.002.121 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 573 | CIP121 | CIP.002.121 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 574 | CIP122 | CIP.002.122 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 575 | CIP122 | CIP.002.122 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 576 | CIP122 | CIP.002.122 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 577 | CIP123 | CIP.002.123 | SERVICE-TRACKING-TYPE | Service Tracking Type | Conditional | A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee. | Value must be in Service Tracking Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 578 | CIP123 | CIP.002.123 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 579 | CIP123 | CIP.002.123 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 580 | CIP123 | CIP.002.123 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 581 | CIP124 | CIP.002.124 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Conditional | On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 582 | CIP124 | CIP.002.124 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 583 | CIP124 | CIP.002.124 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 584 | CIP124 | CIP.002.124 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 585 | CIP124 | CIP.002.124 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Service Tracking Type must be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 586 | CIP124 | CIP.002.124 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Total Medicaid Amount must not be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 587 | CIP125 | CIP.002.125 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Conditional | This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management _x000D_ programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined "medical record" _x000D_ associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Value must be in Fixed Payment Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 588 | CIP125 | CIP.002.125 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 589 | CIP125 | CIP.002.125 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 590 | CIP126 | CIP.002.126 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | Value must be in Funding Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 591 | CIP126 | CIP.002.126 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 592 | CIP126 | CIP.002.126 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 593 | CIP127 | CIP.002.127 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. | Value must be in Funding Source Non-Federal Share List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 594 | CIP127 | CIP.002.127 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 595 | CIP127 | CIP.002.127 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Required | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 596 | CIP128 | CIP.002.128 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Conditional | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. | Value must be in Medicare Combined Deductible Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 597 | CIP128 | CIP.002.128 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 598 | CIP128 | CIP.002.128 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | If value equals '1', then Medicare Coinsurance amount is not populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 599 | CIP128 | CIP.002.128 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must equal '0' if associated Type of Claim is '3', 'C' or 'W' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 600 | CIP128 | CIP.002.128 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 601 | CIP129 | CIP.002.129 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | Value must be in Program Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 602 | CIP129 | CIP.002.129 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 603 | CIP129 | CIP.002.129 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 604 | CIP129 | CIP.002.129 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 605 | CIP129 | CIP.002.129 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 606 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Conditional | A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 607 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 608 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 609 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match Managed Care Plan ID (ELG.014.192) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 610 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match State Plan ID Number (MCR.002.019) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 611 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim (CIP.002.100) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Admission Date (CIP.002.094) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 612 | CIP130 | CIP.002.130 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim (CIP.002.100) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Admission Date (CIP.002.094) occurs between the managed care contract eff/end dates (MCR.002.020/021) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 613 | CIP131 | CIP.002.131 | NATIONAL-HEALTH-CARE-ENTITY-ID | National Health Care Entity ID | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 614 | CIP132 | CIP.002.132 | PAYMENT-LEVEL-IND | Payment Level Indicator | Mandatory | The field denotes whether the payment amount was determined at the claim header or line/detail level. | Value must be in Payment Level Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 615 | CIP132 | CIP.002.132 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 616 | CIP132 | CIP.002.132 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 617 | CIP133 | CIP.002.133 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | Value must be in Medicare Reimbursement Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 618 | CIP133 | CIP.002.133 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | (Crossover Claim) if associated Crossover Indicator value indicates a crossover claim, value is mandatory and must be provided | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 619 | CIP133 | CIP.002.133 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 620 | CIP133 | CIP.002.133 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 621 | CIP134 | CIP.002.134 | NON-COV-DAYS | Non-Covered Days | Conditional | The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service. | Value must be a positive integer | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 622 | CIP134 | CIP.002.134 | NON-COV-DAYS | Non-Covered Days | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 623 | CIP134 | CIP.002.134 | NON-COV-DAYS | Non-Covered Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 624 | CIP134 | CIP.002.134 | NON-COV-DAYS | Non-Covered Days | Not Applicable | Not Applicable | Value must be 5 digits or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 625 | CIP135 | CIP.002.135 | NON-COV-CHARGES | Non-Covered Charges | Conditional | The charges for inpatient care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 626 | CIP135 | CIP.002.135 | NON-COV-CHARGES | Non-Covered Charges | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 627 | CIP135 | CIP.002.135 | NON-COV-CHARGES | Non-Covered Charges | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 628 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Conditional | The number of 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. | Value must be a positive integer | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 629 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 630 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 631 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 632 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value must be 7 digits or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 633 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value is required if the associated Type of Service (CIP.002.257) is in [001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 634 | CIP136 | CIP.002.136 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value is required if at least one associated Revenue Code (CIP.003.245) is in [100-219] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 635 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | Value must be a positive integer | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 636 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be between 0:9999 (inclusive) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 637 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must not include commas or other non-numeric characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 638 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 639 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 640 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 641 | CIP138 | CIP.002.138 | FORCED-CLAIM-IND | Forced Claim Indicator | Conditional | Indicates if the claim was processed by forcing it through a manual override process. | Value must be in Forced Claim Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 642 | CIP138 | CIP.002.138 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 643 | CIP138 | CIP.002.138 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 644 | CIP139 | CIP.002.139 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Conditional | This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site :_x000D_ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
Value must be in Healthcare Acquired Condition Indicator List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 645 | CIP139 | CIP.002.139 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 646 | CIP139 | CIP.002.139 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 647 | CIP140 | CIP.002.140 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 648 | CIP140 | CIP.002.140 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 649 | CIP140 | CIP.002.140 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 650 | CIP141 | CIP.002.141 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 651 | CIP141 | CIP.002.141 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 652 | CIP141 | CIP.002.141 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 653 | CIP142 | CIP.002.142 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 654 | CIP142 | CIP.002.142 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 655 | CIP142 | CIP.002.142 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 656 | CIP143 | CIP.002.143 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 657 | CIP143 | CIP.002.143 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 658 | CIP143 | CIP.002.143 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 659 | CIP144 | CIP.002.144 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 660 | CIP144 | CIP.002.144 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 661 | CIP144 | CIP.002.144 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 662 | CIP145 | CIP.002.145 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 663 | CIP145 | CIP.002.145 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 664 | CIP145 | CIP.002.145 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 665 | CIP146 | CIP.002.146 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 666 | CIP146 | CIP.002.146 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 667 | CIP146 | CIP.002.146 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 668 | CIP147 | CIP.002.147 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 669 | CIP147 | CIP.002.147 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 670 | CIP147 | CIP.002.147 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 671 | CIP148 | CIP.002.148 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 672 | CIP148 | CIP.002.148 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 673 | CIP148 | CIP.002.148 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 674 | CIP149 | CIP.002.149 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 675 | CIP149 | CIP.002.149 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 676 | CIP149 | CIP.002.149 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 677 | CIP150 | CIP.002.150 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 678 | CIP150 | CIP.002.150 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 679 | CIP150 | CIP.002.150 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 680 | CIP150 | CIP.002.150 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 681 | CIP150 | CIP.002.150 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 682 | CIP151 | CIP.002.151 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 683 | CIP151 | CIP.002.151 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 684 | CIP151 | CIP.002.151 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 685 | CIP151 | CIP.002.151 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 686 | CIP151 | CIP.002.151 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 687 | CIP152 | CIP.002.152 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 688 | CIP152 | CIP.002.152 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 689 | CIP152 | CIP.002.152 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 690 | CIP152 | CIP.002.152 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 691 | CIP152 | CIP.002.152 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 692 | CIP153 | CIP.002.153 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 693 | CIP153 | CIP.002.153 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 694 | CIP153 | CIP.002.153 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 695 | CIP153 | CIP.002.153 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 696 | CIP153 | CIP.002.153 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 697 | CIP154 | CIP.002.154 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 698 | CIP154 | CIP.002.154 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 699 | CIP154 | CIP.002.154 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 700 | CIP154 | CIP.002.154 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 701 | CIP154 | CIP.002.154 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 702 | CIP155 | CIP.002.155 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 703 | CIP155 | CIP.002.155 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 704 | CIP155 | CIP.002.155 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 705 | CIP155 | CIP.002.155 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 706 | CIP155 | CIP.002.155 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 707 | CIP156 | CIP.002.156 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 708 | CIP156 | CIP.002.156 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 709 | CIP156 | CIP.002.156 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 710 | CIP156 | CIP.002.156 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 711 | CIP156 | CIP.002.156 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 712 | CIP157 | CIP.002.157 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 713 | CIP157 | CIP.002.157 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 714 | CIP157 | CIP.002.157 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 715 | CIP157 | CIP.002.157 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 716 | CIP157 | CIP.002.157 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 717 | CIP158 | CIP.002.158 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 718 | CIP158 | CIP.002.158 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 719 | CIP158 | CIP.002.158 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 720 | CIP158 | CIP.002.158 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 721 | CIP158 | CIP.002.158 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 722 | CIP159 | CIP.002.159 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 723 | CIP159 | CIP.002.159 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 724 | CIP159 | CIP.002.159 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 725 | CIP159 | CIP.002.159 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 726 | CIP159 | CIP.002.159 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 727 | CIP160 | CIP.002.160 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 728 | CIP160 | CIP.002.160 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 729 | CIP160 | CIP.002.160 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 730 | CIP160 | CIP.002.160 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 731 | CIP161 | CIP.002.161 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 732 | CIP161 | CIP.002.161 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 733 | CIP161 | CIP.002.161 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 734 | CIP161 | CIP.002.161 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 735 | CIP162 | CIP.002.162 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 736 | CIP162 | CIP.002.162 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 737 | CIP162 | CIP.002.162 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 738 | CIP162 | CIP.002.162 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 739 | CIP163 | CIP.002.163 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 740 | CIP163 | CIP.002.163 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 741 | CIP163 | CIP.002.163 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 742 | CIP163 | CIP.002.163 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 743 | CIP164 | CIP.002.164 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 744 | CIP164 | CIP.002.164 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 745 | CIP164 | CIP.002.164 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 746 | CIP164 | CIP.002.164 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 747 | CIP165 | CIP.002.165 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 748 | CIP165 | CIP.002.165 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 749 | CIP165 | CIP.002.165 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 750 | CIP165 | CIP.002.165 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 751 | CIP166 | CIP.002.166 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 752 | CIP166 | CIP.002.166 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 753 | CIP166 | CIP.002.166 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 754 | CIP166 | CIP.002.166 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 755 | CIP167 | CIP.002.167 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 756 | CIP167 | CIP.002.167 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 757 | CIP167 | CIP.002.167 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 758 | CIP167 | CIP.002.167 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 759 | CIP168 | CIP.002.168 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 760 | CIP168 | CIP.002.168 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 761 | CIP168 | CIP.002.168 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 762 | CIP168 | CIP.002.168 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 763 | CIP169 | CIP.002.169 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 764 | CIP169 | CIP.002.169 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 765 | CIP169 | CIP.002.169 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 766 | CIP169 | CIP.002.169 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 767 | CIP170 | CIP.002.170 | BIRTH-WEIGHT-GRAMS | Birth Weight Grams | Conditional | The weight of a newborn at time of birth in grams (applicable to newborns only). The field is required when a claim involves a child birth. | Value must not be greater than 6 digits to the left of the decimal and have no more than 3 digits to the right of the decimal (i.e. 999999.999) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 768 | CIP170 | CIP.002.170 | BIRTH-WEIGHT-GRAMS | Birth Weight Grams | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 769 | CIP171 | CIP.002.171 | PATIENT-CONTROL-NUM | Patient Control Number | Conditional | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of _x000D_ individual financial and clinical records and posting of payment |
Value must be 20 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 770 | CIP171 | CIP.002.171 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 771 | CIP171 | CIP.002.171 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 772 | CIP172 | CIP.002.172 | ELIGIBLE-LAST-NAME | Eligible Last Name | Conditional | The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record _x000D_ with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 773 | CIP172 | CIP.002.172 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 774 | CIP172 | CIP.002.172 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 775 | CIP173 | CIP.002.173 | ELIGIBLE-FIRST-NAME | Eligible First Name | Conditional | The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record _x000D_ with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 776 | CIP173 | CIP.002.173 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 777 | CIP173 | CIP.002.173 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 778 | CIP174 | CIP.002.174 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 779 | CIP174 | CIP.002.174 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 780 | CIP174 | CIP.002.174 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 781 | CIP174 | CIP.002.174 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 782 | CIP175 | CIP.002.175 | DATE-OF-BIRTH | Date of Birth | Mandatory | Date of birth of the individual to whom the services were provided. A patient's age should not be greater than 112 years. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 783 | CIP175 | CIP.002.175 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 784 | CIP175 | CIP.002.175 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 785 | CIP176 | CIP.002.176 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Conditional | Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. States should not submit claim records for an eligible individual that indicate the claim was submitted by a _x000D_ provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or _x000D_ provider group enrolled in the health home model. |
Value must be in Health Home Provider Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 786 | CIP176 | CIP.002.176 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | If there is an associated Health Home Entity Name value, then value must be "1" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 787 | CIP176 | CIP.002.176 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 788 | CIP176 | CIP.002.176 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 789 | CIP177 | CIP.002.177 | WAIVER-TYPE | Waiver Type | Conditional | A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Value must be in Waiver Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 790 | CIP177 | CIP.002.177 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 791 | CIP177 | CIP.002.177 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 792 | CIP177 | CIP.002.177 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must have a corresponding value in Waiver ID (CIP.002.178) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 793 | CIP177 | CIP.002.177 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 794 | CIP178 | CIP.002.178 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the_x000D_ "core" part of the waiver IDs, without including suffixes for renewals or amendments. |
Value must be associated with a populated Waiver Type | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 795 | CIP178 | CIP.002.178 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 796 | CIP178 | CIP.002.178 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 797 | CIP178 | CIP.002.178 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 798 | CIP178 | CIP.002.178 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 799 | CIP179 | CIP.002.179 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity _x000D_ (billing or reporting) to the managed care plan. |
Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 800 | CIP179 | CIP.002.179 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 801 | CIP179 | CIP.002.179 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 802 | CIP179 | CIP.002.179 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1' |
2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 803 | CIP179 | CIP.002.179 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 804 | CIP180 | CIP.002.180 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 805 | CIP180 | CIP.002.180 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 806 | CIP180 | CIP.002.180 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 807 | CIP180 | CIP.002.180 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 808 | CIP181 | CIP.002.181 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the institution billing for the beneficiary. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 809 | CIP181 | CIP.002.181 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 810 | CIP181 | CIP.002.181 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 811 | CIP182 | CIP.002.182 | BILLING-PROV-TYPE | Billing Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 812 | CIP182 | CIP.002.182 | BILLING-PROV-TYPE | Billing Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 813 | CIP182 | CIP.002.182 | BILLING-PROV-TYPE | Billing Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 814 | CIP183 | CIP.002.183 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 815 | CIP183 | CIP.002.183 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 816 | CIP183 | CIP.002.183 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 817 | CIP184 | CIP.002.184 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Not Applicable | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 818 | CIP184 | CIP.002.184 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 819 | CIP185 | CIP.002.185 | ADMITTING-PROV-NUM | Admitting Provider Number | Conditional | The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 820 | CIP185 | CIP.002.185 | ADMITTING-PROV-NUM | Admitting Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 821 | CIP185 | CIP.002.185 | ADMITTING-PROV-NUM | Admitting Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 822 | CIP186 | CIP.002.186 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 823 | CIP186 | CIP.002.186 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 824 | CIP186 | CIP.002.186 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 825 | CIP187 | CIP.002.187 | ADMITTING-PROV-TAXONOMY | Admitting Provider Taxonomy | Conditional | Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 826 | CIP187 | CIP.002.187 | ADMITTING-PROV-TAXONOMY | Admitting Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 827 | CIP187 | CIP.002.187 | ADMITTING-PROV-TAXONOMY | Admitting Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 828 | CIP188 | CIP.002.188 | ADMITTING-PROV-TYPE | Admitting Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 829 | CIP188 | CIP.002.188 | ADMITTING-PROV-TYPE | Admitting Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 830 | CIP188 | CIP.002.188 | ADMITTING-PROV-TYPE | Admitting Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 831 | CIP189 | CIP.002.189 | REFERRING-PROV-NUM | Referring Provider Number | Conditional | A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a _x000D_ group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA _x000D_ ID for this data element. |
Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 832 | CIP189 | CIP.002.189 | REFERRING-PROV-NUM | Referring Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 833 | CIP189 | CIP.002.189 | REFERRING-PROV-NUM | Referring Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 834 | CIP190 | CIP.002.190 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 835 | CIP190 | CIP.002.190 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 836 | CIP190 | CIP.002.190 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 837 | CIP191 | CIP.002.191 | REFERRING-PROV-TAXONOMY | Referring Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 838 | CIP192 | CIP.002.192 | REFERRING-PROV-TYPE | Referring Provider Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 839 | CIP193 | CIP.002.193 | REFERRING-PROV-SPECIALTY | Referring Provider Specialty | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 840 | CIP194 | CIP.002.194 | DRG-OUTLIER-AMT | DRG Outlier Amount | Conditional | The additional payment on a claim that is associated with either a cost outlier or length of stay outlier._x000D_ Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 841 | CIP194 | CIP.002.194 | DRG-OUTLIER-AMT | DRG Outlier Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 842 | CIP194 | CIP.002.194 | DRG-OUTLIER-AMT | DRG Outlier Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 843 | CIP194 | CIP.002.194 | DRG-OUTLIER-AMT | DRG Outlier Amount | Not Applicable | Not Applicable | Value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 844 | CIP195 | CIP.002.195 | DRG-REL-WEIGHT | DRG Relative Weight | Conditional | The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG _x000D_ with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average. |
Value must be 8 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 845 | CIP195 | CIP.002.195 | DRG-REL-WEIGHT | DRG Relative Weight | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 846 | CIP195 | CIP.002.195 | DRG-REL-WEIGHT | DRG Relative Weight | Not Applicable | Not Applicable | When populated value must be zero or greater | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 847 | CIP196 | CIP.002.196 | MEDICARE-HIC-NUM | Medicare HIC Number | Conditional | The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the _x000D_ Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & _x000D_ alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) |
Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 848 | CIP196 | CIP.002.196 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 849 | CIP196 | CIP.002.196 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 850 | CIP196 | CIP.002.196 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 851 | CIP196 | CIP.002.196 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be populated when Crossover Indicator (CIP.002.023) equals '1' and Medicare Beneficiary Identifier (CIP.002.222) is not populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 852 | CIP197 | CIP.002.197 | OUTLIER-CODE | Outlier Code | Conditional | This code indicates the Type of Outlier Code or DRG Source. The field identifies two mutually exclusive conditions. The first, for PPS providers (codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), _x000D_ denotes the source for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code |
Value must be in Outlier Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 853 | CIP197 | CIP.002.197 | OUTLIER-CODE | Outlier Code | Not Applicable | Not Applicable | (Day Outlier) If Outlier Code is 01, then Outlier Days (CIP.002.198) must be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 854 | CIP197 | CIP.002.197 | OUTLIER-CODE | Outlier Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 855 | CIP197 | CIP.002.197 | OUTLIER-CODE | Outlier Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 856 | CIP197 | CIP.002.197 | OUTLIER-CODE | Outlier Code | Not Applicable | Not Applicable | If value equals '00' or '09', then DRG Outlier Amount (CIP.002.194) must not be populated | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 857 | CIP198 | CIP.002.198 | OUTLIER-DAYS | Outlier Days | Conditional | This field specifies the number of days paid as outliers under Prospective Payment System (PPS) and the days over the threshold for the DRG. | Value must be numeric | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 858 | CIP198 | CIP.002.198 | OUTLIER-DAYS | Outlier Days | Not Applicable | Not Applicable | The value may be up to 5 digits in length | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 859 | CIP198 | CIP.002.198 | OUTLIER-DAYS | Outlier Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 860 | CIP199 | CIP.002.199 | PATIENT-STATUS | Patient Status | Mandatory | A code indicating the patient's status as of the last day the claim covers. Values used are from UB-04. This is also referred to as patient discharge status. A valid list of codes can be purchased at https://www.nubc.org/license | Value must be in Patient Status List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 861 | CIP199 | CIP.002.199 | PATIENT-STATUS | Patient Status | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 862 | CIP199 | CIP.002.199 | PATIENT-STATUS | Patient Status | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 863 | CIP199 | CIP.002.199 | PATIENT-STATUS | Patient Status | Not Applicable | Not Applicable | When value in ["20", "40", "41", "42"], then associated Discharge Date (CIP.002.096) must be less than or equal to Date of Death (ELG.002.025) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 864 | CIP201 | CIP.002.201 | BMI | Body Mass Index | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 865 | CIP202 | CIP.002.202 | REMITTANCE-NUM | Remittance Number | Mandatory | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed _x000D_ explanation of the reason for the payment amount. The RA number is not the check number. |
Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 866 | CIP202 | CIP.002.202 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19)) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 867 | CIP202 | CIP.002.202 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 868 | CIP202 | CIP.002.202 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 869 | CIP203 | CIP.002.203 | SPLIT-CLAIM-IND | Split Claim Indicator | Conditional | An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing. | Value must be in Split Claim Indicator List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 870 | CIP203 | CIP.002.203 | SPLIT-CLAIM-IND | Split Claim Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 871 | CIP203 | CIP.002.203 | SPLIT-CLAIM-IND | Split Claim Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 872 | CIP204 | CIP.002.204 | BORDER-STATE-IND | Border State Indicator | Conditional | A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Value must be in Border State Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 873 | CIP204 | CIP.002.204 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 874 | CIP204 | CIP.002.204 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 875 | CIP206 | CIP.002.206 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Conditional | The amount of money the beneficiary paid towards coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 876 | CIP206 | CIP.002.206 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 877 | CIP206 | CIP.002.206 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Date Paid | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 878 | CIP206 | CIP.002.206 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 879 | CIP207 | CIP.002.207 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 880 | CIP207 | CIP.002.207 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 881 | CIP207 | CIP.002.207 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 882 | CIP207 | CIP.002.207 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 883 | CIP208 | CIP.002.208 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Conditional | The amount of money the beneficiary paid towards a co-payment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 884 | CIP208 | CIP.002.208 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 885 | CIP208 | CIP.002.208 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Date Paid | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 886 | CIP208 | CIP.002.208 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 887 | CIP209 | CIP.002.209 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 888 | CIP209 | CIP.002.209 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 889 | CIP209 | CIP.002.209 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Amount | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 890 | CIP209 | CIP.002.209 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 891 | CIP210 | CIP.002.210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Conditional | The amount of money the beneficiary paid towards an annual deductible. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 892 | CIP210 | CIP.002.210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 893 | CIP210 | CIP.002.210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 894 | CIP210 | CIP.002.210 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 895 | CIP211 | CIP.002.211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 896 | CIP211 | CIP.002.211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 897 | CIP211 | CIP.002.211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 898 | CIP211 | CIP.002.211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 899 | CIP212 | CIP.002.212 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Mandatory | An indicator to identify a claim that the state refused pay in its entirety. | Value must be in Claim Denied Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 900 | CIP212 | CIP.002.212 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | If value is '0', then Claim Status Category must equal "F2" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 901 | CIP212 | CIP.002.212 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 902 | CIP212 | CIP.002.212 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 903 | CIP213 | CIP.002.213 | COPAY-WAIVED-IND | Copayment Waived Indicator | Optional | An indicator signifying that the copay was waived by the provider. | Value must be in Copay Waived Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 904 | CIP213 | CIP.002.213 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 905 | CIP213 | CIP.002.213 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 906 | CIP214 | CIP.002.214 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Conditional | A free-form text field to indicate the health home program that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, _x000D_ behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. |
Value must 50 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 907 | CIP214 | CIP.002.214 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 908 | CIP214 | CIP.002.214 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 909 | CIP216 | CIP.002.216 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Optional | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 910 | CIP216 | CIP.002.216 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 911 | CIP216 | CIP.002.216 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 912 | CIP217 | CIP.002.217 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date a Third Party Coinsurance amount was paid on this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 913 | CIP217 | CIP.002.217 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 914 | CIP217 | CIP.002.217 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 915 | CIP218 | CIP.002.218 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Optional | The amount of money a third-party on behalf of the beneficiary paid towards a copayment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 916 | CIP218 | CIP.002.218 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 917 | CIP218 | CIP.002.218 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 918 | CIP219 | CIP.002.219 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Optional | The date a Third Party copayment amount was paid on a claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 919 | CIP219 | CIP.002.219 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 920 | CIP219 | CIP.002.219 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 921 | CIP220 | CIP.002.220 | MEDICAID-AMOUNT-PAID-DSH | Medicaid Amount Paid DSH | Conditional | The amount included in the Total Medicaid Amount (CIP.002.114) that is attributable to a Disproportionate Share Hospital (DSH) payment, when the state makes DSH payments by claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 922 | CIP220 | CIP.002.220 | MEDICAID-AMOUNT-PAID-DSH | Medicaid Amount Paid DSH | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 923 | CIP220 | CIP.002.220 | MEDICAID-AMOUNT-PAID-DSH | Medicaid Amount Paid DSH | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 924 | CIP221 | CIP.002.221 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 925 | CIP221 | CIP.002.221 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 926 | CIP221 | CIP.002.221 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 927 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Conditional | The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI _x000D_ over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. |
Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 928 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must be an 11-character string | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 929 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 1 must be numeric values 1 thru 9 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 930 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 931 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 932 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 4 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 933 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 934 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 935 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 7 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 936 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 937 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 938 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 10 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 939 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 11 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 940 | CIP222 | CIP.002.222 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 941 | CIP223 | CIP.002.223 | OPERATING-PROV-TAXONOMY | Operating Provider Taxonomy | Conditional | Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 942 | CIP223 | CIP.002.223 | OPERATING-PROV-TAXONOMY | Operating Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 943 | CIP223 | CIP.002.223 | OPERATING-PROV-TAXONOMY | Operating Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 944 | CIP224 | CIP.002.224 | UNDER-DIRECTION-OF-PROV-NPI | Under Direction of Provider NPI | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 945 | CIP225 | CIP.002.225 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Under Direction of Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 946 | CIP226 | CIP.002.226 | UNDER-SUPERVISION-OF-PROV-NPI | Under Supervision of Provider NPI | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 947 | CIP227 | CIP.002.227 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Under Supervision of Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 948 | CIP228 | CIP.002.228 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim or adjustment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 949 | CIP228 | CIP.002.228 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 950 | CIP228 | CIP.002.228 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated. | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 951 | CIP228 | CIP.002.228 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 952 | CIP228 | CIP.002.228 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If value is populated, Crossover Indicator must be equal to "1" | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 953 | CIP229 | CIP.002.229 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C1 | 954 | CIP229 | CIP.002.229 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 955 | CIP229 | CIP.002.229 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| D1 | 956 | CIP230 | CIP.002.230 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| C2 | 957 | CIP289 | CIP.002.289 | PROV-LOCATION-ID | Provider Location ID | Mandatory | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| A2 | 958 | CIP289 | CIP.002.289 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 959 | CIP289 | CIP.002.289 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 |
| X1 | 960 | CIP231 | CIP.003.231 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 961 | CIP231 | CIP.003.231 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CIP00003" | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 962 | CIP232 | CIP.003.232 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 963 | CIP232 | CIP.003.232 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 964 | CIP232 | CIP.003.232 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 965 | CIP232 | CIP.003.232 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (CIP.001.007) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 966 | CIP233 | CIP.003.233 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 967 | CIP233 | CIP.003.233 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 968 | CIP233 | CIP.003.233 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 969 | CIP233 | CIP.003.233 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 970 | CIP234 | CIP.003.234 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 971 | CIP234 | CIP.003.234 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 972 | CIP234 | CIP.003.234 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 973 | CIP234 | CIP.003.234 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 974 | CIP234 | CIP.003.234 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 975 | CIP235 | CIP.003.235 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 976 | CIP235 | CIP.003.235 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 977 | CIP235 | CIP.003.235 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 978 | CIP236 | CIP.003.236 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 979 | CIP236 | CIP.003.236 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 980 | CIP236 | CIP.003.236 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 981 | CIP236 | CIP.003.236 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 982 | CIP237 | CIP.003.237 | LINE-NUM-ORIG | Original Line Number | Mandatory | A unique number to identify the transaction line number that is being reported on the original claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 983 | CIP237 | CIP.003.237 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 984 | CIP237 | CIP.003.237 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 985 | CIP237 | CIP.003.237 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 986 | CIP238 | CIP.003.238 | LINE-NUM-ADJ | Adjustment Line Number | Conditional | A unique number to identify the transaction line number that identifies the line number on the adjustment claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 987 | CIP238 | CIP.003.238 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 988 | CIP238 | CIP.003.238 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 989 | CIP238 | CIP.003.238 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 990 | CIP238 | CIP.003.238 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 991 | CIP239 | CIP.003.239 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Conditional | A code to indicate the type of adjustment record claim/encounter represents at claim detail level. | Value must be in Line Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 992 | CIP239 | CIP.003.239 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 993 | CIP239 | CIP.003.239 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6] | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 994 | CIP239 | CIP.003.239 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 995 | CIP239 | CIP.003.239 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 996 | CIP239 | CIP.003.239 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Line Adjustment Number is populated, then value must be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 997 | CIP240 | CIP.003.240 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Value must be in Line Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 998 | CIP240 | CIP.003.240 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 999 | CIP240 | CIP.003.240 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1000 | CIP240 | CIP.003.240 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | When populated, Line Adjustment Indicator must be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1001 | CIP241 | CIP.003.241 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1002 | CIP241 | CIP.003.241 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1003 | CIP242 | CIP.003.242 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The Claim Line Status conveys the status of a specific service line using the X12 Claim Status Codes from the claim adjudication process. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1004 | CIP242 | CIP.003.242 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1005 | CIP242 | CIP.003.242 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1006 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Mandatory | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service _x000D_ covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1007 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1008 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1009 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Ending Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1010 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1011 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1012 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1013 | CIP243 | CIP.003.243 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1014 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Mandatory | 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 _x000D_ claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1015 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1016 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1017 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be greater than or equal to associated Beginning Date of Service value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1018 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1019 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1020 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be equal to or greater than associated Date of Birth (ELG.002.024) value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1021 | CIP244 | CIP.003.244 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1022 | CIP245 | CIP.003.245 | REVENUE-CODE | Revenue Code | Mandatory | A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing _x000D_ Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's _x000D_ 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed _x000D_ care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims. |
Value must be in Revenue Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1023 | CIP245 | CIP.003.245 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | A Revenue Code value requires an associated Revenue Charge | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1024 | CIP245 | CIP.003.245 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1025 | CIP245 | CIP.003.245 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1026 | CIP248 | CIP.003.248 | IMMUNIZATION-TYPE | Immunization Type | Conditional | This field identifies the type of immunization provided in order to track additional detail not currently contained in Current Procedural Terminology codes. | Value must be in Immunization Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1027 | CIP248 | CIP.003.248 | IMMUNIZATION-TYPE | Immunization Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1028 | CIP248 | CIP.003.248 | IMMUNIZATION-TYPE | Immunization Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1029 | CIP249 | CIP.003.249 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | IP LT Quantity of Service Actual | Mandatory | On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. | Value must be numeric | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1030 | CIP249 | CIP.003.249 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | IP LT Quantity of Service Actual | Not Applicable | Not Applicable | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1031 | CIP249 | CIP.003.249 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | IP LT Quantity of Service Actual | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1032 | CIP250 | CIP.003.250 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | IP LT Quantity of Service Allowed | Conditional | On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times _x000D_ the procedure/service being reported was performed. 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. |
Value must be numeric | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1033 | CIP250 | CIP.003.250 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | IP LT Quantity of Service Allowed | Not Applicable | Not Applicable | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1034 | CIP250 | CIP.003.250 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | IP LT Quantity of Service Allowed | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1035 | CIP251 | CIP.003.251 | REVENUE-CHARGE | Revenue Charge | Conditional | The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the _x000D_ managed care plan. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1036 | CIP251 | CIP.003.251 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1037 | CIP251 | CIP.003.251 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | Value must be less than or equal to associated Total Billed Amount value. | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1038 | CIP251 | CIP.003.251 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | When populated, associated claim line Revenue Charge must be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1039 | CIP251 | CIP.003.251 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1040 | CIP252 | CIP.003.252 | ALLOWED-AMT | Allowed Amount | Conditional | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed _x000D_ care encounters the Allowed Amount is determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1041 | CIP252 | CIP.003.252 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1042 | CIP252 | CIP.003.252 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1043 | CIP253 | CIP.003.253 | TPL-AMT | Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1044 | CIP253 | CIP.003.253 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1045 | CIP253 | CIP.003.253 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1046 | CIP254 | CIP.003.254 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Conditional | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire _x000D_ payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1047 | CIP254 | CIP.003.254 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1048 | CIP254 | CIP.003.254 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1049 | CIP255 | CIP.003.255 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Conditional | The amount that would have been paid had the services been provided on a Fee for Service basis. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1050 | CIP255 | CIP.003.255 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1051 | CIP255 | CIP.003.255 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1052 | CIP255 | CIP.003.255 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1053 | CIP256 | CIP.003.256 | BILLING-UNIT | Billing Unit | Conditional | Unit of billing that is used for billing services by the facility. | Value must be in Billing Unit List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1054 | CIP256 | CIP.003.256 | BILLING-UNIT | Billing Unit | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1055 | CIP256 | CIP.003.256 | BILLING-UNIT | Billing Unit | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1056 | CIP257 | CIP.003.257 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Value must be 3 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1057 | CIP257 | CIP.003.257 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1058 | CIP257 | CIP.003.257 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Value must not equal '086' if Sex (ELG.002.023) equals 'M' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1059 | CIP257 | CIP.003.257 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Value must satisfy the requirements of Type of Service (Inpatient Claim) List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1060 | CIP260 | CIP.003.260 | SERVICING-PROV-NUM | Servicing Provider Number | Conditional | A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The _x000D_ value is conditional as its usage varies by state. |
Value must be 30 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1061 | CIP260 | CIP.003.260 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1062 | CIP260 | CIP.003.260 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1063 | CIP260 | CIP.003.260 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID |
2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1064 | CIP261 | CIP.003.261 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Conditional | The NPI of the health care professional who delivers or completes a particular medical service or non-surgical _x000D_ procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending _x000D_ provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility _x000D_ and professional components). Examples are Medicaid clinic bills or critical access hospital claims. |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1065 | CIP261 | CIP.003.261 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1066 | CIP261 | CIP.003.261 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| D1 | 1067 | CIP262 | CIP.003.262 | SERVICING-PROV-TAXONOMY | Servicing Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1068 | CIP263 | CIP.003.263 | SERVICING-PROV-TYPE | Servicing Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1069 | CIP263 | CIP.003.263 | SERVICING-PROV-TYPE | Servicing Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1070 | CIP263 | CIP.003.263 | SERVICING-PROV-TYPE | Servicing Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1071 | CIP264 | CIP.003.264 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1072 | CIP264 | CIP.003.264 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1073 | CIP264 | CIP.003.264 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1074 | CIP265 | CIP.003.265 | OPERATING-PROV-NPI-NUM | Operating Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1075 | CIP265 | CIP.003.265 | OPERATING-PROV-NPI-NUM | Operating Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1076 | CIP265 | CIP.003.265 | OPERATING-PROV-NPI-NUM | Operating Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1077 | CIP266 | CIP.003.266 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1078 | CIP266 | CIP.003.266 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1079 | CIP266 | CIP.003.266 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1080 | CIP267 | CIP.003.267 | PROV-FACILITY-TYPE | Provider Facility Type | Mandatory | The type of facility in which services on the claim were rendered. The Provider Facility Type code set is based on corresponding groups of HIPAA provider taxonomy codes. | Value must be in Provider Facility Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1081 | CIP267 | CIP.003.267 | PROV-FACILITY-TYPE | Provider Facility Type | Not Applicable | Not Applicable | Value must be 9 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1082 | CIP267 | CIP.003.267 | PROV-FACILITY-TYPE | Provider Facility Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1083 | CIP268 | CIP.003.268 | BENEFIT-TYPE | Benefit Type | Mandatory | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types | Value must be in Benefit Type Code List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1084 | CIP268 | CIP.003.268 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1085 | CIP268 | CIP.003.268 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1086 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | Value must be in CMS 64 Category for Federal Reimbursement List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1087 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1088 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3'] | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1089 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1090 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1091 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1092 | CIP269 | CIP.003.269 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1093 | CIP270 | CIP.003.270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Conditional | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation. | Value must be in XIX MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1094 | CIP270 | CIP.003.270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1095 | CIP270 | CIP.003.270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1096 | CIP270 | CIP.003.270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1097 | CIP270 | CIP.003.270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1098 | CIP270 | CIP.003.270 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If XXI MBESCBES Category of Service is populated then must not be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1099 | CIP271 | CIP.003.271 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Conditional | A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. | Value must be in XXI MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1100 | CIP271 | CIP.003.271 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1101 | CIP271 | CIP.003.271 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1102 | CIP271 | CIP.003.271 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | If XIX MBESCBES Category of Service is populated then value must not be populated | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1103 | CIP271 | CIP.003.271 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1104 | CIP272 | CIP.003.272 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1105 | CIP272 | CIP.003.272 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1106 | CIP272 | CIP.003.272 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1107 | CIP273 | CIP.003.273 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1108 | CIP273 | CIP.003.273 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1109 | CIP273 | CIP.003.273 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| D1 | 1110 | CIP274 | CIP.003.274 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1111 | CIP278 | CIP.003.278 | NDC-QUANTITY | NDC Quantity | Conditional | This field is to capture the actual quantity of the National Drug Code being prescribed on the claim. | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1112 | CIP278 | CIP.003.278 | NDC-QUANTITY | NDC Quantity | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C1 | 1113 | CIP279 | CIP.003.279 | HCPCS-RATE | HCPCS Rate | Conditional | This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44. (NOTE: This element varies slightly by claim file time, and claim-file-specific requirements will be specified at in the file specification for each claim type.) | Value must be in HCPCS Rate List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1114 | CIP279 | CIP.003.279 | HCPCS-RATE | HCPCS Rate | Not Applicable | Not Applicable | Value must be 14 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1115 | CIP279 | CIP.003.279 | HCPCS-RATE | HCPCS Rate | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1116 | CIP279 | CIP.003.279 | HCPCS-RATE | HCPCS Rate | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1117 | CIP284 | CIP.003.284 | NATIONAL-DRUG-CODE | National Drug Code | Conditional | A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. | Characters 1-5 of value must be numeric | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1118 | CIP284 | CIP.003.284 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 6-9 of value must be numeric | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1119 | CIP284 | CIP.003.284 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 10-12 of value must be numeric or blank | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1120 | CIP284 | CIP.003.284 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be 12 digits or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1121 | CIP284 | CIP.003.284 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be a valid National Drug Code | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1122 | CIP284 | CIP.003.284 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1123 | CIP285 | CIP.003.285 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Conditional | A code to indicate the basis by which the quantity of the National Drug Code is expressed. | Value must be in NDC Unit of Measure List (VVL). | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1124 | CIP285 | CIP.003.285 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1125 | CIP285 | CIP.003.285 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1126 | CIP286 | CIP.003.286 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1127 | CIP286 | CIP.003.286 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1128 | CIP286 | CIP.003.286 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1129 | CIP286 | CIP.003.286 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1130 | CIP286 | CIP.003.286 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or after associated Admission Date value | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1131 | CIP287 | CIP.003.287 | SELF-DIRECTION-TYPE | Self Direction Type | Conditional | This data element is not applicable to this file type. | Value must be in Self Direction Type List (VVL) | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1132 | CIP287 | CIP.003.287 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1133 | CIP287 | CIP.003.287 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| A2 | 1134 | CIP288 | CIP.003.288 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Conditional | A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). | Value must be 18 characters or less | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| C2 | 1135 | CIP288 | CIP.003.288 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1136 | CIP288 | CIP.003.288 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 |
| X1 | 1137 | CLT001 | CLT.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1138 | CLT001 | CLT.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CLT00001" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1139 | CLT002 | CLT.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1140 | CLT002 | CLT.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1141 | CLT002 | CLT.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1142 | CLT003 | CLT.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1143 | CLT003 | CLT.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1144 | CLT003 | CLT.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1145 | CLT004 | CLT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1146 | CLT004 | CLT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1147 | CLT004 | CLT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1148 | CLT005 | CLT.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1149 | CLT005 | CLT.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1150 | CLT006 | CLT.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'CLAIM-LT' | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1151 | CLT007 | CLT.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1152 | CLT007 | CLT.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1153 | CLT007 | CLT.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1154 | CLT008 | CLT.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1155 | CLT008 | CLT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1156 | CLT008 | CLT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1157 | CLT008 | CLT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1158 | CLT008 | CLT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1159 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1160 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1161 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1162 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1163 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1164 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1165 | CLT009 | CLT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1166 | CLT010 | CLT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1167 | CLT010 | CLT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1168 | CLT010 | CLT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1169 | CLT010 | CLT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1170 | CLT010 | CLT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1171 | CLT010 | CLT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1172 | CLT011 | CLT.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1173 | CLT011 | CLT.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1174 | CLT011 | CLT.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1175 | CLT012 | CLT.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability _x000D_ files. |
Value must be in SSN Indicator List (VVL) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1176 | CLT012 | CLT.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1177 | CLT012 | CLT.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1178 | CLT013 | CLT.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1179 | CLT013 | CLT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1180 | CLT013 | CLT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1181 | CLT013 | CLT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1182 | CLT013 | CLT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1183 | CLT014 | CLT.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1184 | CLT014 | CLT.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1185 | CLT014 | CLT.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| D1 | 1186 | CLT015 | CLT.001.015 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1187 | CLT227 | CLT.001.227 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the _x000D_ original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject _x000D_ area). |
Value must between 1 and 9999 | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1188 | CLT227 | CLT.001.227 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| C2 | 1189 | CLT227 | CLT.001.227 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| A2 | 1190 | CLT227 | CLT.001.227 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1191 | CLT227 | CLT.001.227 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 |
| X1 | 1192 | CLT016 | CLT.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1193 | CLT016 | CLT.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CLT00002" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1194 | CLT017 | CLT.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1195 | CLT017 | CLT.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1196 | CLT017 | CLT.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1197 | CLT017 | CLT.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (CLT.001.007) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1198 | CLT018 | CLT.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1199 | CLT018 | CLT.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1200 | CLT018 | CLT.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1201 | CLT018 | CLT.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1202 | CLT019 | CLT.002.019 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1203 | CLT019 | CLT.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1204 | CLT019 | CLT.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1205 | CLT020 | CLT.002.020 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1206 | CLT020 | CLT.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1207 | CLT020 | CLT.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1208 | CLT020 | CLT.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1209 | CLT021 | CLT.002.021 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1210 | CLT021 | CLT.002.021 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1211 | CLT022 | CLT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1212 | CLT022 | CLT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1213 | CLT022 | CLT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1214 | CLT022 | CLT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1215 | CLT022 | CLT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1216 | CLT022 | CLT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1217 | CLT023 | CLT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Conditional | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Value must be in Crossover Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1218 | CLT023 | CLT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1219 | CLT023 | CLT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1220 | CLT023 | CLT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1221 | CLT023 | CLT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If the TYPE-OF-CLAIM value is in ["1", "3", "A", "C"], then value is mandatory and must be reported. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1222 | CLT024 | CLT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration. | Value must be in 1115A Demonstration Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1223 | CLT024 | CLT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1224 | CLT024 | CLT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1225 | CLT024 | CLT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1226 | CLT025 | CLT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | Value must be in Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1227 | CLT025 | CLT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1228 | CLT025 | CLT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1229 | CLT025 | CLT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1230 | CLT025 | CLT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1231 | CLT026 | CLT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. If the amount paid is different from the amount billed you need an adjustment reason code. | Value must be in Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1232 | CLT026 | CLT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1233 | CLT026 | CLT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1234 | CLT026 | CLT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must not be populated when associated Adjustment Indicator equals "0" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1235 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1236 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1237 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1238 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1239 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1240 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1241 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1242 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1243 | CLT027 | CLT.002.027 | ADMITTING-DIAGNOSIS-CODE | Admitting Diagnosis Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1244 | CLT028 | CLT.002.028 | ADMITTING-DIAGNOSIS-CODE-FLAG | Admitting Diagnosis Code Flag | Mandatory | A flag that identifies the coding system used for the Admitting Diagnosis Code. | Value must be in Diagnosis Code Flag(VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1245 | CLT028 | CLT.002.028 | ADMITTING-DIAGNOSIS-CODE-FLAG | Admitting Diagnosis Code Flag | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1246 | CLT028 | CLT.002.028 | ADMITTING-DIAGNOSIS-CODE-FLAG | Admitting Diagnosis Code Flag | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1247 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1248 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1249 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1250 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1251 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1252 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1253 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1254 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1255 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1256 | CLT029 | CLT.002.029 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If Type of Claim (CLT.002.100) in ("1", "3", "A", "C", "U", "W") then Diagnosis Code 1 (CLT.002.032) must be populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1257 | CLT030 | CLT.002.030 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1258 | CLT030 | CLT.002.030 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1259 | CLT030 | CLT.002.030 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1260 | CLT030 | CLT.002.030 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1261 | CLT031 | CLT.002.031 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1262 | CLT031 | CLT.002.031 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1263 | CLT031 | CLT.002.031 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1264 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1265 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1266 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1267 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1268 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1269 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1270 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1271 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1272 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1273 | CLT032 | CLT.002.032 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 1 (CLT.002.029) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1274 | CLT033 | CLT.002.033 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1275 | CLT033 | CLT.002.033 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1276 | CLT033 | CLT.002.033 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1277 | CLT033 | CLT.002.033 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1278 | CLT034 | CLT.002.034 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1279 | CLT034 | CLT.002.034 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1280 | CLT034 | CLT.002.034 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1281 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1282 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1283 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1284 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1285 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1286 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1287 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1288 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1289 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1290 | CLT035 | CLT.002.035 | DIAGNOSIS-CODE-3 | Diagnosis Code 3 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 2 (CLT.002.032) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1291 | CLT036 | CLT.002.036 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1292 | CLT036 | CLT.002.036 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1293 | CLT036 | CLT.002.036 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1294 | CLT036 | CLT.002.036 | DIAGNOSIS-CODE-FLAG-3 | Diagnosis Code Flag 3 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1295 | CLT037 | CLT.002.037 | DIAGNOSIS-POA-FLAG-3 | Diagnosis POA Flag 3 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1296 | CLT037 | CLT.002.037 | DIAGNOSIS-POA-FLAG-3 | Diagnosis POA Flag 3 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1297 | CLT037 | CLT.002.037 | DIAGNOSIS-POA-FLAG-3 | Diagnosis POA Flag 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1298 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1299 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1300 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1301 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1302 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1303 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1304 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1305 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1306 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1307 | CLT038 | CLT.002.038 | DIAGNOSIS-CODE-4 | Diagnosis Code 4 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 3 (CLT.002.035) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1308 | CLT039 | CLT.002.039 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1309 | CLT039 | CLT.002.039 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1310 | CLT039 | CLT.002.039 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1311 | CLT039 | CLT.002.039 | DIAGNOSIS-CODE-FLAG-4 | Diagnosis Code Flag 4 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1312 | CLT040 | CLT.002.040 | DIAGNOSIS-POA-FLAG-4 | Diagnosis POA Flag 4 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1313 | CLT040 | CLT.002.040 | DIAGNOSIS-POA-FLAG-4 | Diagnosis POA Flag 4 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1314 | CLT040 | CLT.002.040 | DIAGNOSIS-POA-FLAG-4 | Diagnosis POA Flag 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1315 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1316 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1317 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1318 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1319 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1320 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1321 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1322 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1323 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1324 | CLT041 | CLT.002.041 | DIAGNOSIS-CODE-5 | Diagnosis Code 5 | Not Applicable | Not Applicable | Value must not be populated when Diagnosis Code 4 (CLT.002.038) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1325 | CLT042 | CLT.002.042 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1326 | CLT042 | CLT.002.042 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1327 | CLT042 | CLT.002.042 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1328 | CLT042 | CLT.002.042 | DIAGNOSIS-CODE-FLAG-5 | Diagnosis Code Flag 5 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1329 | CLT043 | CLT.002.043 | DIAGNOSIS-POA-FLAG-5 | Diagnosis POA Flag 5 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1330 | CLT043 | CLT.002.043 | DIAGNOSIS-POA-FLAG-5 | Diagnosis POA Flag 5 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1331 | CLT043 | CLT.002.043 | DIAGNOSIS-POA-FLAG-5 | Diagnosis POA Flag 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1332 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Mandatory | The date on which the recipient was admitted to a psychiatric or long-term care facility. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1333 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1334 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be less than or equal to associated Discharge Date value in the claim header. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1335 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated eligible Date of Birth value. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1336 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Value must be less than or equal to associated eligible Date of Death value. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1337 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1338 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1339 | CLT044 | CLT.002.044 | ADMISSION-DATE | Admission Date | Not Applicable | Not Applicable | When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1340 | CLT045 | CLT.002.045 | ADMISSION-HOUR | Admission Hour | Conditional | The time of admission to a psychiatric or long-term care facility. | Value must be in Hour List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1341 | CLT045 | CLT.002.045 | ADMISSION-HOUR | Admission Hour | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1342 | CLT045 | CLT.002.045 | ADMISSION-HOUR | Admission Hour | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1343 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Conditional | The date on which the recipient was discharged from a psychiatric or long-term care facility. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1344 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1345 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be less than or equal to associated Adjudication Date value. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1346 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Admission Date value. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1347 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated eligible Date of Birth value. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1348 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Value must be less than or equal to associated eligible Date of Death value. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1349 | CLT046 | CLT.002.046 | DISCHARGE-DATE | Discharge Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1350 | CLT047 | CLT.002.047 | DISCHARGE-HOUR | Discharge Hour | Conditional | The time of discharge from a psychiatric or long-term care facility. | Value must be in Hour List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1351 | CLT047 | CLT.002.047 | DISCHARGE-HOUR | Discharge Hour | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1352 | CLT047 | CLT.002.047 | DISCHARGE-HOUR | Discharge Hour | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1353 | CLT047 | CLT.002.047 | DISCHARGE-HOUR | Discharge Hour | Not Applicable | Not Applicable | When populated, Discharge Date (CLT.002.046) must be populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1354 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Mandatory | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service _x000D_covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1355 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1356 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1357 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Ending Date of Service value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1358 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1359 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1360 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1361 | CLT048 | CLT.002.048 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1362 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Mandatory | 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 _x000D_ claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1363 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1364 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1365 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be greater than or equal to associated Beginning Date of Service value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1366 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1367 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1368 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be equal to or greater than associated Date of Birth (ELG.002.024) value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1369 | CLT049 | CLT.002.049 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1370 | CLT050 | CLT.002.050 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1371 | CLT050 | CLT.002.050 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1372 | CLT050 | CLT.002.050 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1373 | CLT050 | CLT.002.050 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1374 | CLT050 | CLT.002.050 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or after associated Admission Date value | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1375 | CLT051 | CLT.002.051 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1376 | CLT051 | CLT.002.051 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1377 | CLT051 | CLT.002.051 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Must have an associated Total Medicaid Paid Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1378 | CLT051 | CLT.002.051 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1379 | CLT052 | CLT.002.052 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. | Value must be in Type of Claim List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1380 | CLT052 | CLT.002.052 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1381 | CLT052 | CLT.002.052 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1382 | CLT052 | CLT.002.052 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | When value equals 'Z', claim denied indicator must equal '0' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1383 | CLT053 | CLT.002.053 | TYPE-OF-BILL | Type of Bill | Mandatory | A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) | Value must be in Type of Bill List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1384 | CLT053 | CLT.002.053 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | Value must be 4 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1385 | CLT053 | CLT.002.053 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | First character must be a '0' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1386 | CLT053 | CLT.002.053 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1387 | CLT054 | CLT.002.054 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1388 | CLT054 | CLT.002.054 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1389 | CLT054 | CLT.002.054 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1390 | CLT054 | CLT.002.054 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | If value in [ 26, 87, 542, 585, 654 ], Claim Denied Indicator must be '0' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1391 | CLT055 | CLT.002.055 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The Claim Status Category conveys the status of the entire claim using the X12 Claim Status Category Codes from the claim adjudication process. | Value must be in Claim Status Category List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1392 | CLT055 | CLT.002.055 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1393 | CLT055 | CLT.002.055 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1394 | CLT055 | CLT.002.055 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1395 | CLT055 | CLT.002.055 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1396 | CLT056 | CLT.002.056 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. | Value must be in Source Location List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1397 | CLT056 | CLT.002.056 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1398 | CLT056 | CLT.002.056 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1399 | CLT057 | CLT.002.057 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | Value must be 15 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1400 | CLT057 | CLT.002.057 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must have an associated Check Effective Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1401 | CLT057 | CLT.002.057 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1402 | CLT057 | CLT.002.057 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1403 | CLT058 | CLT.002.058 | CHECK-EFF-DATE | Check Effective Date | Conditional | The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1404 | CLT058 | CLT.002.058 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1405 | CLT058 | CLT.002.058 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Value may be the same as associated Remittance Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1406 | CLT058 | CLT.002.058 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Must have an associated Check Number | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1407 | CLT058 | CLT.002.058 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1408 | CLT059 | CLT.002.059 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1409 | CLT059 | CLT.002.059 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1410 | CLT059 | CLT.002.059 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1411 | CLT059 | CLT.002.059 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1412 | CLT060 | CLT.002.060 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1413 | CLT060 | CLT.002.060 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1414 | CLT060 | CLT.002.060 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1415 | CLT060 | CLT.002.060 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1416 | CLT060 | CLT.002.060 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 1 (CLT.002.059) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1417 | CLT061 | CLT.002.061 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1418 | CLT061 | CLT.002.061 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1419 | CLT061 | CLT.002.061 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1420 | CLT061 | CLT.002.061 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1421 | CLT061 | CLT.002.061 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 2 (CLT.002.060) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1422 | CLT062 | CLT.002.062 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1423 | CLT062 | CLT.002.062 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1424 | CLT062 | CLT.002.062 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1425 | CLT062 | CLT.002.062 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1426 | CLT062 | CLT.002.062 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 3 (CLT.002.061) is not populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1427 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Conditional | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial _x000D_ transactions. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1428 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1429 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must equal the sum of all Billed Amount instances for the associated claim | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1430 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1431 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1432 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value should not be populated when associated Type of Claim (CIP.002.100) is equal to '4', 'D' or 'X' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1433 | CLT063 | CLT.002.063 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1434 | CLT064 | CLT.002.064 | TOT-ALLOWED-AMT | Total Allowed Amount | Conditional | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is _x000D_ determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1435 | CLT064 | CLT.002.064 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1436 | CLT064 | CLT.002.064 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1437 | CLT064 | CLT.002.064 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1438 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Conditional | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1439 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1440 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Must have an associated Medicaid Paid Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1441 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1442 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1443 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1444 | CLT065 | CLT.002.065 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must not be greater than Total Allowed Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1445 | CLT066 | CLT.002.066 | TOT-COPAY-AMT | Total Copayment Amount | Conditional | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1446 | CLT066 | CLT.002.066 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1447 | CLT066 | CLT.002.066 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1448 | CLT067 | CLT.002.067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Conditional | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and _x000D_ deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a "1" and leave Total Medicare Coinsurance Amount unpopulated. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1449 | CLT067 | CLT.002.067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1450 | CLT067 | CLT.002.067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1451 | CLT067 | CLT.002.067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1452 | CLT067 | CLT.002.067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1453 | CLT067 | CLT.002.067 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1454 | CLT068 | CLT.002.068 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Conditional | The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1455 | CLT068 | CLT.002.068 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1456 | CLT068 | CLT.002.068 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1457 | CLT068 | CLT.002.068 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1458 | CLT068 | CLT.002.068 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Medicare Combined Deductible Indicator is '1', then value must not be populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1459 | CLT068 | CLT.002.068 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1460 | CLT069 | CLT.002.069 | TOT-TPL-AMT | Total Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1461 | CLT069 | CLT.002.069 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1462 | CLT069 | CLT.002.069 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1463 | CLT069 | CLT.002.069 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1464 | CLT070 | CLT.002.070 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1465 | CLT070 | CLT.002.070 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1466 | CLT070 | CLT.002.070 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1467 | CLT071 | CLT.002.071 | OTHER-INSURANCE-IND | Other Insurance Indicator | Conditional | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Value must be in Other Insurance Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1468 | CLT071 | CLT.002.071 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1469 | CLT071 | CLT.002.071 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1470 | CLT072 | CLT.002.072 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1471 | CLT072 | CLT.002.072 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1472 | CLT072 | CLT.002.072 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1473 | CLT073 | CLT.002.073 | SERVICE-TRACKING-TYPE | Service Tracking Type | Conditional | A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee. | Value must be in Service Tracking Type List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1474 | CLT073 | CLT.002.073 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1475 | CLT073 | CLT.002.073 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1476 | CLT073 | CLT.002.073 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1477 | CLT074 | CLT.002.074 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Conditional | On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1478 | CLT074 | CLT.002.074 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1479 | CLT074 | CLT.002.074 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1480 | CLT074 | CLT.002.074 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1481 | CLT074 | CLT.002.074 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Service Tracking Type must be populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1482 | CLT074 | CLT.002.074 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Total Medicaid Amount must not be populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1483 | CLT075 | CLT.002.075 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Conditional | This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management _x000D_ programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined "medical record" _x000D_ associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Value must be in Fixed Payment Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1484 | CLT075 | CLT.002.075 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1485 | CLT075 | CLT.002.075 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1486 | CLT076 | CLT.002.076 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | Value must be in Funding Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1487 | CLT076 | CLT.002.076 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1488 | CLT076 | CLT.002.076 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1489 | CLT077 | CLT.002.077 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. | Value must be in Funding Source Non-Federal Share List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1490 | CLT077 | CLT.002.077 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1491 | CLT077 | CLT.002.077 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Required | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1492 | CLT078 | CLT.002.078 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Conditional | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. | Value must be in Medicare Combined Deductible Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1493 | CLT078 | CLT.002.078 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1494 | CLT078 | CLT.002.078 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | If value equals '1', then Medicare Coinsurance amount is not populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1495 | CLT078 | CLT.002.078 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must equal '0' if associated Type of Claim is '3', 'C' or 'W' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1496 | CLT078 | CLT.002.078 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1497 | CLT079 | CLT.002.079 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | Value must be in Program Type List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1498 | CLT079 | CLT.002.079 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1499 | CLT079 | CLT.002.079 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1500 | CLT079 | CLT.002.079 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1501 | CLT079 | CLT.002.079 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1502 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Conditional | A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. | Value must be 12 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1503 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1504 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1505 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match Managed Care Plan ID (ELG.014.192) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1506 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match State Plan ID Number (MCR.002.019) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1507 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value should not be populated when Type of Claim is not equal to '3', 'C' or 'W' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1508 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (CLT.002.048) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1509 | CLT080 | CLT.002.080 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (CLT.002.048) occurs between the managed care contract eff/end dates (MCR.002.020/021) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1510 | CLT081 | CLT.002.081 | NATIONAL-HEALTH-CARE-ENTITY-ID | National Health Care Entity ID | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1511 | CLT082 | CLT.002.082 | PAYMENT-LEVEL-IND | Payment Level Indicator | Mandatory | The field denotes whether the payment amount was determined at the claim header or line/detail level. | Value must be in Payment Level Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1512 | CLT082 | CLT.002.082 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1513 | CLT082 | CLT.002.082 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1514 | CLT083 | CLT.002.083 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | Value must be in Medicare Reimbursement Type List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1515 | CLT083 | CLT.002.083 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | (Crossover Claim) if associated Crossover Indicator value indicates a crossover claim, value is mandatory and must be provided | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1516 | CLT083 | CLT.002.083 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1517 | CLT083 | CLT.002.083 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1518 | CLT084 | CLT.002.084 | NON-COV-DAYS | Non-Covered Days | Conditional | The number of days of institutional long-term care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service. | Value must be a positive integer | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1519 | CLT084 | CLT.002.084 | NON-COV-DAYS | Non-Covered Days | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1520 | CLT084 | CLT.002.084 | NON-COV-DAYS | Non-Covered Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1521 | CLT084 | CLT.002.084 | NON-COV-DAYS | Non-Covered Days | Not Applicable | Not Applicable | Value must be 5 digits or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1522 | CLT085 | CLT.002.085 | NON-COV-CHARGES | Non-Covered Charges | Conditional | The charges for institutional long-term care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1523 | CLT085 | CLT.002.085 | NON-COV-CHARGES | Non-Covered Charges | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1524 | CLT085 | CLT.002.085 | NON-COV-CHARGES | Non-Covered Charges | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1525 | CLT086 | CLT.002.086 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Conditional | The number of inpatient psychiatric days covered by Medicaid on this claim. | Value must be a positive integer | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1526 | CLT086 | CLT.002.086 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1527 | CLT086 | CLT.002.086 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1528 | CLT086 | CLT.002.086 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value must be less than or equal to double the number of days between Admission Date (CLT.002.044) and Discharge Date (CLT.002.046) plus one day | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1529 | CLT086 | CLT.002.086 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | Value must be 5 digits or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1530 | CLT086 | CLT.002.086 | MEDICAID-COV-INPATIENT-DAYS | Medicaid Covered Inpatient Days | Not Applicable | Not Applicable | (inpatient mental health/psychiatric services) when associated Type of Service (CLT.003.211) in [044, 048, 050], this field must be populated | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1531 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | Value must be a positive integer | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1532 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be between 0:9999 (inclusive) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1533 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must not include commas or other non-numeric characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1534 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1535 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1536 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1537 | CLT090 | CLT.002.090 | FORCED-CLAIM-IND | Forced Claim Indicator | Conditional | Indicates if the claim was processed by forcing it through a manual override process. | Value must be in Forced Claim Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1538 | CLT090 | CLT.002.090 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1539 | CLT090 | CLT.002.090 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1540 | CLT091 | CLT.002.091 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Conditional | This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site :_x000D_ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
Value must be in Healthcare Acquired Condition Indicator List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1541 | CLT091 | CLT.002.091 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1542 | CLT091 | CLT.002.091 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1543 | CLT092 | CLT.002.092 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1544 | CLT092 | CLT.002.092 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1545 | CLT092 | CLT.002.092 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1546 | CLT093 | CLT.002.093 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1547 | CLT093 | CLT.002.093 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1548 | CLT093 | CLT.002.093 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1549 | CLT094 | CLT.002.094 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1550 | CLT094 | CLT.002.094 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1551 | CLT094 | CLT.002.094 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1552 | CLT095 | CLT.002.095 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1553 | CLT095 | CLT.002.095 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1554 | CLT095 | CLT.002.095 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1555 | CLT096 | CLT.002.096 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1556 | CLT096 | CLT.002.096 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1557 | CLT096 | CLT.002.096 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1558 | CLT097 | CLT.002.097 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1559 | CLT097 | CLT.002.097 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1560 | CLT097 | CLT.002.097 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1561 | CLT098 | CLT.002.098 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1562 | CLT098 | CLT.002.098 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1563 | CLT098 | CLT.002.098 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1564 | CLT099 | CLT.002.099 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1565 | CLT099 | CLT.002.099 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1566 | CLT099 | CLT.002.099 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1567 | CLT100 | CLT.002.100 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1568 | CLT100 | CLT.002.100 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1569 | CLT100 | CLT.002.100 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1570 | CLT101 | CLT.002.101 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1571 | CLT101 | CLT.002.101 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1572 | CLT101 | CLT.002.101 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1573 | CLT102 | CLT.002.102 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1574 | CLT102 | CLT.002.102 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1575 | CLT102 | CLT.002.102 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1576 | CLT102 | CLT.002.102 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1577 | CLT102 | CLT.002.102 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1578 | CLT103 | CLT.002.103 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1579 | CLT103 | CLT.002.103 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1580 | CLT103 | CLT.002.103 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1581 | CLT103 | CLT.002.103 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1582 | CLT103 | CLT.002.103 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1583 | CLT104 | CLT.002.104 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1584 | CLT104 | CLT.002.104 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1585 | CLT104 | CLT.002.104 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1586 | CLT104 | CLT.002.104 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1587 | CLT104 | CLT.002.104 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1588 | CLT105 | CLT.002.105 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1589 | CLT105 | CLT.002.105 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1590 | CLT105 | CLT.002.105 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1591 | CLT105 | CLT.002.105 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1592 | CLT105 | CLT.002.105 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1593 | CLT106 | CLT.002.106 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1594 | CLT106 | CLT.002.106 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1595 | CLT106 | CLT.002.106 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1596 | CLT106 | CLT.002.106 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1597 | CLT106 | CLT.002.106 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1598 | CLT107 | CLT.002.107 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1599 | CLT107 | CLT.002.107 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1600 | CLT107 | CLT.002.107 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1601 | CLT107 | CLT.002.107 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1602 | CLT107 | CLT.002.107 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1603 | CLT108 | CLT.002.108 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1604 | CLT108 | CLT.002.108 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1605 | CLT108 | CLT.002.108 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1606 | CLT108 | CLT.002.108 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1607 | CLT108 | CLT.002.108 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1608 | CLT109 | CLT.002.109 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1609 | CLT109 | CLT.002.109 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1610 | CLT109 | CLT.002.109 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1611 | CLT109 | CLT.002.109 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1612 | CLT109 | CLT.002.109 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1613 | CLT110 | CLT.002.110 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1614 | CLT110 | CLT.002.110 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1615 | CLT110 | CLT.002.110 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1616 | CLT110 | CLT.002.110 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1617 | CLT110 | CLT.002.110 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1618 | CLT111 | CLT.002.111 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1619 | CLT111 | CLT.002.111 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1620 | CLT111 | CLT.002.111 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1621 | CLT111 | CLT.002.111 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1622 | CLT111 | CLT.002.111 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1623 | CLT112 | CLT.002.112 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1624 | CLT112 | CLT.002.112 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1625 | CLT112 | CLT.002.112 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1626 | CLT112 | CLT.002.112 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1627 | CLT113 | CLT.002.113 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1628 | CLT113 | CLT.002.113 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1629 | CLT113 | CLT.002.113 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1630 | CLT113 | CLT.002.113 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1631 | CLT114 | CLT.002.114 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1632 | CLT114 | CLT.002.114 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1633 | CLT114 | CLT.002.114 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1634 | CLT114 | CLT.002.114 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1635 | CLT115 | CLT.002.115 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1636 | CLT115 | CLT.002.115 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1637 | CLT115 | CLT.002.115 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1638 | CLT115 | CLT.002.115 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1639 | CLT116 | CLT.002.116 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1640 | CLT116 | CLT.002.116 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1641 | CLT116 | CLT.002.116 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1642 | CLT116 | CLT.002.116 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1643 | CLT117 | CLT.002.117 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1644 | CLT117 | CLT.002.117 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1645 | CLT117 | CLT.002.117 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1646 | CLT117 | CLT.002.117 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1647 | CLT118 | CLT.002.118 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1648 | CLT118 | CLT.002.118 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1649 | CLT118 | CLT.002.118 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1650 | CLT118 | CLT.002.118 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1651 | CLT119 | CLT.002.119 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1652 | CLT119 | CLT.002.119 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1653 | CLT119 | CLT.002.119 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1654 | CLT119 | CLT.002.119 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1655 | CLT120 | CLT.002.120 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1656 | CLT120 | CLT.002.120 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1657 | CLT120 | CLT.002.120 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1658 | CLT120 | CLT.002.120 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1659 | CLT121 | CLT.002.121 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1660 | CLT121 | CLT.002.121 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1661 | CLT121 | CLT.002.121 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1662 | CLT121 | CLT.002.121 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1663 | CLT122 | CLT.002.122 | PATIENT-CONTROL-NUM | Patient Control Number | Conditional | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment | Value must be 20 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1664 | CLT122 | CLT.002.122 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1665 | CLT122 | CLT.002.122 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1666 | CLT123 | CLT.002.123 | ELIGIBLE-LAST-NAME | Eligible Last Name | Conditional | The last name of the individual to whom the services were provided. (The patients name should be captured as it _x000D_ appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification _x000D_ Number will be used to associate a claim record with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1667 | CLT123 | CLT.002.123 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1668 | CLT123 | CLT.002.123 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1669 | CLT124 | CLT.002.124 | ELIGIBLE-FIRST-NAME | Eligible First Name | Conditional | The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record _x000D_ with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1670 | CLT124 | CLT.002.124 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1671 | CLT124 | CLT.002.124 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1672 | CLT125 | CLT.002.125 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1673 | CLT125 | CLT.002.125 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1674 | CLT125 | CLT.002.125 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1675 | CLT125 | CLT.002.125 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1676 | CLT126 | CLT.002.126 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1677 | CLT126 | CLT.002.126 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1678 | CLT126 | CLT.002.126 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1679 | CLT126 | CLT.002.126 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Value must equal Date of Birth (ELG.002.024) when Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1680 | CLT127 | CLT.002.127 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Conditional | Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. States should not submit claim records for an eligible individual that indicate the claim was submitted by a _x000D_ provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or _x000D_ provider group enrolled in the health home model. |
Value must be in Health Home Provider Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1681 | CLT127 | CLT.002.127 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | If there is an associated Health Home Entity Name value, then value must be "1" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1682 | CLT127 | CLT.002.127 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1683 | CLT127 | CLT.002.127 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1684 | CLT128 | CLT.002.128 | WAIVER-TYPE | Waiver Type | Conditional | A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Value must be in Waiver Type List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1685 | CLT128 | CLT.002.128 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1686 | CLT128 | CLT.002.128 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1687 | CLT128 | CLT.002.128 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must have a corresponding value in Waiver ID (CLT.002.129) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1688 | CLT128 | CLT.002.128 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1689 | CLT129 | CLT.002.129 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the_x000D_ "core" part of the waiver IDs, without including suffixes for renewals or amendments. |
Value must be associated with a populated Waiver Type | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1690 | CLT129 | CLT.002.129 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1691 | CLT129 | CLT.002.129 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1692 | CLT129 | CLT.002.129 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1693 | CLT129 | CLT.002.129 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1694 | CLT130 | CLT.002.130 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity _x000D_ (billing or reporting) to the managed care plan. |
Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1695 | CLT130 | CLT.002.130 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1696 | CLT130 | CLT.002.130 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1697 | CLT130 | CLT.002.130 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1' |
2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1698 | CLT130 | CLT.002.130 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1699 | CLT131 | CLT.002.131 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1700 | CLT131 | CLT.002.131 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1701 | CLT131 | CLT.002.131 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1702 | CLT131 | CLT.002.131 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1703 | CLT132 | CLT.002.132 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the institution billing for the beneficiary. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1704 | CLT132 | CLT.002.132 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1705 | CLT132 | CLT.002.132 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1706 | CLT133 | CLT.002.133 | BILLING-PROV-TYPE | Billing Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1707 | CLT133 | CLT.002.133 | BILLING-PROV-TYPE | Billing Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1708 | CLT133 | CLT.002.133 | BILLING-PROV-TYPE | Billing Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1709 | CLT134 | CLT.002.134 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1710 | CLT134 | CLT.002.134 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1711 | CLT134 | CLT.002.134 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1712 | CLT135 | CLT.002.135 | REFERRING-PROV-NUM | Referring Provider Number | Conditional | A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a _x000D_ group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA _x000D_ ID for this data element. |
Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1713 | CLT135 | CLT.002.135 | REFERRING-PROV-NUM | Referring Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1714 | CLT135 | CLT.002.135 | REFERRING-PROV-NUM | Referring Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1715 | CLT136 | CLT.002.136 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1716 | CLT136 | CLT.002.136 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1717 | CLT136 | CLT.002.136 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1718 | CLT137 | CLT.002.137 | REFERRING-PROV-TAXONOMY | Referring Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1719 | CLT138 | CLT.002.138 | REFERRING-PROV-TYPE | Referring Provider Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1720 | CLT139 | CLT.002.139 | REFERRING-PROV-SPECIALTY | Referring Provider Specialty | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1721 | CLT140 | CLT.002.140 | MEDICARE-HIC-NUM | Medicare HIC Number | Conditional | The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the _x000D_ Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & _x000D_ alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) |
Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1722 | CLT140 | CLT.002.140 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1723 | CLT140 | CLT.002.140 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1724 | CLT140 | CLT.002.140 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1725 | CLT140 | CLT.002.140 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be populated when Crossover Indicator (CLT.002.023) equals '1' and Medicare Beneficiary Identifier (CLT.002.168) is not populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1726 | CLT141 | CLT.002.141 | PATIENT-STATUS | Patient Status | Mandatory | A code indicating the patient's status as of the last day the claim covers. Values used are from UB-04. This is also referred to as patient discharge status. A valid list of codes can be purchased at https://www.nubc.org/license | Value must be in Patient Status List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1727 | CLT141 | CLT.002.141 | PATIENT-STATUS | Patient Status | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1728 | CLT141 | CLT.002.141 | PATIENT-STATUS | Patient Status | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1729 | CLT143 | CLT.002.143 | BMI | Body Mass Index | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1730 | CLT144 | CLT.002.144 | REMITTANCE-NUM | Remittance Number | Mandatory | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed _x000D_ explanation of the reason for the payment amount. The RA number is not the check number. |
Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1731 | CLT144 | CLT.002.144 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19)) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1732 | CLT144 | CLT.002.144 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1733 | CLT144 | CLT.002.144 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1734 | CLT145 | CLT.002.145 | LTC-RCP-LIAB-AMT | LTC RCP Liability Amount | Conditional | 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. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1735 | CLT145 | CLT.002.145 | LTC-RCP-LIAB-AMT | LTC RCP Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1736 | CLT145 | CLT.002.145 | LTC-RCP-LIAB-AMT | LTC RCP Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1737 | CLT146 | CLT.002.146 | DAILY-RATE | Daily Rate | Conditional | The amount a policy will pay per day for a covered service. | Value must be between 0.00 and 99999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1738 | CLT146 | CLT.002.146 | DAILY-RATE | Daily Rate | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1739 | CLT146 | CLT.002.146 | DAILY-RATE | Daily Rate | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1740 | CLT147 | CLT.002.147 | ICF-IID-DAYS | ICF IID Days | Conditional | The number of days of intermediate care for individuals with an intellectual disability that were paid for in whole or in part by Medicaid. If value exceeds 99998 days, code as 99998. (e.g., code 100023 as 99998). | Value must be 5 digits or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1741 | CLT147 | CLT.002.147 | ICF-IID-DAYS | ICF IID Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1742 | CLT147 | CLT.002.147 | ICF-IID-DAYS | ICF IID Days | Not Applicable | Not Applicable | Value is mandatory when associated Type of Service (CLT.003.211) = '046' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1743 | CLT147 | CLT.002.147 | ICF-IID-DAYS | ICF IID Days | Not Applicable | Not Applicable | Value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1744 | CLT147 | CLT.002.147 | ICF-IID-DAYS | ICF IID Days | Not Applicable | Not Applicable | When populated, if value is greater than 0 and less than 99998, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '004' (ICF/IID) for the same month as the begin and end date of service | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1745 | CLT148 | CLT.002.148 | LEAVE-DAYS | Leave Days | Conditional | The number of days, during the period covered by Medicaid, on which the patient did not reside in the long term care facility. | Value must be numeric | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1746 | CLT148 | CLT.002.148 | LEAVE-DAYS | Leave Days | Not Applicable | Not Applicable | Value must be 5 digits or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1747 | CLT148 | CLT.002.148 | LEAVE-DAYS | Leave Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1748 | CLT148 | CLT.002.148 | LEAVE-DAYS | Leave Days | Not Applicable | Not Applicable | (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009, 045, 046, 047, 059] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1749 | CLT149 | CLT.002.149 | NURSING-FACILITY-DAYS | Nursing Facility Days | Conditional | 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. If value exceeds 99998 days, code as 99998. | Value must be numeric | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1750 | CLT149 | CLT.002.149 | NURSING-FACILITY-DAYS | Nursing Facility Days | Not Applicable | Not Applicable | Value must be 5 digits or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1751 | CLT149 | CLT.002.149 | NURSING-FACILITY-DAYS | Nursing Facility Days | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1752 | CLT149 | CLT.002.149 | NURSING-FACILITY-DAYS | Nursing Facility Days | Not Applicable | Not Applicable | When populated, value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1753 | CLT149 | CLT.002.149 | NURSING-FACILITY-DAYS | Nursing Facility Days | Not Applicable | Not Applicable | (nursing facility) value is required when the Type of Service in [009, 045, 047, 059] | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1754 | CLT149 | CLT.002.149 | NURSING-FACILITY-DAYS | Nursing Facility Days | Not Applicable | Not Applicable | When populated, if value is greater than zero, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '003' (Nursing Facility) for the same month as the begin and end date of service | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1755 | CLT150 | CLT.002.150 | SPLIT-CLAIM-IND | Split Claim Indicator | Conditional | An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing. | Value must be in Split Claim Indicator List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1756 | CLT150 | CLT.002.150 | SPLIT-CLAIM-IND | Split Claim Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1757 | CLT150 | CLT.002.150 | SPLIT-CLAIM-IND | Split Claim Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1758 | CLT151 | CLT.002.151 | BORDER-STATE-IND | Border State Indicator | Conditional | A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Value must be in Border State Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1759 | CLT151 | CLT.002.151 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1760 | CLT151 | CLT.002.151 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1761 | CLT153 | CLT.002.153 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Conditional | The amount of money the beneficiary paid towards coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1762 | CLT153 | CLT.002.153 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1763 | CLT153 | CLT.002.153 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Date Paid | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1764 | CLT153 | CLT.002.153 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1765 | CLT154 | CLT.002.154 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1766 | CLT154 | CLT.002.154 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1767 | CLT154 | CLT.002.154 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1768 | CLT154 | CLT.002.154 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1769 | CLT155 | CLT.002.155 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Conditional | The amount of money the beneficiary paid towards a co-payment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1770 | CLT155 | CLT.002.155 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1771 | CLT155 | CLT.002.155 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Date Paid | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1772 | CLT155 | CLT.002.155 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1773 | CLT156 | CLT.002.156 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1774 | CLT156 | CLT.002.156 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1775 | CLT156 | CLT.002.156 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Amount | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1776 | CLT156 | CLT.002.156 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1777 | CLT157 | CLT.002.157 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Conditional | The amount of money the beneficiary paid towards an annual deductible. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1778 | CLT157 | CLT.002.157 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1779 | CLT157 | CLT.002.157 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1780 | CLT157 | CLT.002.157 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1781 | CLT158 | CLT.002.158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1782 | CLT158 | CLT.002.158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1783 | CLT158 | CLT.002.158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1784 | CLT158 | CLT.002.158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1785 | CLT159 | CLT.002.159 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Mandatory | An indicator to identify a claim that the state refused pay in its entirety. | Value must be in Claim Denied Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1786 | CLT159 | CLT.002.159 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | If value is '0', then Claim Status Category must equal "F2" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1787 | CLT159 | CLT.002.159 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1788 | CLT159 | CLT.002.159 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1789 | CLT160 | CLT.002.160 | COPAY-WAIVED-IND | Copayment Waived Indicator | Optional | An indicator signifying that the copay was waived by the provider. | Value must be in Copay Waived Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1790 | CLT160 | CLT.002.160 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1791 | CLT160 | CLT.002.160 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1792 | CLT161 | CLT.002.161 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Conditional | A free-form text field to indicate the health home program that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, _x000D_ behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. |
Value must 50 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1793 | CLT161 | CLT.002.161 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1794 | CLT161 | CLT.002.161 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1795 | CLT163 | CLT.002.163 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Optional | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1796 | CLT163 | CLT.002.163 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1797 | CLT163 | CLT.002.163 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1798 | CLT164 | CLT.002.164 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date a Third Party Coinsurance amount was paid on this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1799 | CLT164 | CLT.002.164 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1800 | CLT164 | CLT.002.164 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1801 | CLT165 | CLT.002.165 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Optional | The amount of money a third-party on behalf of the beneficiary paid towards a copayment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1802 | CLT165 | CLT.002.165 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1803 | CLT165 | CLT.002.165 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1804 | CLT166 | CLT.002.166 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Optional | The date a Third Party copayment amount was paid on a claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1805 | CLT166 | CLT.002.166 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1806 | CLT166 | CLT.002.166 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1807 | CLT167 | CLT.002.167 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1808 | CLT167 | CLT.002.167 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1809 | CLT167 | CLT.002.167 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1810 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Conditional | The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI _x000D_ over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. |
Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1811 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must be an 11-character string | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1812 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 1 must be numeric values 1 thru 9 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1813 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1814 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1815 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 4 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1816 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1817 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1818 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 7 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1819 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1820 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1821 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 10 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1822 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 11 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1823 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1824 | CLT168 | CLT.002.168 | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1825 | CLT169 | CLT.002.169 | UNDER-DIRECTION-OF-PROV-NPI | Under Direction of Provider NPI | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1826 | CLT170 | CLT.002.170 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Under Direction of Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1827 | CLT171 | CLT.002.171 | UNDER-SUPERVISION-OF-PROV-NPI | Under Supervision of Provider NPI | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1828 | CLT172 | CLT.002.172 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Under Supervision of Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1829 | CLT173 | CLT.002.173 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1830 | CLT173 | CLT.002.173 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1831 | CLT173 | CLT.002.173 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1832 | CLT174 | CLT.002.174 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1833 | CLT174 | CLT.002.174 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C1 | 1834 | CLT174 | CLT.002.174 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1835 | CLT175 | CLT.002.175 | ADMITTING-PROV-NUM | Admitting Provider Number | Conditional | The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1836 | CLT175 | CLT.002.175 | ADMITTING-PROV-NUM | Admitting Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1837 | CLT175 | CLT.002.175 | ADMITTING-PROV-NUM | Admitting Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1838 | CLT176 | CLT.002.176 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1839 | CLT176 | CLT.002.176 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1840 | CLT176 | CLT.002.176 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1841 | CLT177 | CLT.002.177 | ADMITTING-PROV-TAXONOMY | Admitting Provider Taxonomy | Conditional | Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1842 | CLT177 | CLT.002.177 | ADMITTING-PROV-TAXONOMY | Admitting Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1843 | CLT177 | CLT.002.177 | ADMITTING-PROV-TAXONOMY | Admitting Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1844 | CLT178 | CLT.002.178 | ADMITTING-PROV-TYPE | Admitting Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1845 | CLT178 | CLT.002.178 | ADMITTING-PROV-TYPE | Admitting Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1846 | CLT178 | CLT.002.178 | ADMITTING-PROV-TYPE | Admitting Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1847 | CLT179 | CLT.002.179 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim or adjustment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1848 | CLT179 | CLT.002.179 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1849 | CLT179 | CLT.002.179 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated. | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1850 | CLT179 | CLT.002.179 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| A2 | 1851 | CLT179 | CLT.002.179 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If value is populated, Crossover Indicator must be equal to "1" | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| D1 | 1852 | CLT183 | CLT.002.183 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1853 | CLT237 | CLT.002.237 | PROV-LOCATION-ID | Provider Location ID | Mandatory | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| C2 | 1854 | CLT237 | CLT.002.237 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1855 | CLT237 | CLT.002.237 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 |
| X1 | 1856 | CLT184 | CLT.003.184 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1857 | CLT184 | CLT.003.184 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CLT00003" | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1858 | CLT185 | CLT.003.185 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1859 | CLT185 | CLT.003.185 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1860 | CLT185 | CLT.003.185 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1861 | CLT185 | CLT.003.185 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (CLT.001.007) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1862 | CLT186 | CLT.003.186 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1863 | CLT186 | CLT.003.186 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1864 | CLT186 | CLT.003.186 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1865 | CLT186 | CLT.003.186 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1866 | CLT187 | CLT.003.187 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1867 | CLT187 | CLT.003.187 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1868 | CLT187 | CLT.003.187 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1869 | CLT187 | CLT.003.187 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1870 | CLT187 | CLT.003.187 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1871 | CLT188 | CLT.003.188 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1872 | CLT188 | CLT.003.188 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1873 | CLT188 | CLT.003.188 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1874 | CLT189 | CLT.003.189 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1875 | CLT189 | CLT.003.189 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1876 | CLT189 | CLT.003.189 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1877 | CLT189 | CLT.003.189 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1878 | CLT190 | CLT.003.190 | LINE-NUM-ORIG | Original Line Number | Mandatory | A unique number to identify the transaction line number that is being reported on the original claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1879 | CLT190 | CLT.003.190 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1880 | CLT190 | CLT.003.190 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1881 | CLT190 | CLT.003.190 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1882 | CLT191 | CLT.003.191 | LINE-NUM-ADJ | Adjustment Line Number | Conditional | A unique number to identify the transaction line number that identifies the line number on the adjustment claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1883 | CLT191 | CLT.003.191 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1884 | CLT191 | CLT.003.191 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1885 | CLT191 | CLT.003.191 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1886 | CLT191 | CLT.003.191 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1887 | CLT192 | CLT.003.192 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Conditional | A code to indicate the type of adjustment record claim/encounter represents at claim detail level. | Value must be in Line Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1888 | CLT192 | CLT.003.192 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1889 | CLT192 | CLT.003.192 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6] | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1890 | CLT192 | CLT.003.192 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1891 | CLT192 | CLT.003.192 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1892 | CLT192 | CLT.003.192 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Line Adjustment Number is populated, then value must be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1893 | CLT193 | CLT.003.193 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Value must be in Line Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1894 | CLT193 | CLT.003.193 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1895 | CLT193 | CLT.003.193 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1896 | CLT193 | CLT.003.193 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | When populated, Line Adjustment Indicator must be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1897 | CLT194 | CLT.003.194 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C1 | 1898 | CLT194 | CLT.003.194 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1899 | CLT195 | CLT.003.195 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The Claim Line Status conveys the status of a specific service line using the X12 Claim Status Codes from the claim adjudication process. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1900 | CLT195 | CLT.003.195 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1901 | CLT195 | CLT.003.195 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1902 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Mandatory | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service _x000D_ covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1903 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1904 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1905 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Ending Date of Service value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1906 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1907 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1908 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1909 | CLT196 | CLT.003.196 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1910 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Mandatory | 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 _x000D_ claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1911 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1912 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1913 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be greater than or equal to associated Beginning Date of Service value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1914 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1915 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1916 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be equal to or greater than associated Date of Birth (ELG.002.024) value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1917 | CLT197 | CLT.003.197 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1918 | CLT198 | CLT.003.198 | REVENUE-CODE | Revenue Code | Mandatory | A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing _x000D_ Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's _x000D_ 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed _x000D_ care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims. |
Value must be in Revenue Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1919 | CLT198 | CLT.003.198 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | A Revenue Code value requires an associated Revenue Charge | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1920 | CLT198 | CLT.003.198 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1921 | CLT198 | CLT.003.198 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| D1 | 1922 | CLT201 | CLT.003.201 | IMMUNIZATION-TYPE | Immunization Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| D1 | 1923 | CLT202 | CLT.003.202 | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | IP LT Quantity of Service Actual | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| D1 | 1924 | CLT203 | CLT.003.203 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | IP LT Quantity of Service Allowed | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1925 | CLT204 | CLT.003.204 | REVENUE-CHARGE | Revenue Charge | Conditional | The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the _x000D_ managed care plan. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1926 | CLT204 | CLT.003.204 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1927 | CLT204 | CLT.003.204 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | Value must be less than or equal to associated Total Billed Amount value. | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1928 | CLT204 | CLT.003.204 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | When populated, associated claim line Revenue Charge must be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1929 | CLT204 | CLT.003.204 | REVENUE-CHARGE | Revenue Charge | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1930 | CLT205 | CLT.003.205 | ALLOWED-AMT | Allowed Amount | Conditional | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed _x000D_ care encounters the Allowed Amount is determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1931 | CLT205 | CLT.003.205 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1932 | CLT205 | CLT.003.205 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1933 | CLT206 | CLT.003.206 | TPL-AMT | Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1934 | CLT206 | CLT.003.206 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1935 | CLT206 | CLT.003.206 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1936 | CLT207 | CLT.003.207 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1937 | CLT207 | CLT.003.207 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1938 | CLT207 | CLT.003.207 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1939 | CLT208 | CLT.003.208 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Conditional | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire _x000D_ payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1940 | CLT208 | CLT.003.208 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C1 | 1941 | CLT208 | CLT.003.208 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1942 | CLT209 | CLT.003.209 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Conditional | The amount that would have been paid had the services been provided on a Fee for Service basis. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1943 | CLT209 | CLT.003.209 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1944 | CLT209 | CLT.003.209 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1945 | CLT209 | CLT.003.209 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1946 | CLT210 | CLT.003.210 | BILLING-UNIT | Billing Unit | Conditional | Unit of billing that is used for billing services by the facility. | Value must be in Billing Unit List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1947 | CLT210 | CLT.003.210 | BILLING-UNIT | Billing Unit | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1948 | CLT210 | CLT.003.210 | BILLING-UNIT | Billing Unit | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1949 | CLT211 | CLT.003.211 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Value must be 3 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1950 | CLT211 | CLT.003.211 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1951 | CLT211 | CLT.003.211 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Value must satisfy the requirements of Type of Service (Long Term Claim) List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1952 | CLT212 | CLT.003.212 | SERVICING-PROV-NUM | Servicing Provider Number | Conditional | A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The _x000D_ value is conditional as its usage varies by state. |
Value must be 30 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1953 | CLT212 | CLT.003.212 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C1 | 1954 | CLT212 | CLT.003.212 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1955 | CLT212 | CLT.003.212 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID |
2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1956 | CLT213 | CLT.003.213 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1957 | CLT213 | CLT.003.213 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1958 | CLT213 | CLT.003.213 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1959 | CLT213 | CLT.003.213 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| D1 | 1960 | CLT214 | CLT.003.214 | SERVICING-PROV-TAXONOMY | Servicing Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1961 | CLT215 | CLT.003.215 | SERVICING-PROV-TYPE | Servicing Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1962 | CLT215 | CLT.003.215 | SERVICING-PROV-TYPE | Servicing Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1963 | CLT215 | CLT.003.215 | SERVICING-PROV-TYPE | Servicing Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1964 | CLT216 | CLT.003.216 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1965 | CLT216 | CLT.003.216 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1966 | CLT216 | CLT.003.216 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1967 | CLT217 | CLT.003.217 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1968 | CLT217 | CLT.003.217 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1969 | CLT217 | CLT.003.217 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1970 | CLT218 | CLT.003.218 | BENEFIT-TYPE | Benefit Type | Mandatory | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types | Value must be in Benefit Type Code List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1971 | CLT218 | CLT.003.218 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1972 | CLT218 | CLT.003.218 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1973 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | Value must be in CMS 64 Category for Federal Reimbursement List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1974 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1975 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3'] | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1976 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1' | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C1 | 1977 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1978 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1979 | CLT219 | CLT.003.219 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1980 | CLT221 | CLT.003.221 | PROV-FACILITY-TYPE | Provider Facility Type | Mandatory | The type of facility in which services on the claim were rendered. The Provider Facility Type code set is based on corresponding groups of HIPAA provider taxonomy codes. | Value must be in Provider Facility Type List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1981 | CLT221 | CLT.003.221 | PROV-FACILITY-TYPE | Provider Facility Type | Not Applicable | Not Applicable | Value must be 9 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1982 | CLT221 | CLT.003.221 | PROV-FACILITY-TYPE | Provider Facility Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1983 | CLT224 | CLT.003.224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Conditional | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation. | Value must be in XIX MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1984 | CLT224 | CLT.003.224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1985 | CLT224 | CLT.003.224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1986 | CLT224 | CLT.003.224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1987 | CLT224 | CLT.003.224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1988 | CLT224 | CLT.003.224 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If XXI MBESCBES Category of Service is populated then must not be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1989 | CLT225 | CLT.003.225 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Conditional | A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. | Value must be in XXI MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1990 | CLT225 | CLT.003.225 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1991 | CLT225 | CLT.003.225 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1992 | CLT225 | CLT.003.225 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | If XIX MBESCBES Category of Service is populated then value must not be populated | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1993 | CLT225 | CLT.003.225 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 1994 | CLT226 | CLT.003.226 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 1995 | CLT226 | CLT.003.226 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1996 | CLT226 | CLT.003.226 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1997 | CLT228 | CLT.003.228 | NATIONAL-DRUG-CODE | National Drug Code | Conditional | A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. | Characters 1-5 of value must be numeric | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1998 | CLT228 | CLT.003.228 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 6-9 of value must be numeric | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 1999 | CLT228 | CLT.003.228 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 10-12 of value must be numeric or blank | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2000 | CLT228 | CLT.003.228 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be 12 digits or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2001 | CLT228 | CLT.003.228 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be a valid National Drug Code | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2002 | CLT228 | CLT.003.228 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2003 | CLT229 | CLT.003.229 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Conditional | A code to indicate the basis by which the quantity of the National Drug Code is expressed. | Value must be in NDC Unit of Measure List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2004 | CLT229 | CLT.003.229 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2005 | CLT229 | CLT.003.229 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2006 | CLT230 | CLT.003.230 | NDC-QUANTITY | NDC Quantity | Conditional | This field is to capture the actual quantity of the National Drug Code being prescribed on the claim. | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2007 | CLT230 | CLT.003.230 | NDC-QUANTITY | NDC Quantity | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C1 | 2008 | CLT231 | CLT.003.231 | HCPCS-RATE | HCPCS Rate | Conditional | This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44. (NOTE: This element varies slightly by claim file time, and claim-file-specific requirements will be specified at in the file specification for each claim type.) | Value must be in HCPCS Rate List (VVL). | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C1 | 2009 | CLT231 | CLT.003.231 | HCPCS-RATE | HCPCS Rate | Not Applicable | Not Applicable | Value must be 14 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2010 | CLT231 | CLT.003.231 | HCPCS-RATE | HCPCS Rate | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2011 | CLT231 | CLT.003.231 | HCPCS-RATE | HCPCS Rate | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 2012 | CLT233 | CLT.003.233 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 2013 | CLT233 | CLT.003.233 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 2014 | CLT233 | CLT.003.233 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2015 | CLT233 | CLT.003.233 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2016 | CLT233 | CLT.003.233 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or after associated Admission Date value | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2017 | CLT234 | CLT.003.234 | SELF-DIRECTION-TYPE | Self Direction Type | Conditional | This data element is not applicable to this file type. | Value must be in Self Direction Type List (VVL) | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2018 | CLT234 | CLT.003.234 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2019 | CLT234 | CLT.003.234 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| A2 | 2020 | CLT235 | CLT.003.235 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Conditional | A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). | Value must be 18 characters or less | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| C2 | 2021 | CLT235 | CLT.003.235 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2022 | CLT235 | CLT.003.235 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| D1 | 2023 | CLT238 | CLT.003.238 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 |
| X1 | 2024 | COT001 | COT.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2025 | COT001 | COT.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "COT00001" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2026 | COT002 | COT.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2027 | COT002 | COT.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2028 | COT002 | COT.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2029 | COT003 | COT.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2030 | COT003 | COT.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2031 | COT003 | COT.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2032 | COT004 | COT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2033 | COT004 | COT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2034 | COT004 | COT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2035 | COT005 | COT.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2036 | COT005 | COT.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2037 | COT006 | COT.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'CLAIM-OT' | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2038 | COT007 | COT.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2039 | COT007 | COT.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2040 | COT007 | COT.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2041 | COT008 | COT.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2042 | COT008 | COT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2043 | COT008 | COT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2044 | COT008 | COT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2045 | COT008 | COT.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2046 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2047 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2048 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2049 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2050 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2051 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2052 | COT009 | COT.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2053 | COT010 | COT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2054 | COT010 | COT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2055 | COT010 | COT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2056 | COT010 | COT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2057 | COT010 | COT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2058 | COT010 | COT.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2059 | COT011 | COT.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2060 | COT011 | COT.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2061 | COT011 | COT.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2062 | COT012 | COT.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability _x000D_ files. |
Value must be in SSN Indicator List (VVL) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2063 | COT012 | COT.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2064 | COT012 | COT.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2065 | COT013 | COT.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2066 | COT013 | COT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2067 | COT013 | COT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2068 | COT013 | COT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2069 | COT013 | COT.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2070 | COT014 | COT.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| C2 | 2071 | COT014 | COT.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2072 | COT014 | COT.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| D1 | 2073 | COT015 | COT.001.015 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2074 | COT216 | COT.001.216 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the _x000D_ original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject _x000D_ area). |
Value must between 1 and 9999 | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2075 | COT216 | COT.001.216 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2076 | COT216 | COT.001.216 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| A2 | 2077 | COT216 | COT.001.216 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2078 | COT216 | COT.001.216 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 |
| X1 | 2079 | COT016 | COT.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2080 | COT016 | COT.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "COT00002" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2081 | COT017 | COT.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2082 | COT017 | COT.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2083 | COT017 | COT.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2084 | COT017 | COT.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (COT.001.007) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2085 | COT018 | COT.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2086 | COT018 | COT.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2087 | COT018 | COT.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2088 | COT018 | COT.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2089 | COT019 | COT.002.019 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2090 | COT019 | COT.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2091 | COT019 | COT.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2092 | COT020 | COT.002.020 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2093 | COT020 | COT.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2094 | COT020 | COT.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2095 | COT020 | COT.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2096 | COT021 | COT.002.021 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2097 | COT021 | COT.002.021 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2098 | COT022 | COT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2099 | COT022 | COT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2100 | COT022 | COT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2101 | COT022 | COT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2102 | COT022 | COT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2103 | COT022 | COT.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2104 | COT023 | COT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Conditional | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Value must be in Crossover Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2105 | COT023 | COT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2106 | COT023 | COT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2107 | COT023 | COT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2108 | COT023 | COT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If the TYPE-OF-CLAIM value is in ["1", "3", "A", "C"], then value is mandatory and must be reported. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2109 | COT024 | COT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration. | Value must be in 1115A Demonstration Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2110 | COT024 | COT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2111 | COT024 | COT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2112 | COT024 | COT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2113 | COT025 | COT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | Value must be in Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2114 | COT025 | COT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2115 | COT025 | COT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2116 | COT025 | COT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2117 | COT025 | COT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2118 | COT026 | COT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. If the amount paid is different from the amount billed you need an adjustment reason code. | Value must be in Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2119 | COT026 | COT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2120 | COT026 | COT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2121 | COT026 | COT.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must not be populated when associated Adjustment Indicator equals "0" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2122 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2123 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2124 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2125 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2126 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2127 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2128 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2129 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2130 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2131 | COT027 | COT.002.027 | DIAGNOSIS-CODE-1 | Diagnosis Code 1 | Not Applicable | Not Applicable | If Type of Claim (COT.002.037) is in ("1", "3", "A", "C", "U", "W") then Diagnosis Code 1 (COT.002.027) must be populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2132 | COT028 | COT.002.028 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2133 | COT028 | COT.002.028 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2134 | COT028 | COT.002.028 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2135 | COT028 | COT.002.028 | DIAGNOSIS-CODE-FLAG-1 | Diagnosis Code Flag 1 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2136 | COT029 | COT.002.029 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2137 | COT029 | COT.002.029 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2138 | COT029 | COT.002.029 | DIAGNOSIS-POA-FLAG-1 | Diagnosis POA Flag 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2139 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Conditional | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, _x000D_ adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be _x000D_ passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing _x000D_ the decimal). For example: 210.5 is coded as "2105". |
When populated, a Diagnosis Code Flag is required | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2140 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2141 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Codes List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2142 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must be a minimum of 3 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2143 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Value must not contain a decimal point | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2144 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2145 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2146 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | When there is more than one diagnosis code on a claim, each value must be unique | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2147 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2148 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | When populated, value cannot equal Diagnosis Code 1 (COT.002.027) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2149 | COT030 | COT.002.030 | DIAGNOSIS-CODE-2 | Diagnosis Code 2 | Not Applicable | Not Applicable | When Diagnosis Code 1 (COT.002.027) is not populated, value should not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2150 | COT031 | COT.002.031 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Conditional | Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, _x000D_ where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis Code Flag List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2151 | COT031 | COT.002.031 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2152 | COT031 | COT.002.031 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2153 | COT031 | COT.002.031 | DIAGNOSIS-CODE-FLAG-2 | Diagnosis Code Flag 2 | Not Applicable | Not Applicable | Value should not be populated, if the associated diagnosis code is not populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2154 | COT032 | COT.002.032 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Conditional | A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery._x000D_ POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably _x000D_ have been prevented through the application of evidence-based guidelines._x000D_ *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature._x000D_ Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1. |
Value must be in Diagnosis POA Flag List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2155 | COT032 | COT.002.032 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2156 | COT032 | COT.002.032 | DIAGNOSIS-POA-FLAG-2 | Diagnosis POA Flag 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2157 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Mandatory | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service _x000D_ covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2158 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2159 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2160 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Ending Date of Service value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2161 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2162 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2163 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2164 | COT033 | COT.002.033 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2165 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Mandatory | 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 _x000D_ claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2166 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2167 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2168 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be greater than or equal to associated Beginning Date of Service value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2169 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2170 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2171 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be equal to or greater than associated Date of Birth (ELG.002.024) value | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2172 | COT034 | COT.002.034 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2173 | COT035 | COT.002.035 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2174 | COT035 | COT.002.035 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2175 | COT035 | COT.002.035 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2176 | COT035 | COT.002.035 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2177 | COT036 | COT.002.036 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2178 | COT036 | COT.002.036 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2179 | COT036 | COT.002.036 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Must have an associated Total Medicaid Paid Amount | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2180 | COT036 | COT.002.036 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2181 | COT037 | COT.002.037 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. | Value must be in Type of Claim List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2182 | COT037 | COT.002.037 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2183 | COT037 | COT.002.037 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2184 | COT037 | COT.002.037 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | When value equals 'Z', claim denied indicator must equal '0' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2185 | COT038 | COT.002.038 | TYPE-OF-BILL | Type of Bill | Conditional | A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) | Value must be in Type of Bill List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2186 | COT038 | COT.002.038 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | Value must be 4 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2187 | COT038 | COT.002.038 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | First character must be a '0' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2188 | COT038 | COT.002.038 | TYPE-OF-BILL | Type of Bill | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2189 | COT039 | COT.002.039 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2190 | COT039 | COT.002.039 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2191 | COT039 | COT.002.039 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2192 | COT039 | COT.002.039 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | If value in [ 26, 87, 542, 585, 654 ], Claim Denied Indicator must be '0' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2193 | COT040 | COT.002.040 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The Claim Status Category conveys the status of the entire claim using the X12 Claim Status Category Codes from the claim adjudication process. | Value must be in Claim Status Category List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2194 | COT040 | COT.002.040 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2195 | COT040 | COT.002.040 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2196 | COT040 | COT.002.040 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2197 | COT040 | COT.002.040 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2198 | COT041 | COT.002.041 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. | Value must be in Source Location List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2199 | COT041 | COT.002.041 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2200 | COT041 | COT.002.041 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2201 | COT042 | COT.002.042 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | Value must be 15 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2202 | COT042 | COT.002.042 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must have an associated Check Effective Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2203 | COT042 | COT.002.042 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2204 | COT042 | COT.002.042 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2205 | COT043 | COT.002.043 | CHECK-EFF-DATE | Check Effective Date | Conditional | The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2206 | COT043 | COT.002.043 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2207 | COT043 | COT.002.043 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Value may be the same as associated Remittance Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2208 | COT043 | COT.002.043 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Must have an associated Check Number | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2209 | COT043 | COT.002.043 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2210 | COT044 | COT.002.044 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2211 | COT044 | COT.002.044 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2212 | COT044 | COT.002.044 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2213 | COT044 | COT.002.044 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2214 | COT045 | COT.002.045 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2215 | COT045 | COT.002.045 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2216 | COT045 | COT.002.045 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2217 | COT045 | COT.002.045 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2218 | COT045 | COT.002.045 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 1 is not populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2219 | COT046 | COT.002.046 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2220 | COT046 | COT.002.046 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2221 | COT046 | COT.002.046 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2222 | COT046 | COT.002.046 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2223 | COT046 | COT.002.046 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 2 is not populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2224 | COT047 | COT.002.047 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2225 | COT047 | COT.002.047 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2226 | COT047 | COT.002.047 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2227 | COT047 | COT.002.047 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2228 | COT047 | COT.002.047 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 3 is not populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2229 | COT048 | COT.002.048 | TOT-BILLED-AMT | Total Billed Amount | Conditional | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial _x000D_ transactions. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2230 | COT048 | COT.002.048 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2231 | COT048 | COT.002.048 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must equal the sum of all Billed Amount instances for the associated claim | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2232 | COT048 | COT.002.048 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2233 | COT048 | COT.002.048 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2234 | COT048 | COT.002.048 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | If associated Type of Claim value is 2, 4, 5, B, D, or E, then value should not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2235 | COT049 | COT.002.049 | TOT-ALLOWED-AMT | Total Allowed Amount | Conditional | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is _x000D_ determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2236 | COT049 | COT.002.049 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2237 | COT049 | COT.002.049 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2238 | COT049 | COT.002.049 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2239 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Conditional | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2240 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2241 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Must have an associated Medicaid Paid Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2242 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2243 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2244 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2245 | COT050 | COT.002.050 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must not be greater than Total Allowed Amount (COT.002.049) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2246 | COT051 | COT.002.051 | TOT-COPAY-AMT | Total Copayment Amount | Conditional | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2247 | COT051 | COT.002.051 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2248 | COT051 | COT.002.051 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2249 | COT052 | COT.002.052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Conditional | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and _x000D_ deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a "1" and leave Total Medicare Coinsurance Amount unpopulated. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2250 | COT052 | COT.002.052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2251 | COT052 | COT.002.052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2252 | COT052 | COT.002.052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2253 | COT052 | COT.002.052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2254 | COT052 | COT.002.052 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2255 | COT053 | COT.002.053 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Conditional | The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2256 | COT053 | COT.002.053 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2257 | COT053 | COT.002.053 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2258 | COT053 | COT.002.053 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2259 | COT053 | COT.002.053 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Medicare Combined Deductible Indicator is '1', then value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2260 | COT053 | COT.002.053 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2261 | COT054 | COT.002.054 | TOT-TPL-AMT | Total Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2262 | COT054 | COT.002.054 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2263 | COT054 | COT.002.054 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2264 | COT054 | COT.002.054 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2265 | COT056 | COT.002.056 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2266 | COT056 | COT.002.056 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2267 | COT056 | COT.002.056 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2268 | COT057 | COT.002.057 | OTHER-INSURANCE-IND | Other Insurance Indicator | Conditional | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Value must be in Other Insurance Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2269 | COT057 | COT.002.057 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2270 | COT057 | COT.002.057 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2271 | COT058 | COT.002.058 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2272 | COT058 | COT.002.058 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2273 | COT058 | COT.002.058 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2274 | COT059 | COT.002.059 | SERVICE-TRACKING-TYPE | Service Tracking Type | Conditional | A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee. | Value must be in Service Tracking Type List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2275 | COT059 | COT.002.059 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2276 | COT059 | COT.002.059 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2277 | COT059 | COT.002.059 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2278 | COT060 | COT.002.060 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Conditional | On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2279 | COT060 | COT.002.060 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2280 | COT060 | COT.002.060 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2281 | COT060 | COT.002.060 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2282 | COT060 | COT.002.060 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Service Tracking Type must be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2283 | COT060 | COT.002.060 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Total Medicaid Amount must not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2284 | COT061 | COT.002.061 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Conditional | This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management _x000D_ programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined "medical record" _x000D_ associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Value must be in Fixed Payment Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2285 | COT061 | COT.002.061 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2286 | COT061 | COT.002.061 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2287 | COT062 | COT.002.062 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | Value must be in Funding Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2288 | COT062 | COT.002.062 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2289 | COT062 | COT.002.062 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2290 | COT063 | COT.002.063 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. | Value must be in Funding Source Non-Federal Share List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2291 | COT063 | COT.002.063 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2292 | COT063 | COT.002.063 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Required | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2293 | COT064 | COT.002.064 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Conditional | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. | Value must be in Medicare Combined Deductible Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2294 | COT064 | COT.002.064 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2295 | COT064 | COT.002.064 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | If value equals '1', then Medicare Coinsurance amount is not populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2296 | COT064 | COT.002.064 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must equal '0' if associated Type of Claim is '3', 'C' or 'W' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2297 | COT064 | COT.002.064 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2298 | COT065 | COT.002.065 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | Value must be in Program Type List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2299 | COT065 | COT.002.065 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2300 | COT065 | COT.002.065 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2301 | COT065 | COT.002.065 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2302 | COT065 | COT.002.065 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2303 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Conditional | A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. | Value must be 12 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2304 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2305 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2306 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match Managed Care Plan ID (ELG.014.192) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2307 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match State Plan ID Number (MCR.002.019) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2308 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2309 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.033) occurs between the managed care contract eff/end dates (MCR.002.020/021) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2310 | COT066 | COT.002.066 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | If Type of Claim (COT.002.037) does not equal 3, C, W (Encounter Record) and Type of Service (COT.003.186) does not equal 119, 120, 121, 122 (Capitation payments) value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2311 | COT067 | COT.002.067 | NATIONAL-HEALTH-CARE-ENTITY-ID | National Health Care Entity ID | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2312 | COT068 | COT.002.068 | PAYMENT-LEVEL-IND | Payment Level Indicator | Mandatory | The field denotes whether the payment amount was determined at the claim header or line/detail level. | Value must be in Payment Level Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2313 | COT068 | COT.002.068 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2314 | COT068 | COT.002.068 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2315 | COT069 | COT.002.069 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | Value must be in Medicare Reimbursement Type List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2316 | COT069 | COT.002.069 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | (Crossover Claim) if associated Crossover Indicator value indicates a crossover claim, value is mandatory and must be provided | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2317 | COT069 | COT.002.069 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2318 | COT069 | COT.002.069 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2319 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | Value must be a positive integer | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2320 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be between 0:9999 (inclusive) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2321 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must not include commas or other non-numeric characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2322 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2323 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2324 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2325 | COT072 | COT.002.072 | FORCED-CLAIM-IND | Forced Claim Indicator | Conditional | The charges for inpatient care, which are not reimbursable by the primary payer. The non-covered charges do not refer _x000D_ to charges not covered for any other service. see US Dollar Amount (DT.008) |
Value must be in Forced Claim Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2326 | COT072 | COT.002.072 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2327 | COT072 | COT.002.072 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2328 | COT073 | COT.002.073 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Conditional | This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site :_x000D_ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
Value must be in Healthcare Acquired Condition Indicator List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2329 | COT073 | COT.002.073 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2330 | COT073 | COT.002.073 | HEALTH-CARE-ACQUIRED-CONDITION-IND | Healthcare Acquired Condition Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2331 | COT074 | COT.002.074 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2332 | COT074 | COT.002.074 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2333 | COT074 | COT.002.074 | OCCURRENCE-CODE-01 | Occurrence Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2334 | COT075 | COT.002.075 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2335 | COT075 | COT.002.075 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2336 | COT075 | COT.002.075 | OCCURRENCE-CODE-02 | Occurrence Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2337 | COT076 | COT.002.076 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2338 | COT076 | COT.002.076 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2339 | COT076 | COT.002.076 | OCCURRENCE-CODE-03 | Occurrence Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2340 | COT077 | COT.002.077 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2341 | COT077 | COT.002.077 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2342 | COT077 | COT.002.077 | OCCURRENCE-CODE-04 | Occurrence Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2343 | COT078 | COT.002.078 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2344 | COT078 | COT.002.078 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2345 | COT078 | COT.002.078 | OCCURRENCE-CODE-05 | Occurrence Code 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2346 | COT079 | COT.002.079 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2347 | COT079 | COT.002.079 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2348 | COT079 | COT.002.079 | OCCURRENCE-CODE-06 | Occurrence Code 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2349 | COT080 | COT.002.080 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2350 | COT080 | COT.002.080 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2351 | COT080 | COT.002.080 | OCCURRENCE-CODE-07 | Occurrence Code 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2352 | COT081 | COT.002.081 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2353 | COT081 | COT.002.081 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2354 | COT081 | COT.002.081 | OCCURRENCE-CODE-08 | Occurrence Code 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2355 | COT082 | COT.002.082 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2356 | COT082 | COT.002.082 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2357 | COT082 | COT.002.082 | OCCURRENCE-CODE-09 | Occurrence Code 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2358 | COT083 | COT.002.083 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Conditional | A code to describe specific event(s) relating to this billing period covered by the claim. (These are FLs 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | Value must be in Occurrence Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2359 | COT083 | COT.002.083 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2360 | COT083 | COT.002.083 | OCCURRENCE-CODE-10 | Occurrence Code 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2361 | COT084 | COT.002.084 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2362 | COT084 | COT.002.084 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2363 | COT084 | COT.002.084 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2364 | COT084 | COT.002.084 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2365 | COT084 | COT.002.084 | OCCURRENCE-CODE-EFF-DATE-01 | Occurrence Code Effective Date 1 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2366 | COT085 | COT.002.085 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2367 | COT085 | COT.002.085 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2368 | COT085 | COT.002.085 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2369 | COT085 | COT.002.085 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2370 | COT085 | COT.002.085 | OCCURRENCE-CODE-EFF-DATE-02 | Occurrence Code Effective Date 2 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2371 | COT086 | COT.002.086 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2372 | COT086 | COT.002.086 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2373 | COT086 | COT.002.086 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2374 | COT086 | COT.002.086 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2375 | COT086 | COT.002.086 | OCCURRENCE-CODE-EFF-DATE-03 | Occurrence Code Effective Date 3 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2376 | COT087 | COT.002.087 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2377 | COT087 | COT.002.087 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2378 | COT087 | COT.002.087 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2379 | COT087 | COT.002.087 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2380 | COT087 | COT.002.087 | OCCURRENCE-CODE-EFF-DATE-04 | Occurrence Code Effective Date 4 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2381 | COT088 | COT.002.088 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2382 | COT088 | COT.002.088 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2383 | COT088 | COT.002.088 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2384 | COT088 | COT.002.088 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2385 | COT088 | COT.002.088 | OCCURRENCE-CODE-EFF-DATE-05 | Occurrence Code Effective Date 5 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2386 | COT089 | COT.002.089 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2387 | COT089 | COT.002.089 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2388 | COT089 | COT.002.089 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2389 | COT089 | COT.002.089 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2390 | COT089 | COT.002.089 | OCCURRENCE-CODE-EFF-DATE-06 | Occurrence Code Effective Date 6 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2391 | COT090 | COT.002.090 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2392 | COT090 | COT.002.090 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2393 | COT090 | COT.002.090 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2394 | COT090 | COT.002.090 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2395 | COT090 | COT.002.090 | OCCURRENCE-CODE-EFF-DATE-07 | Occurrence Code Effective Date 7 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2396 | COT091 | COT.002.091 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2397 | COT091 | COT.002.091 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2398 | COT091 | COT.002.091 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2399 | COT091 | COT.002.091 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2400 | COT091 | COT.002.091 | OCCURRENCE-CODE-EFF-DATE-08 | Occurrence Code Effective Date 8 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2401 | COT092 | COT.002.092 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2402 | COT092 | COT.002.092 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2403 | COT092 | COT.002.092 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2404 | COT092 | COT.002.092 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2405 | COT092 | COT.002.092 | OCCURRENCE-CODE-EFF-DATE-09 | Occurrence Code Effective Date 9 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2406 | COT093 | COT.002.093 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Conditional | The start date of the corresponding occurrence code or occurrence span codes. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2407 | COT093 | COT.002.093 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2408 | COT093 | COT.002.093 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | When populated, value must have an associated populated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2409 | COT093 | COT.002.093 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2410 | COT093 | COT.002.093 | OCCURRENCE-CODE-EFF-DATE-10 | Occurrence Code Effective Date 10 | Not Applicable | Not Applicable | Value must be less than or equal to Occurrence Code End Date | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2411 | COT094 | COT.002.094 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2412 | COT094 | COT.002.094 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2413 | COT094 | COT.002.094 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2414 | COT094 | COT.002.094 | OCCURRENCE-CODE-END-DATE-01 | Occurrence Code End Date 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2415 | COT095 | COT.002.095 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2416 | COT095 | COT.002.095 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2417 | COT095 | COT.002.095 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2418 | COT095 | COT.002.095 | OCCURRENCE-CODE-END-DATE-02 | Occurrence Code End Date 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2419 | COT096 | COT.002.096 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2420 | COT096 | COT.002.096 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2421 | COT096 | COT.002.096 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2422 | COT096 | COT.002.096 | OCCURRENCE-CODE-END-DATE-03 | Occurrence Code End Date 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2423 | COT097 | COT.002.097 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2424 | COT097 | COT.002.097 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2425 | COT097 | COT.002.097 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2426 | COT097 | COT.002.097 | OCCURRENCE-CODE-END-DATE-04 | Occurrence Code End Date 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2427 | COT098 | COT.002.098 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2428 | COT098 | COT.002.098 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2429 | COT098 | COT.002.098 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2430 | COT098 | COT.002.098 | OCCURRENCE-CODE-END-DATE-05 | Occurrence Code End Date 5 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2431 | COT099 | COT.002.099 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2432 | COT099 | COT.002.099 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2433 | COT099 | COT.002.099 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2434 | COT099 | COT.002.099 | OCCURRENCE-CODE-END-DATE-06 | Occurrence Code End Date 6 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2435 | COT100 | COT.002.100 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2436 | COT100 | COT.002.100 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2437 | COT100 | COT.002.100 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2438 | COT100 | COT.002.100 | OCCURRENCE-CODE-END-DATE-07 | Occurrence Code End Date 7 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2439 | COT101 | COT.002.101 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2440 | COT101 | COT.002.101 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2441 | COT101 | COT.002.101 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2442 | COT101 | COT.002.101 | OCCURRENCE-CODE-END-DATE-08 | Occurrence Code End Date 8 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2443 | COT102 | COT.002.102 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2444 | COT102 | COT.002.102 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2445 | COT102 | COT.002.102 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2446 | COT102 | COT.002.102 | OCCURRENCE-CODE-END-DATE-09 | Occurrence Code End Date 9 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2447 | COT103 | COT.002.103 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Conditional | The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2448 | COT103 | COT.002.103 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2449 | COT103 | COT.002.103 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | Must have an associated Occurrence Code | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2450 | COT103 | COT.002.103 | OCCURRENCE-CODE-END-DATE-10 | Occurrence Code End Date 10 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2451 | COT104 | COT.002.104 | PATIENT-CONTROL-NUM | Patient Control Number | Conditional | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment | Value must be 20 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2452 | COT104 | COT.002.104 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2453 | COT104 | COT.002.104 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2454 | COT105 | COT.002.105 | ELIGIBLE-LAST-NAME | Eligible Last Name | Conditional | The last name of the individual to whom the services were provided. (The patients name should be captured as it _x000D_ appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification _x000D_ Number will be used to associate a claim record with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2455 | COT105 | COT.002.105 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2456 | COT105 | COT.002.105 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2457 | COT106 | COT.002.106 | ELIGIBLE-FIRST-NAME | Eligible First Name | Conditional | The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record _x000D_ with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2458 | COT106 | COT.002.106 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2459 | COT106 | COT.002.106 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2460 | COT107 | COT.002.107 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2461 | COT107 | COT.002.107 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2462 | COT107 | COT.002.107 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2463 | COT107 | COT.002.107 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2464 | COT108 | COT.002.108 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2465 | COT108 | COT.002.108 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2466 | COT108 | COT.002.108 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2467 | COT109 | COT.002.109 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Conditional | Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. States should not submit claim records for an eligible individual that indicate the claim was submitted by a _x000D_ provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or _x000D_ provider group enrolled in the health home model. |
Value must be in Health Home Provider Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2468 | COT109 | COT.002.109 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | If there is an associated Health Home Entity Name value, then value must be "1" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2469 | COT109 | COT.002.109 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2470 | COT109 | COT.002.109 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2471 | COT110 | COT.002.110 | WAIVER-TYPE | Waiver Type | Conditional | A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Value must be in Waiver Type List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2472 | COT110 | COT.002.110 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2473 | COT110 | COT.002.110 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2474 | COT110 | COT.002.110 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | When populated, Waiver ID (COT.002.111) must be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2475 | COT110 | COT.002.110 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2476 | COT111 | COT.002.111 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the_x000D_ "core" part of the waiver IDs, without including suffixes for renewals or amendments. |
Value must be associated with a populated Waiver Type | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2477 | COT111 | COT.002.111 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2478 | COT111 | COT.002.111 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2479 | COT111 | COT.002.111 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2480 | COT111 | COT.002.111 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2481 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity _x000D_ (billing or reporting) to the managed care plan. |
Value must be 30 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2482 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2483 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2484 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1' |
2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2485 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2486 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | When Type of Service (COT..003.186) is in ['119', '120', '122'] value must match Plan ID Number (COT.002.066) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2487 | COT113 | COT.002.113 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2488 | COT113 | COT.002.113 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2489 | COT113 | COT.002.113 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2490 | COT113 | COT.002.113 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2491 | COT114 | COT.002.114 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the provider billing for the service. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2492 | COT114 | COT.002.114 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2493 | COT114 | COT.002.114 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2494 | COT114 | COT.002.114 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Value is in [119, 120, 121, 122 ], then value should not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2495 | COT115 | COT.002.115 | BILLING-PROV-TYPE | Billing Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2496 | COT115 | COT.002.115 | BILLING-PROV-TYPE | Billing Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2497 | COT115 | COT.002.115 | BILLING-PROV-TYPE | Billing Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2498 | COT116 | COT.002.116 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2499 | COT116 | COT.002.116 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2500 | COT116 | COT.002.116 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2501 | COT117 | COT.002.117 | REFERRING-PROV-NUM | Referring Provider Number | Conditional | A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a _x000D_ group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA _x000D_ ID for this data element. |
Value must be 30 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2502 | COT117 | COT.002.117 | REFERRING-PROV-NUM | Referring Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2503 | COT117 | COT.002.117 | REFERRING-PROV-NUM | Referring Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C1 | 2504 | COT118 | COT.002.118 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2505 | COT118 | COT.002.118 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2506 | COT118 | COT.002.118 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2507 | COT119 | COT.002.119 | REFERRING-PROV-TAXONOMY | Referring Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2508 | COT120 | COT.002.120 | REFERRING-PROV-TYPE | Referring Provider Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2509 | COT121 | COT.002.121 | REFERRING-PROV-SPECIALTY | Referring Provider Specialty | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2510 | COT122 | COT.002.122 | MEDICARE-HIC-NUM | Medicare HIC Number | Conditional | The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the _x000D_ Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & _x000D_ alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) |
Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2511 | COT122 | COT.002.122 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2512 | COT122 | COT.002.122 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2513 | COT122 | COT.002.122 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2514 | COT122 | COT.002.122 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be populated when Crossover Indicator (COT.002.023) equals '1' and Medicare Beneficiary Identifier (COT.002.147) is not populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2515 | COT123 | COT.002.123 | PLACE-OF-SERVICE | Place of Service | Conditional | A data element corresponding with line 24b on the CMS-1500 that indicates where the services took place. This is a pass-through data element that should not be modified or derived when missing unless otherwise specified. | Value must be in Place of Service List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2516 | COT123 | COT.002.123 | PLACE-OF-SERVICE | Place of Service | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2517 | COT123 | COT.002.123 | PLACE-OF-SERVICE | Place of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2518 | COT123 | COT.002.123 | PLACE-OF-SERVICE | Place of Service | Not Applicable | Not Applicable | If value is populated on a non-denied claim, then Procedure Code (COT.003.169) must be populated. | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2519 | COT123 | COT.002.123 | PLACE-OF-SERVICE | Place of Service | Not Applicable | Not Applicable | When Type of Service (COT.003.186) is in [119-122], Place of Service (COT.002.123) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2520 | COT125 | COT.002.125 | BMI | Body Mass Index | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2521 | COT126 | COT.002.126 | REMITTANCE-NUM | Remittance Number | Mandatory | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed _x000D_ explanation of the reason for the payment amount. The RA number is not the check number. |
Value must be 30 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2522 | COT126 | COT.002.126 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19)) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2523 | COT126 | COT.002.126 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2524 | COT126 | COT.002.126 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2525 | COT127 | COT.002.127 | DAILY-RATE | Daily Rate | Conditional | The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as a flat rate. see US Dollar Amount (DT.008) | Value must be between 0.00 and 99999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2526 | COT127 | COT.002.127 | DAILY-RATE | Daily Rate | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2527 | COT127 | COT.002.127 | DAILY-RATE | Daily Rate | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2528 | COT128 | COT.002.128 | BORDER-STATE-IND | Border State Indicator | Conditional | A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Value must be in Border State Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2529 | COT128 | COT.002.128 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2530 | COT128 | COT.002.128 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2531 | COT130 | COT.002.130 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Conditional | The amount of money the beneficiary paid towards coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2532 | COT130 | COT.002.130 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2533 | COT130 | COT.002.130 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Date Paid | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2534 | COT130 | COT.002.130 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2535 | COT131 | COT.002.131 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2536 | COT131 | COT.002.131 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2537 | COT131 | COT.002.131 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Amount | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2538 | COT131 | COT.002.131 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2539 | COT132 | COT.002.132 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Conditional | The amount of money the beneficiary paid towards a co-payment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2540 | COT132 | COT.002.132 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2541 | COT132 | COT.002.132 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Date Paid | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2542 | COT132 | COT.002.132 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2543 | COT133 | COT.002.133 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2544 | COT133 | COT.002.133 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2545 | COT133 | COT.002.133 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Amount | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2546 | COT133 | COT.002.133 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2547 | COT134 | COT.002.134 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Conditional | The amount of money the beneficiary paid towards an annual deductible. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2548 | COT134 | COT.002.134 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2549 | COT134 | COT.002.134 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2550 | COT134 | COT.002.134 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2551 | COT135 | COT.002.135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2552 | COT135 | COT.002.135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2553 | COT135 | COT.002.135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2554 | COT135 | COT.002.135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2555 | COT136 | COT.002.136 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Mandatory | An indicator to identify a claim that the state refused pay in its entirety. | Value must be in Claim Denied Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2556 | COT136 | COT.002.136 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | If value is '0', then Claim Status Category must equal "F2" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2557 | COT136 | COT.002.136 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2558 | COT136 | COT.002.136 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2559 | COT137 | COT.002.137 | COPAY-WAIVED-IND | Copayment Waived Indicator | Optional | An indicator signifying that the copay was waived by the provider. | Value must be in Copay Waived Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2560 | COT137 | COT.002.137 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2561 | COT137 | COT.002.137 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2562 | COT138 | COT.002.138 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Conditional | A free-form text field to indicate the health home program that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, _x000D_ behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. |
Value must 50 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2563 | COT138 | COT.002.138 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2564 | COT138 | COT.002.138 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2565 | COT140 | COT.002.140 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Optional | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance on the claim or claim line item. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2566 | COT140 | COT.002.140 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2567 | COT140 | COT.002.140 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2568 | COT141 | COT.002.141 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date a Third Party Coinsurance amount was paid on this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2569 | COT141 | COT.002.141 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2570 | COT141 | COT.002.141 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2571 | COT142 | COT.002.142 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Optional | The amount of money a third-party on behalf of the beneficiary paid towards a copayment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2572 | COT142 | COT.002.142 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2573 | COT142 | COT.002.142 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2574 | COT143 | COT.002.143 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Optional | The date a Third Party copayment amount was paid on a claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2575 | COT143 | COT.002.143 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2576 | COT143 | COT.002.143 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2577 | COT144 | COT.002.144 | DATE-CAPITATED-AMOUNT-REQUESTED | Date Capitated Amount Requested | Conditional | The date that the managed care entity submitted the capitated payment bill to the state. see Date (DT.001) | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2578 | COT144 | COT.002.144 | DATE-CAPITATED-AMOUNT-REQUESTED | Date Capitated Amount Requested | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2579 | COT144 | COT.002.144 | DATE-CAPITATED-AMOUNT-REQUESTED | Date Capitated Amount Requested | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2580 | COT145 | COT.002.145 | CAPITATED-PAYMENT-AMT-REQUESTED | Capitated Payment Amount Requested | Conditional | The amount of the capitated payment bill submitted by the managed care entity to the state. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2581 | COT145 | COT.002.145 | CAPITATED-PAYMENT-AMT-REQUESTED | Capitated Payment Amount Requested | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2582 | COT145 | COT.002.145 | CAPITATED-PAYMENT-AMT-REQUESTED | Capitated Payment Amount Requested | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2583 | COT146 | COT.002.146 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2584 | COT146 | COT.002.146 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2585 | COT146 | COT.002.146 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2586 | COT146 | COT.002.146 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | When Type of Service (COT.003.186) equals '121', value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2587 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Conditional | The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI _x000D_ over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. |
Conditional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2588 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must be an 11-character string | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2589 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 1 must be numeric values 1 thru 9 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2590 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2591 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2592 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 4 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2593 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2594 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2595 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 7 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2596 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2597 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2598 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 10 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2599 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 11 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2600 | COT147 | COT.002.147 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2601 | COT148 | COT.002.148 | UNDER-DIRECTION-OF-PROV-NPI | Under Direction of Provider NPI | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2602 | COT149 | COT.002.149 | UNDER-DIRECTION-OF-PROV-TAXONOMY | Under Direction of Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2603 | COT150 | COT.002.150 | UNDER-SUPERVISION-OF-PROV-NPI | Under Supervision of Provider NPI | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2604 | COT151 | COT.002.151 | UNDER-SUPERVISION-OF-PROV-TAXONOMY | Under Supervision of Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2605 | COT152 | COT.002.152 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2606 | COT152 | COT.002.152 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2607 | COT152 | COT.002.152 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| D1 | 2608 | COT153 | COT.002.153 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| C2 | 2609 | COT226 | COT.002.226 | PROV-LOCATION-ID | Provider Location ID | Mandatory | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| A2 | 2610 | COT226 | COT.002.226 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2611 | COT226 | COT.002.226 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 |
| X1 | 2612 | COT154 | COT.003.154 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2613 | COT154 | COT.003.154 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "COT00003" | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2614 | COT155 | COT.003.155 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2615 | COT155 | COT.003.155 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2616 | COT155 | COT.003.155 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2617 | COT155 | COT.003.155 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (COT.001.007) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2618 | COT156 | COT.003.156 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2619 | COT156 | COT.003.156 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2620 | COT156 | COT.003.156 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2621 | COT156 | COT.003.156 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2622 | COT157 | COT.003.157 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2623 | COT157 | COT.003.157 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2624 | COT157 | COT.003.157 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2625 | COT157 | COT.003.157 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2626 | COT157 | COT.003.157 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2627 | COT158 | COT.003.158 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2628 | COT158 | COT.003.158 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2629 | COT158 | COT.003.158 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2630 | COT159 | COT.003.159 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2631 | COT159 | COT.003.159 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2632 | COT159 | COT.003.159 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2633 | COT159 | COT.003.159 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2634 | COT160 | COT.003.160 | LINE-NUM-ORIG | Original Line Number | Mandatory | A unique number to identify the transaction line number that is being reported on the original claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2635 | COT160 | COT.003.160 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2636 | COT160 | COT.003.160 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2637 | COT160 | COT.003.160 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2638 | COT161 | COT.003.161 | LINE-NUM-ADJ | Adjustment Line Number | Conditional | A unique number to identify the transaction line number that identifies the line number on the adjustment claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2639 | COT161 | COT.003.161 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2640 | COT161 | COT.003.161 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2641 | COT161 | COT.003.161 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2642 | COT161 | COT.003.161 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2643 | COT162 | COT.003.162 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Conditional | A code to indicate the type of adjustment record claim/encounter represents at claim detail level. | Value must be in Line Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2644 | COT162 | COT.003.162 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2645 | COT162 | COT.003.162 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6] | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2646 | COT162 | COT.003.162 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2647 | COT162 | COT.003.162 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2648 | COT162 | COT.003.162 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Line Adjustment Number is populated, then value must be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2649 | COT163 | COT.003.163 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Value must be in Line Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2650 | COT163 | COT.003.163 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2651 | COT163 | COT.003.163 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2652 | COT163 | COT.003.163 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | When populated, Line Adjustment Indicator must be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2653 | COT164 | COT.003.164 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C1 | 2654 | COT164 | COT.003.164 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2655 | COT165 | COT.003.165 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The Claim Line Status conveys the status of a specific service line using the X12 Claim Status Codes from the claim adjudication process. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2656 | COT165 | COT.003.165 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2657 | COT165 | COT.003.165 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2658 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Mandatory | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service _x000D_ covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2659 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2660 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2661 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Ending Date of Service value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2662 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2663 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2664 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2665 | COT166 | COT.003.166 | BEGINNING-DATE-OF-SERVICE | Beginning Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2666 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Mandatory | 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 _x000D_ claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2667 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2668 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2669 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be greater than or equal to associated Beginning Date of Service value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2670 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2671 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2672 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Value must be equal to or greater than associated Date of Birth (ELG.002.024) value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2673 | COT167 | COT.003.167 | ENDING-DATE-OF-SERVICE | Ending Date of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2674 | COT168 | COT.003.168 | REVENUE-CODE | Revenue Code | Conditional | A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing _x000D_ Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's _x000D_ 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed _x000D_ care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims. |
Value must be in Revenue Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2675 | COT168 | COT.003.168 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | A Revenue Code value requires an associated Revenue Charge | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2676 | COT168 | COT.003.168 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2677 | COT168 | COT.003.168 | REVENUE-CODE | Revenue Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2678 | COT169 | COT.003.169 | PROCEDURE-CODE | Procedure Code | Conditional | A field to capture the CPT or HCPCS code that describes a service or good rendered by the provider to an enrollee on the specified date of service. | When populated, there must be a corresponding Procedure Code Flag | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2679 | COT169 | COT.003.169 | PROCEDURE-CODE | Procedure Code | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an CPT-4 encoding '01', then value must be a valid CPT-4 procedure code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2680 | COT169 | COT.003.169 | PROCEDURE-CODE | Procedure Code | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2681 | COT169 | COT.003.169 | PROCEDURE-CODE | Procedure Code | Not Applicable | Not Applicable | If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding '06', then value must be a valid HCPCS code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2682 | COT169 | COT.003.169 | PROCEDURE-CODE | Procedure Code | Not Applicable | Not Applicable | Value must be 8 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2683 | COT169 | COT.003.169 | PROCEDURE-CODE | Procedure Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2684 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Conditional | The date upon which a reported medical procedure was performed. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2685 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2686 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Value must be before associated Ending Date of Service value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2687 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Value must be provided with an associated Procedure Code value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2688 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Value must be on or after associated Beginning Date of Service value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2689 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Value must be on or before associated Eligible Date of Death value | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2690 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Value must be not be populated when associated Procedure Code is not populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2691 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2692 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Not Applicable | Not Applicable | Value must be populated when Procedure Code (COT.003.169) is populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C1 | 2693 | COT171 | COT.003.171 | PROCEDURE-CODE-FLAG | Procedure Code Flag | Conditional | A flag that identifies the coding system used for an associated procedure code. | When populated, there must be a corresponding Procedure Code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2694 | COT171 | COT.003.171 | PROCEDURE-CODE-FLAG | Procedure Code Flag | Not Applicable | Not Applicable | Value must be in Procedure Code Flag List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2695 | COT171 | COT.003.171 | PROCEDURE-CODE-FLAG | Procedure Code Flag | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2696 | COT171 | COT.003.171 | PROCEDURE-CODE-FLAG | Procedure Code Flag | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2697 | COT172 | COT.003.172 | PROCEDURE-CODE-MOD-1 | Procedure Code Modifier 1 | Conditional | The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. | Must be associated with a Procedure Code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2698 | COT172 | COT.003.172 | PROCEDURE-CODE-MOD-1 | Procedure Code Modifier 1 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2699 | COT172 | COT.003.172 | PROCEDURE-CODE-MOD-1 | Procedure Code Modifier 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| D1 | 2700 | COT173 | COT.003.173 | IMMUNIZATION-TYPE | Immunization Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2701 | COT174 | COT.003.174 | BILLED-AMT | Billed Amount | Conditional | The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2702 | COT174 | COT.003.174 | BILLED-AMT | Billed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2703 | COT174 | COT.003.174 | BILLED-AMT | Billed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2704 | COT175 | COT.003.175 | ALLOWED-AMT | Allowed Amount | Conditional | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed _x000D_ care encounters the Allowed Amount is determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2705 | COT175 | COT.003.175 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2706 | COT175 | COT.003.175 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2707 | COT176 | COT.003.176 | COPAY-AMT | Copayment Amount | Conditional | The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. | Value must be 5 digits or less left of the decimal i.e. 99999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2708 | COT176 | COT.003.176 | COPAY-AMT | Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2709 | COT177 | COT.003.177 | TPL-AMT | Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2710 | COT177 | COT.003.177 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2711 | COT177 | COT.003.177 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2712 | COT178 | COT.003.178 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Conditional | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire _x000D_ payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2713 | COT178 | COT.003.178 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2714 | COT178 | COT.003.178 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2715 | COT179 | COT.003.179 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Conditional | The amount that would have been paid had the services been provided on a Fee for Service basis. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2716 | COT179 | COT.003.179 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2717 | COT179 | COT.003.179 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2718 | COT179 | COT.003.179 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2719 | COT182 | COT.003.182 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim or adjustment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2720 | COT182 | COT.003.182 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2721 | COT182 | COT.003.182 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated. | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2722 | COT182 | COT.003.182 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2723 | COT182 | COT.003.182 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If value is populated, Crossover Indicator must be equal to "1" | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2724 | COT183 | COT.003.183 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Conditional | The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span. 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 _x000D_ 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 _x000D_ filled vials, use 1 as the number of units. |
Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C1 | 2725 | COT183 | COT.003.183 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2726 | COT183 | COT.003.183 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Not Applicable | Not Applicable | If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported. | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2727 | COT183 | COT.003.183 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Not Applicable | Not Applicable | When populated, corresponding Unit of Measure must be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2728 | COT184 | COT.003.184 | OT-RX-CLAIM-QUANTITY-ALLOWED | OT RX Claim Quantity Allowed | Conditional | The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2729 | COT184 | COT.003.184 | OT-RX-CLAIM-QUANTITY-ALLOWED | OT RX Claim Quantity Allowed | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2730 | COT184 | COT.003.184 | OT-RX-CLAIM-QUANTITY-ALLOWED | OT RX Claim Quantity Allowed | Not Applicable | Not Applicable | If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported. | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2731 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Value must be 3 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2732 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Mandatory | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2733 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2734 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2735 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Value must satisfy the requirements of Type of Service (Other Claim) List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2736 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2737 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2738 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2739 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Plan ID Number (COT.002.066) must equal Billing Provider Number (COT.002.112) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2740 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2741 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2742 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2743 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | When value is not in ['025','085'], Sex (ELG.002.023) equals 'M' | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2744 | COT187 | COT.003.187 | HCBS-SERVICE-CODE | HCBS Service Code | Conditional | A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. _x000D_ 1915(c), 1915(i), 1915(j), and 1915(k) services). |
Value must be in HCBS Service Code List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2745 | COT187 | COT.003.187 | HCBS-SERVICE-CODE | HCBS Service Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2746 | COT187 | COT.003.187 | HCBS-SERVICE-CODE | HCBS Service Code | Not Applicable | Not Applicable | If value is 1-7, then HCBS Taxonomy must be populated. | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2747 | COT187 | COT.003.187 | HCBS-SERVICE-CODE | HCBS Service Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2748 | COT188 | COT.003.188 | HCBS-TAXONOMY | HCBS Taxonomy | Conditional | A code to classify the home and community based services listed on the claim into the HCBS taxonomy. | Value must be in HCBS Taxonomy Code List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2749 | COT188 | COT.003.188 | HCBS-TAXONOMY | HCBS Taxonomy | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2750 | COT188 | COT.003.188 | HCBS-TAXONOMY | HCBS Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2751 | COT189 | COT.003.189 | SERVICING-PROV-NUM | Servicing Provider Number | Conditional | A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The _x000D_ value is conditional as its usage varies by state. |
Value must be 30 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2752 | COT189 | COT.003.189 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2753 | COT189 | COT.003.189 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2754 | COT189 | COT.003.189 | SERVICING-PROV-NUM | Servicing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID |
2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C1 | 2755 | COT190 | COT.003.190 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2756 | COT190 | COT.003.190 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2757 | COT190 | COT.003.190 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2758 | COT190 | COT.003.190 | SERVICING-PROV-NPI-NUM | Servicing Provider NPI Number | Not Applicable | Not Applicable | When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| D1 | 2759 | COT191 | COT.003.191 | SERVICING-PROV-TAXONOMY | Servicing Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2760 | COT192 | COT.003.192 | SERVICING-PROV-TYPE | Servicing Provider Type | Conditional | A code to describe the type of entity billing for the service. | Value must be in Provider Type Code List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2761 | COT192 | COT.003.192 | SERVICING-PROV-TYPE | Servicing Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2762 | COT192 | COT.003.192 | SERVICING-PROV-TYPE | Servicing Provider Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2763 | COT193 | COT.003.193 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2764 | COT193 | COT.003.193 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2765 | COT193 | COT.003.193 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2766 | COT194 | COT.003.194 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2767 | COT194 | COT.003.194 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2768 | COT194 | COT.003.194 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2769 | COT195 | COT.003.195 | TOOTH-DESIGNATION-SYSTEM | Tooth Designation System | Conditional | A code to identify the tooth numbering system is being used. | Value must be in Tooth Designation System List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2770 | COT195 | COT.003.195 | TOOTH-DESIGNATION-SYSTEM | Tooth Designation System | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2771 | COT195 | COT.003.195 | TOOTH-DESIGNATION-SYSTEM | Tooth Designation System | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2772 | COT195 | COT.003.195 | TOOTH-DESIGNATION-SYSTEM | Tooth Designation System | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2773 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Conditional | The tooth number serviced based on the tooth numbering system identified in the TOOTH-DESIGNATION-SYSTEM field. see Tooth Number List (VVL.171) | Value must be in Tooth Number List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2774 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Not Applicable | Not Applicable | If Tooth Designation System (COT.003.195) is 'JP' value must be found in [1..32][51-82][A..T]or [AS..KS] | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2775 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Not Applicable | Not Applicable | If Tooth Designation System (COT.003.195) is 'JO' value must have 1 digit before and after the decimal (N.N) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2776 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Not Applicable | Not Applicable | If Tooth Designation System (COT.003.195) is 'JO' value must be a first digit of 1-4 and the decimal must be between 1-8 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2777 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Not Applicable | Not Applicable | Value must be 2 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2778 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2779 | COT196 | COT.003.196 | TOOTH-NUM | Tooth Number | Not Applicable | Not Applicable | When value is in ['A'-'T'], the difference between Ending Date of Service (COT.002.034) and Date of Birth (COT.002.108) is less than 15 years | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2780 | COT197 | COT.003.197 | TOOTH-QUAD-CODE | Tooth Quad Code | Conditional | The area of the oral cavity is designated by a two-digit code. | Value must be in Tooth Quad Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2781 | COT197 | COT.003.197 | TOOTH-QUAD-CODE | Tooth Quad Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2782 | COT197 | COT.003.197 | TOOTH-QUAD-CODE | Tooth Quad Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2783 | COT197 | COT.003.197 | TOOTH-QUAD-CODE | Tooth Quad Code | Not Applicable | Not Applicable | When populated, associated type of service value must be in [013, 029, 035] | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2784 | COT198 | COT.003.198 | TOOTH-SURFACE-CODE | Tooth Surface Code | Conditional | A code to identify the tooth's surface on which the service was performed. | Value must be in Tooth Surface Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2785 | COT198 | COT.003.198 | TOOTH-SURFACE-CODE | Tooth Surface Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2786 | COT198 | COT.003.198 | TOOTH-SURFACE-CODE | Tooth Surface Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2787 | COT198 | COT.003.198 | TOOTH-SURFACE-CODE | Tooth Surface Code | Not Applicable | Not Applicable | When populated, associated type of service value must be in [013, 029, 035] | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2788 | COT199 | COT.003.199 | ORIGINATION-ADDR-LN1 | Origination Address Line 1 | Conditional | The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. | Value must be 60 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2789 | COT199 | COT.003.199 | ORIGINATION-ADDR-LN1 | Origination Address Line 1 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 2 or Address Line 3 value(s) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2790 | COT199 | COT.003.199 | ORIGINATION-ADDR-LN1 | Origination Address Line 1 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2791 | COT199 | COT.003.199 | ORIGINATION-ADDR-LN1 | Origination Address Line 1 | Not Applicable | Not Applicable | When populated, the associated Address Type is required | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2792 | COT199 | COT.003.199 | ORIGINATION-ADDR-LN1 | Origination Address Line 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2793 | COT200 | COT.003.200 | ORIGINATION-ADDR-LN2 | Origination Address Line 2 | Conditional | The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. | Value must be 60 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2794 | COT200 | COT.003.200 | ORIGINATION-ADDR-LN2 | Origination Address Line 2 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 3 value(s) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2795 | COT200 | COT.003.200 | ORIGINATION-ADDR-LN2 | Origination Address Line 2 | Not Applicable | Not Applicable | There must be an Address Line 1 in order to have an Address Line 2 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2796 | COT200 | COT.003.200 | ORIGINATION-ADDR-LN2 | Origination Address Line 2 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2797 | COT200 | COT.003.200 | ORIGINATION-ADDR-LN2 | Origination Address Line 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2798 | COT201 | COT.003.201 | ORIGINATION-CITY | Origination City | Conditional | The name of the origination city from which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. | Value must be 28 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2799 | COT201 | COT.003.201 | ORIGINATION-CITY | Origination City | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2800 | COT201 | COT.003.201 | ORIGINATION-CITY | Origination City | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2801 | COT202 | COT.003.202 | ORIGINATION-STATE | Origination State | Conditional | The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a health care provider to a health care provider for healthcare services or vice versa. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2802 | COT202 | COT.003.202 | ORIGINATION-STATE | Origination State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2803 | COT202 | COT.003.202 | ORIGINATION-STATE | Origination State | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2804 | COT202 | COT.003.202 | ORIGINATION-STATE | Origination State | Not Applicable | Not Applicable | (transportation claim) value is mandatory and must be provided for all transportation claims | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2805 | COT203 | COT.003.203 | ORIGINATION-ZIP-CODE | Origination Zip Code | Conditional | U.S. Zip Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) | Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2806 | COT203 | COT.003.203 | ORIGINATION-ZIP-CODE | Origination Zip Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2807 | COT204 | COT.003.204 | DESTINATION-ADDR-LN1 | Destination Address Line 1 | Conditional | The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. | Value must be 60 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2808 | COT204 | COT.003.204 | DESTINATION-ADDR-LN1 | Destination Address Line 1 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 2 or Address Line 3 value(s) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2809 | COT204 | COT.003.204 | DESTINATION-ADDR-LN1 | Destination Address Line 1 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2810 | COT204 | COT.003.204 | DESTINATION-ADDR-LN1 | Destination Address Line 1 | Not Applicable | Not Applicable | When populated, the associated Address Type is required | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2811 | COT204 | COT.003.204 | DESTINATION-ADDR-LN1 | Destination Address Line 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2812 | COT205 | COT.003.205 | DESTINATION-ADDR-LN2 | Destination Address Line 2 | Conditional | The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. | Value must be 60 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2813 | COT205 | COT.003.205 | DESTINATION-ADDR-LN2 | Destination Address Line 2 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 3 value(s) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2814 | COT205 | COT.003.205 | DESTINATION-ADDR-LN2 | Destination Address Line 2 | Not Applicable | Not Applicable | There must be an Address Line 1 in order to have an Address Line 2 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2815 | COT205 | COT.003.205 | DESTINATION-ADDR-LN2 | Destination Address Line 2 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2816 | COT205 | COT.003.205 | DESTINATION-ADDR-LN2 | Destination Address Line 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2817 | COT206 | COT.003.206 | DESTINATION-CITY | Destination City | Conditional | The name of the destination city to which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Value must be 28 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2818 | COT206 | COT.003.206 | DESTINATION-CITY | Destination City | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2819 | COT206 | COT.003.206 | DESTINATION-CITY | Destination City | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2820 | COT207 | COT.003.207 | DESTINATION-STATE | Destination State | Conditional | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2821 | COT207 | COT.003.207 | DESTINATION-STATE | Destination State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2822 | COT207 | COT.003.207 | DESTINATION-STATE | Destination State | Not Applicable | Not Applicable | (transportation claim) value is mandatory and must be provided for all transportation claims | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2823 | COT207 | COT.003.207 | DESTINATION-STATE | Destination State | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2824 | COT208 | COT.003.208 | DESTINATION-ZIP-CODE | Destination Zip Code | Conditional | U.S. Zip Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) | Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2825 | COT208 | COT.003.208 | DESTINATION-ZIP-CODE | Destination Zip Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2826 | COT209 | COT.003.209 | BENEFIT-TYPE | Benefit Type | Mandatory | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types | Value must be in Benefit Type Code List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2827 | COT209 | COT.003.209 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2828 | COT209 | COT.003.209 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2829 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | Value must be in CMS 64 Category for Federal Reimbursement List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2830 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2831 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3'] | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2832 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1' | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2833 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2834 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2835 | COT210 | COT.003.210 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2836 | COT211 | COT.003.211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Conditional | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation. | Value must be in XIX MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2837 | COT211 | COT.003.211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2838 | COT211 | COT.003.211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2839 | COT211 | COT.003.211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2840 | COT211 | COT.003.211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2841 | COT211 | COT.003.211 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If XXI MBESCBES Category of Service is populated then must not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2842 | COT212 | COT.003.212 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Conditional | A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. | Value must be in XXI MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2843 | COT212 | COT.003.212 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2844 | COT212 | COT.003.212 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2845 | COT212 | COT.003.212 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | If XIX MBESCBES Category of Service is populated then value must not be populated | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2846 | COT212 | COT.003.212 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2847 | COT213 | COT.003.213 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2848 | COT213 | COT.003.213 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2849 | COT213 | COT.003.213 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2850 | COT214 | COT.003.214 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2851 | COT214 | COT.003.214 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2852 | COT214 | COT.003.214 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| D1 | 2853 | COT215 | COT.003.215 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2854 | COT217 | COT.003.217 | NATIONAL-DRUG-CODE | National Drug Code | Conditional | A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. | Characters 1-5 of value must be numeric | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2855 | COT217 | COT.003.217 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 6-9 of value must be numeric | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2856 | COT217 | COT.003.217 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 10-12 of value must be numeric or blank | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2857 | COT217 | COT.003.217 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be 12 digits or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2858 | COT217 | COT.003.217 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be a valid National Drug Code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2859 | COT217 | COT.003.217 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2860 | COT218 | COT.003.218 | PROCEDURE-CODE-MOD-3 | Procedure Code Modifier 3 | Conditional | The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. | Must be associated with a Procedure Code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2861 | COT218 | COT.003.218 | PROCEDURE-CODE-MOD-3 | Procedure Code Modifier 3 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2862 | COT218 | COT.003.218 | PROCEDURE-CODE-MOD-3 | Procedure Code Modifier 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2863 | COT219 | COT.003.219 | PROCEDURE-CODE-MOD-4 | Procedure Code Modifier 4 | Conditional | The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. | Must be associated with a Procedure Code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2864 | COT219 | COT.003.219 | PROCEDURE-CODE-MOD-4 | Procedure Code Modifier 4 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2865 | COT219 | COT.003.219 | PROCEDURE-CODE-MOD-4 | Procedure Code Modifier 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| D1 | 2866 | COT220 | COT.003.220 | HCPCS-RATE | HCPCS Rate | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2867 | COT221 | COT.003.221 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2868 | COT221 | COT.003.221 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2869 | COT221 | COT.003.221 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2870 | COT221 | COT.003.221 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2871 | COT222 | COT.003.222 | SELF-DIRECTION-TYPE | Self Direction Type | Conditional | A data element to identify how the beneficiary self-directed the service, i.e. hiring authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services), budget authority (The beneficiary has decision-making authority over how the _x000D_ Medicaid funds in a budget are spent), or both hiring and budget authority. |
Value must be in Self Direction Type List (VVL) | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2872 | COT222 | COT.003.222 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2873 | COT222 | COT.003.222 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2874 | COT223 | COT.003.223 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Conditional | A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). | Value must be 18 characters or less | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2875 | COT223 | COT.003.223 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2876 | COT223 | COT.003.223 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2877 | COT224 | COT.003.224 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Conditional | A code to indicate the basis by which the quantity of the National Drug Code is expressed. | Value must be in NDC Unit of Measure List (VVL). | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2878 | COT224 | COT.003.224 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2879 | COT224 | COT.003.224 | NDC-UNIT-OF-MEASURE | NDC Unit of Measure | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2880 | COT225 | COT.003.225 | NDC-QUANTITY | NDC Quantity | Conditional | This field is to capture the actual quantity of the National Drug Code being prescribed on the claim. | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2881 | COT225 | COT.003.225 | NDC-QUANTITY | NDC Quantity | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| C2 | 2882 | COT227 | COT.003.227 | PROCEDURE-CODE-MOD-2 | Procedure Code Modifier 2 | Conditional | The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. | Must be associated with a Procedure Code | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| A2 | 2883 | COT227 | COT.003.227 | PROCEDURE-CODE-MOD-2 | Procedure Code Modifier 2 | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2884 | COT227 | COT.003.227 | PROCEDURE-CODE-MOD-2 | Procedure Code Modifier 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 |
| X1 | 2885 | CRX001 | CRX.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2886 | CRX001 | CRX.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CRX00001" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2887 | CRX002 | CRX.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2888 | CRX002 | CRX.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2889 | CRX002 | CRX.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2890 | CRX003 | CRX.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2891 | CRX003 | CRX.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2892 | CRX003 | CRX.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2893 | CRX004 | CRX.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2894 | CRX004 | CRX.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2895 | CRX004 | CRX.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2896 | CRX005 | CRX.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2897 | CRX005 | CRX.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2898 | CRX006 | CRX.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'CLAIM-RX' | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2899 | CRX007 | CRX.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2900 | CRX007 | CRX.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2901 | CRX007 | CRX.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2902 | CRX008 | CRX.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2903 | CRX008 | CRX.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2904 | CRX008 | CRX.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2905 | CRX008 | CRX.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2906 | CRX008 | CRX.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2907 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2908 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2909 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2910 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2911 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2912 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2913 | CRX009 | CRX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2914 | CRX010 | CRX.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2915 | CRX010 | CRX.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2916 | CRX010 | CRX.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2917 | CRX010 | CRX.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2918 | CRX010 | CRX.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2919 | CRX010 | CRX.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2920 | CRX011 | CRX.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2921 | CRX011 | CRX.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2922 | CRX011 | CRX.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2923 | CRX012 | CRX.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability _x000D_ files. |
Value must be in SSN Indicator List (VVL) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2924 | CRX012 | CRX.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2925 | CRX012 | CRX.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2926 | CRX013 | CRX.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2927 | CRX013 | CRX.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2928 | CRX013 | CRX.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2929 | CRX013 | CRX.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2930 | CRX013 | CRX.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2931 | CRX014 | CRX.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2932 | CRX014 | CRX.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2933 | CRX014 | CRX.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| D1 | 2934 | CRX015 | CRX.001.015 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2935 | CRX155 | CRX.001.155 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the _x000D_ original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject _x000D_ area). |
Value must between 1 and 9999 | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2936 | CRX155 | CRX.001.155 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| C2 | 2937 | CRX155 | CRX.001.155 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| A2 | 2938 | CRX155 | CRX.001.155 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2939 | CRX155 | CRX.001.155 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 |
| X1 | 2940 | CRX016 | CRX.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2941 | CRX016 | CRX.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CRX00002" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2942 | CRX017 | CRX.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2943 | CRX017 | CRX.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2944 | CRX017 | CRX.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2945 | CRX017 | CRX.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (CRX.001.007) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2946 | CRX018 | CRX.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2947 | CRX018 | CRX.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2948 | CRX018 | CRX.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2949 | CRX018 | CRX.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2950 | CRX019 | CRX.002.019 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2951 | CRX019 | CRX.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2952 | CRX019 | CRX.002.019 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2953 | CRX020 | CRX.002.020 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2954 | CRX020 | CRX.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2955 | CRX020 | CRX.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2956 | CRX020 | CRX.002.020 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2957 | CRX021 | CRX.002.021 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2958 | CRX021 | CRX.002.021 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2959 | CRX022 | CRX.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2960 | CRX022 | CRX.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2961 | CRX022 | CRX.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2962 | CRX022 | CRX.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2963 | CRX022 | CRX.002.022 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2964 | CRX023 | CRX.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Conditional | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | Value must be in Crossover Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2965 | CRX023 | CRX.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2966 | CRX023 | CRX.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2967 | CRX023 | CRX.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2968 | CRX023 | CRX.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Not Applicable | Not Applicable | If the TYPE-OF-CLAIM value is in ["1", "3", "A", "C"], then value is mandatory and must be reported. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2969 | CRX024 | CRX.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration. | Value must be in 1115A Demonstration Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2970 | CRX024 | CRX.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2971 | CRX024 | CRX.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2972 | CRX024 | CRX.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2973 | CRX025 | CRX.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | Value must be in Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2974 | CRX025 | CRX.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2975 | CRX025 | CRX.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2976 | CRX025 | CRX.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2977 | CRX025 | CRX.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2978 | CRX026 | CRX.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a claim was paid differently than it was billed. If the amount paid is different from the amount billed you need an adjustment reason code. | Value must be in Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2979 | CRX026 | CRX.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2980 | CRX026 | CRX.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2981 | CRX026 | CRX.002.026 | ADJUSTMENT-REASON-CODE | Adjustment Reason Code | Not Applicable | Not Applicable | Value must not be populated when associated Adjustment Indicator equals "0" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2982 | CRX027 | CRX.002.027 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2983 | CRX027 | CRX.002.027 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2984 | CRX027 | CRX.002.027 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2985 | CRX027 | CRX.002.027 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2986 | CRX028 | CRX.002.028 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2987 | CRX028 | CRX.002.028 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 2988 | CRX028 | CRX.002.028 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Must have an associated Total Medicaid Paid Amount | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2989 | CRX028 | CRX.002.028 | MEDICAID-PAID-DATE | Medicaid Paid Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2990 | CRX029 | CRX.002.029 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. | Value must be in Type of Claim List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2991 | CRX029 | CRX.002.029 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2992 | CRX029 | CRX.002.029 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2993 | CRX029 | CRX.002.029 | TYPE-OF-CLAIM | Type of Claim | Not Applicable | Not Applicable | When value equals 'Z', claim denied indicator must equal '0' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2994 | CRX030 | CRX.002.030 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 2995 | CRX030 | CRX.002.030 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2996 | CRX030 | CRX.002.030 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C1 | 2997 | CRX030 | CRX.002.030 | CLAIM-STATUS | Claim Status | Not Applicable | Not Applicable | If value in [ 26, 87, 542, 585, 654 ], Claim Denied Indicator must be '0' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2998 | CRX031 | CRX.002.031 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The Claim Status Category conveys the status of the entire claim using the X12 Claim Status Category Codes from the claim adjudication process. | Value must be in Claim Status Category List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 2999 | CRX031 | CRX.002.031 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3000 | CRX031 | CRX.002.031 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | (Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3001 | CRX031 | CRX.002.031 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3002 | CRX031 | CRX.002.031 | CLAIM-STATUS-CATEGORY | Claim Status Category | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3003 | CRX032 | CRX.002.032 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. | Value must be in Source Location List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3004 | CRX032 | CRX.002.032 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3005 | CRX032 | CRX.002.032 | SOURCE-LOCATION | Source Location | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3006 | CRX033 | CRX.002.033 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | Value must be 15 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3007 | CRX033 | CRX.002.033 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must have an associated Check Effective Date | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3008 | CRX033 | CRX.002.033 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3009 | CRX033 | CRX.002.033 | CHECK-NUM | Check Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3010 | CRX034 | CRX.002.034 | CHECK-EFF-DATE | Check Effective Date | Conditional | The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3011 | CRX034 | CRX.002.034 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3012 | CRX034 | CRX.002.034 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Value may be the same as associated Remittance Date | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3013 | CRX034 | CRX.002.034 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Must have an associated Check Number | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3014 | CRX034 | CRX.002.034 | CHECK-EFF-DATE | Check Effective Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3015 | CRX035 | CRX.002.035 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3016 | CRX035 | CRX.002.035 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3017 | CRX035 | CRX.002.035 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3018 | CRX035 | CRX.002.035 | CLAIM-PYMT-REM-CODE-1 | Claim Payment Remark Code 1 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3019 | CRX036 | CRX.002.036 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3020 | CRX036 | CRX.002.036 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3021 | CRX036 | CRX.002.036 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3022 | CRX036 | CRX.002.036 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3023 | CRX036 | CRX.002.036 | CLAIM-PYMT-REM-CODE-2 | Claim Payment Remark Code 2 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 1 (CRX.002.035) is not populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3024 | CRX037 | CRX.002.037 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3025 | CRX037 | CRX.002.037 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3026 | CRX037 | CRX.002.037 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3027 | CRX037 | CRX.002.037 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3028 | CRX037 | CRX.002.037 | CLAIM-PYMT-REM-CODE-3 | Claim Payment Remark Code 3 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 2 (CRX.002.036) is not populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3029 | CRX038 | CRX.002.038 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Conditional | Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as _x000D_ shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the _x000D_ Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
Value must be in Claim Payment Remittance Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3030 | CRX038 | CRX.002.038 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3031 | CRX038 | CRX.002.038 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3032 | CRX038 | CRX.002.038 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | When more than one code is populated, all values must be unique | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3033 | CRX038 | CRX.002.038 | CLAIM-PYMT-REM-CODE-4 | Claim Payment Remark Code 4 | Not Applicable | Not Applicable | Value must not be populated when Claim Payment Remark Code 3 (CRX.002.037) is not populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3034 | CRX039 | CRX.002.039 | TOT-BILLED-AMT | Total Billed Amount | Conditional | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial _x000D_ transactions. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3035 | CRX039 | CRX.002.039 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3036 | CRX039 | CRX.002.039 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value must equal the sum of all Billed Amount instances for the associated claim | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3037 | CRX039 | CRX.002.039 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C1 | 3038 | CRX039 | CRX.002.039 | TOT-BILLED-AMT | Total Billed Amount | Not Applicable | Not Applicable | Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3039 | CRX040 | CRX.002.040 | TOT-ALLOWED-AMT | Total Allowed Amount | Conditional | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is _x000D_ determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3040 | CRX040 | CRX.002.040 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C1 | 3041 | CRX040 | CRX.002.040 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3042 | CRX040 | CRX.002.040 | TOT-ALLOWED-AMT | Total Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3043 | CRX041 | CRX.002.041 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Conditional | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3044 | CRX041 | CRX.002.041 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3045 | CRX041 | CRX.002.041 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Must have an associated Medicaid Paid Date | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3046 | CRX041 | CRX.002.041 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3047 | CRX041 | CRX.002.041 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3048 | CRX041 | CRX.002.041 | TOT-MEDICAID-PAID-AMT | Total Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3049 | CRX042 | CRX.002.042 | TOT-COPAY-AMT | Total Copayment Amount | Conditional | The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3050 | CRX042 | CRX.002.042 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3051 | CRX042 | CRX.002.042 | TOT-COPAY-AMT | Total Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3052 | CRX043 | CRX.002.043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Conditional | The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and _x000D_ deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a "1" and leave Total Medicare Coinsurance Amount unpopulated. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3053 | CRX043 | CRX.002.043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3054 | CRX043 | CRX.002.043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3055 | CRX043 | CRX.002.043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3056 | CRX043 | CRX.002.043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3057 | CRX043 | CRX.002.043 | TOT-MEDICARE-DEDUCTIBLE-AMT | Total Medicare Deductible Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3058 | CRX044 | CRX.002.044 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Conditional | The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3059 | CRX044 | CRX.002.044 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3060 | CRX044 | CRX.002.044 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3061 | CRX044 | CRX.002.044 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3062 | CRX044 | CRX.002.044 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | If associated Medicare Combined Deductible Indicator is '1', then value must not be populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3063 | CRX044 | CRX.002.044 | TOT-MEDICARE-COINS-AMT | Total Medicare Coinsurance Amount | Not Applicable | Not Applicable | When populated, value must be less than or equal to Total Billed Amount | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3064 | CRX045 | CRX.002.045 | TOT-TPL-AMT | Total Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3065 | CRX045 | CRX.002.045 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3066 | CRX045 | CRX.002.045 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3067 | CRX045 | CRX.002.045 | TOT-TPL-AMT | Total Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3068 | CRX047 | CRX.002.047 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3069 | CRX047 | CRX.002.047 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3070 | CRX047 | CRX.002.047 | TOT-OTHER-INSURANCE-AMT | Total Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3071 | CRX048 | CRX.002.048 | OTHER-INSURANCE-IND | Other Insurance Indicator | Conditional | The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. | Value must be in Other Insurance Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3072 | CRX048 | CRX.002.048 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3073 | CRX048 | CRX.002.048 | OTHER-INSURANCE-IND | Other Insurance Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3074 | CRX049 | CRX.002.049 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3075 | CRX049 | CRX.002.049 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3076 | CRX049 | CRX.002.049 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3077 | CRX050 | CRX.002.050 | SERVICE-TRACKING-TYPE | Service Tracking Type | Conditional | A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee. | Value must be in Service Tracking Type List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3078 | CRX050 | CRX.002.050 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3079 | CRX050 | CRX.002.050 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3080 | CRX050 | CRX.002.050 | SERVICE-TRACKING-TYPE | Service Tracking Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3081 | CRX051 | CRX.002.051 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Conditional | On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3082 | CRX051 | CRX.002.051 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3083 | CRX051 | CRX.002.051 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3084 | CRX051 | CRX.002.051 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3085 | CRX051 | CRX.002.051 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Service Tracking Type must be populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3086 | CRX051 | CRX.002.051 | SERVICE-TRACKING-PAYMENT-AMT | Service Tracking Payment Amount | Not Applicable | Not Applicable | When populated, Total Medicaid Amount must not be populated | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3087 | CRX052 | CRX.002.052 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Conditional | This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management _x000D_programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined "medical record". _x000D_ associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
Value must be in Fixed Payment Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3088 | CRX052 | CRX.002.052 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3089 | CRX052 | CRX.002.052 | FIXED-PAYMENT-IND | Fixed Payment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3090 | CRX053 | CRX.002.053 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | Value must be in Funding Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3091 | CRX053 | CRX.002.053 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3092 | CRX053 | CRX.002.053 | FUNDING-CODE | Funding Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3093 | CRX054 | CRX.002.054 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. | Value must be in Funding Source Non-Federal Share List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3094 | CRX054 | CRX.002.054 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3095 | CRX054 | CRX.002.054 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Not Applicable | Not Applicable | Required | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3096 | CRX055 | CRX.002.055 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | Value must be in Program Type List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3097 | CRX055 | CRX.002.055 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3098 | CRX055 | CRX.002.055 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3099 | CRX055 | CRX.002.055 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3100 | CRX055 | CRX.002.055 | PROGRAM-TYPE | Program Type | Not Applicable | Not Applicable | If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3101 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Conditional | A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. | Value must be 12 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3102 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3103 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3104 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match Managed Care Plan ID (ELG.014.192) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3105 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value must match State Plan ID Number (MCR.002.019) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3106 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | Value should be populated when Type of Claim (CRX.002.029) is in [3, C, W, 2, B, V] | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3107 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3108 | CRX056 | CRX.002.056 | PLAN-ID-NUMBER | Plan ID Number | Not Applicable | Not Applicable | When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| D1 | 3109 | CRX057 | CRX.002.057 | NATIONAL-HEALTH-CARE-ENTITY-ID | National Health Care Entity ID | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3110 | CRX058 | CRX.002.058 | PAYMENT-LEVEL-IND | Payment Level Indicator | Mandatory | The field denotes whether the payment amount was determined at the claim header or line/detail level. | Value must be in Payment Level Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3111 | CRX058 | CRX.002.058 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3112 | CRX058 | CRX.002.058 | PAYMENT-LEVEL-IND | Payment Level Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3113 | CRX059 | CRX.002.059 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | Value must be in Medicare Reimbursement Type List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3114 | CRX059 | CRX.002.059 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | (Crossover Claim) if associated Crossover Indicator value indicates a crossover claim, value is mandatory and must be provided | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3115 | CRX059 | CRX.002.059 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3116 | CRX059 | CRX.002.059 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3117 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | Value must be a positive integer | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3118 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be between 0:9999 (inclusive) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3119 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must not include commas or other non-numeric characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3120 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3121 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3122 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3123 | CRX061 | CRX.002.061 | FORCED-CLAIM-IND | Forced Claim Indicator | Conditional | Indicates if the claim was processed by forcing it through a manual override process. | Value must be in Forced Claim Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3124 | CRX061 | CRX.002.061 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3125 | CRX061 | CRX.002.061 | FORCED-CLAIM-IND | Forced Claim Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3126 | CRX062 | CRX.002.062 | PATIENT-CONTROL-NUM | Patient Control Number | Conditional | A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment | Value must be 20 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3127 | CRX062 | CRX.002.062 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3128 | CRX062 | CRX.002.062 | PATIENT-CONTROL-NUM | Patient Control Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3129 | CRX063 | CRX.002.063 | ELIGIBLE-LAST-NAME | Eligible Last Name | Conditional | The last name of the individual to whom the services were provided. (The patients name should be captured as it _x000D_ appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification _x000D_ Number will be used to associate a claim record with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3130 | CRX063 | CRX.002.063 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3131 | CRX063 | CRX.002.063 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3132 | CRX064 | CRX.002.064 | ELIGIBLE-FIRST-NAME | Eligible First Name | Conditional | The first name of the individual to whom the services were provided.(The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record _x000D_ with the appropriate eligibility data.) |
Value must be 30 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3133 | CRX064 | CRX.002.064 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3134 | CRX064 | CRX.002.064 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3135 | CRX065 | CRX.002.065 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3136 | CRX065 | CRX.002.065 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3137 | CRX065 | CRX.002.065 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3138 | CRX065 | CRX.002.065 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3139 | CRX066 | CRX.002.066 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3140 | CRX066 | CRX.002.066 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3141 | CRX066 | CRX.002.066 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3142 | CRX067 | CRX.002.067 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Conditional | Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model. Health home providers provide service for patients with chronic illnesses. States should not submit claim records for an eligible individual that indicate the claim was submitted by a _x000D_ provider or provider group enrolled in a health home model if the eligible individual is not enrolled in the health home program. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or _x000D_ provider group enrolled in the health home model. |
Value must be in Health Home Provider Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C1 | 3143 | CRX067 | CRX.002.067 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | If there is an associated Health Home Entity Name value, then value must be "1" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3144 | CRX067 | CRX.002.067 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3145 | CRX067 | CRX.002.067 | HEALTH-HOME-PROV-IND | Health Home Provider Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3146 | CRX068 | CRX.002.068 | WAIVER-TYPE | Waiver Type | Conditional | A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. | Value must be in Waiver Type List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3147 | CRX068 | CRX.002.068 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3148 | CRX068 | CRX.002.068 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3149 | CRX068 | CRX.002.068 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Value must have a corresponding value in Waive ID (CRX.002.069) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3150 | CRX068 | CRX.002.068 | WAIVER-TYPE | Waiver Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3151 | CRX069 | CRX.002.069 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the_x000D_ "core" part of the waiver IDs, without including suffixes for renewals or amendments. |
Value must be associated with a populated Waiver Type | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3152 | CRX069 | CRX.002.069 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3153 | CRX069 | CRX.002.069 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3154 | CRX069 | CRX.002.069 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3155 | CRX069 | CRX.002.069 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3156 | CRX070 | CRX.002.070 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity _x000D_ (billing or reporting) to the managed care plan. |
Value must be 30 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3157 | CRX070 | CRX.002.070 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3158 | CRX070 | CRX.002.070 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3159 | CRX070 | CRX.002.070 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1' |
2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3160 | CRX070 | CRX.002.070 | BILLING-PROV-NUM | Billing Provider Number | Not Applicable | Not Applicable | Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3161 | CRX071 | CRX.002.071 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3162 | CRX071 | CRX.002.071 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3163 | CRX071 | CRX.002.071 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3164 | CRX071 | CRX.002.071 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Not Applicable | Not Applicable | When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3165 | CRX072 | CRX.002.072 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the provider billing for the service. | Value must be in Provider Taxonomy List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3166 | CRX072 | CRX.002.072 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3167 | CRX072 | CRX.002.072 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3168 | CRX073 | CRX.002.073 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | Value must be in Provider Specialty List (VVL). | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3169 | CRX073 | CRX.002.073 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3170 | CRX073 | CRX.002.073 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3171 | CRX074 | CRX.002.074 | PRESCRIBING-PROV-NUM | Prescribing Provider Number | Mandatory | A unique identification number assigned by the state to the provider who prescribed the drug, device, or supply. This must be the individual's ID number, not a group identification number. If the prescribing physician provider ID is not available, but the physician's Drug Enforcement Agency (DEA) _x000D_ ID is on the state file, then the State should use the DEA ID for this data element |
Value must be 30 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3172 | CRX074 | CRX.002.074 | PRESCRIBING-PROV-NUM | Prescribing Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3173 | CRX074 | CRX.002.074 | PRESCRIBING-PROV-NUM | Prescribing Provider Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3174 | CRX075 | CRX.002.075 | PRESCRIBING-PROV-NPI-NUM | Prescribing Provider NPI Number | Mandatory | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3175 | CRX075 | CRX.002.075 | PRESCRIBING-PROV-NPI-NUM | Prescribing Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3176 | CRX075 | CRX.002.075 | PRESCRIBING-PROV-NPI-NUM | Prescribing Provider NPI Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| D1 | 3177 | CRX076 | CRX.002.076 | PRESCRIBING-PROV-TAXONOMY | Prescribing Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| D1 | 3178 | CRX077 | CRX.002.077 | PRESCRIBING-PROV-TYPE | Prescribing Provider Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| D1 | 3179 | CRX078 | CRX.002.078 | PRESCRIBING-PROV-SPECIALTY | Prescribing Provider Specialty | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3180 | CRX079 | CRX.002.079 | MEDICARE-HIC-NUM | Medicare HIC Number | Conditional | The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the _x000D_ Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & _x000D_ alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) |
Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3181 | CRX079 | CRX.002.079 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3182 | CRX079 | CRX.002.079 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3183 | CRX079 | CRX.002.079 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3184 | CRX079 | CRX.002.079 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be populated when Crossover Indicator (CRX.002.023) equals '1' and Medicare Beneficiary Identifier (CRX.002.105) must not be populated. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3185 | CRX081 | CRX.002.081 | REMITTANCE-NUM | Remittance Number | Mandatory | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed _x000D_ explanation of the reason for the payment amount. The RA number is not the check number. |
Value must be 30 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3186 | CRX081 | CRX.002.081 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19)) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3187 | CRX081 | CRX.002.081 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3188 | CRX081 | CRX.002.081 | REMITTANCE-NUM | Remittance Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3189 | CRX082 | CRX.002.082 | BORDER-STATE-IND | Border State Indicator | Conditional | A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Value must be in Border State Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3190 | CRX082 | CRX.002.082 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3191 | CRX082 | CRX.002.082 | BORDER-STATE-IND | Border State Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3192 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Mandatory | The date the drug, device, or supply was prescribed by the physician or other practitioner. This should not be confused with the PRESCRIPTION-FILL-DATE, which represents the date the prescription was actually filled by the provider. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3193 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3194 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | Value must be on or after associated eligible party's Date of Birth (ELG.002.024) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3195 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | Value must be on or before associated Prescription Fill Date (CRX.002.085) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3196 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | Value must be on or before associated Adjudication Date (CRX.002.027) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3197 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | Value must be on or before associated eligible party's Date of Death (ELG.002.025) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3198 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3199 | CRX084 | CRX.002.084 | DATE-PRESCRIBED | Date Prescribed | Not Applicable | Not Applicable | Value should be on or before End of Time Period (CRX.001.010) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3200 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Mandatory | Date the drug, device, or supply was dispensed by the provider. see Date (DT.001) | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3201 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3202 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Value must be on or before associated End of Time Period (CRX.001.010) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3203 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Value must be on or after associated Start of Time Period (CRX.001.009) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3204 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Value must be on or after associated Date Prescribed (CRX.002.084) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3205 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Value must be on or after associated eligible party's Date of Birth (ELG.002.024) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3206 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Value must be on or before associated eligible party's Date of Death (ELG.002.025) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3207 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Value must be populated when Adjustment Indicator (CRX.002.025) does not equal '1' and Type of Claim (CRX.002.029) does not equal 'Z' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3208 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3209 | CRX086 | CRX.002.086 | COMPOUND-DRUG-IND | Compound Drug Indicator | Conditional | Indicator to specify if the drug is compound or not. see Compound Drug Indicator List (VVL.038) | Value must be in Compound Drug Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3210 | CRX086 | CRX.002.086 | COMPOUND-DRUG-IND | Compound Drug Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3211 | CRX086 | CRX.002.086 | COMPOUND-DRUG-IND | Compound Drug Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3212 | CRX087 | CRX.002.087 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Conditional | The amount of money the beneficiary paid towards coinsurance. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3213 | CRX087 | CRX.002.087 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3214 | CRX087 | CRX.002.087 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Date Paid | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3215 | CRX087 | CRX.002.087 | BENEFICIARY-COINSURANCE-AMOUNT | Beneficiary Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3216 | CRX088 | CRX.002.088 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3217 | CRX088 | CRX.002.088 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3218 | CRX088 | CRX.002.088 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Coinsurance Amount | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3219 | CRX088 | CRX.002.088 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3220 | CRX089 | CRX.002.089 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Conditional | The amount of money the beneficiary paid towards a co-payment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3221 | CRX089 | CRX.002.089 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3222 | CRX089 | CRX.002.089 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Date Paid | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3223 | CRX089 | CRX.002.089 | BENEFICIARY-COPAYMENT-AMOUNT | Beneficiary Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3224 | CRX090 | CRX.002.090 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3225 | CRX090 | CRX.002.090 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3226 | CRX090 | CRX.002.090 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Copayment Amount | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3227 | CRX090 | CRX.002.090 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3228 | CRX092 | CRX.002.092 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Conditional | The amount of money the beneficiary paid towards an annual deductible. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3229 | CRX092 | CRX.002.092 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3230 | CRX092 | CRX.002.092 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3231 | CRX092 | CRX.002.092 | BENEFICIARY-DEDUCTIBLE-AMOUNT | Beneficiary Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3232 | CRX093 | CRX.002.093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3233 | CRX093 | CRX.002.093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3234 | CRX093 | CRX.002.093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Must have an associated Beneficiary Deductible Date Paid | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3235 | CRX093 | CRX.002.093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3236 | CRX094 | CRX.002.094 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Mandatory | An indicator to identify a claim that the state refused pay in its entirety. | Value must be in Claim Denied Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3237 | CRX094 | CRX.002.094 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | If value is '0', then Claim Status Category must equal "F2" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3238 | CRX094 | CRX.002.094 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C1 | 3239 | CRX094 | CRX.002.094 | CLAIM-DENIED-INDICATOR | Claim Denied Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3240 | CRX095 | CRX.002.095 | COPAY-WAIVED-IND | Copayment Waived Indicator | Optional | An indicator signifying that the copay was waived by the provider. | Value must be in Copay Waived Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3241 | CRX095 | CRX.002.095 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3242 | CRX095 | CRX.002.095 | COPAY-WAIVED-IND | Copayment Waived Indicator | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3243 | CRX096 | CRX.002.096 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Conditional | A free-form text field to indicate the health home program that authorized payment for the service on the claim. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, _x000D_ behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. |
Value must 50 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3244 | CRX096 | CRX.002.096 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3245 | CRX096 | CRX.002.096 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3246 | CRX099 | CRX.002.099 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date a Third Party Coinsurance amount was paid on this claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3247 | CRX099 | CRX.002.099 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3248 | CRX099 | CRX.002.099 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3249 | CRX100 | CRX.002.100 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Optional | The amount of money a third-party on behalf of the beneficiary paid towards a copayment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3250 | CRX100 | CRX.002.100 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3251 | CRX100 | CRX.002.100 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3252 | CRX101 | CRX.002.101 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Optional | The date a Third Party copayment amount was paid on a claim or adjustment. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3253 | CRX101 | CRX.002.101 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3254 | CRX101 | CRX.002.101 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3255 | CRX102 | CRX.002.102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Dispensing Prescription Drug Provider NPI Number | Mandatory | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3256 | CRX102 | CRX.002.102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Dispensing Prescription Drug Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3257 | CRX102 | CRX.002.102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Dispensing Prescription Drug Provider NPI Number | Not Applicable | Not Applicable | When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3258 | CRX102 | CRX.002.102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Dispensing Prescription Drug Provider NPI Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| D1 | 3259 | CRX103 | CRX.002.103 | DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | Dispensing Prescription Drug Provider Taxonomy | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3260 | CRX104 | CRX.002.104 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, _x000D_ intelligence-free numeric identifier (10-digit number). |
Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3261 | CRX104 | CRX.002.104 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type equal to '2' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3262 | CRX104 | CRX.002.104 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3263 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Conditional | The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI _x000D_ over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. |
Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3264 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must be an 11-character string | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3265 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 1 must be numeric values 1 thru 9 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3266 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3267 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3268 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 4 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3269 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3270 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3271 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 7 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3272 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3273 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3274 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 10 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3275 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 11 must be numeric values 0 thru 9 | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3276 | CRX105 | CRX.002.105 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3277 | CRX106 | CRX.002.106 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3278 | CRX106 | CRX.002.106 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3279 | CRX106 | CRX.002.106 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| D1 | 3280 | CRX107 | CRX.002.107 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3281 | CRX156 | CRX.002.156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Dispensing Prescription Drug Provider Number | Mandatory | The state-specific provider id of the provider who actually dispensed the prescription medication. | Value must be 30 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3282 | CRX156 | CRX.002.156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Dispensing Prescription Drug Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3283 | CRX156 | CRX.002.156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Dispensing Prescription Drug Provider Number | Not Applicable | Not Applicable | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Submitting State Provider ID (PRV.002.019) or When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) = '1' |
2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3284 | CRX156 | CRX.002.156 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | Dispensing Prescription Drug Provider Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3285 | CRX160 | CRX.002.160 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Conditional | Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. | Value must be in Medicare Combined Deductible Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3286 | CRX160 | CRX.002.160 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3287 | CRX160 | CRX.002.160 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | If value equals '1', then Medicare Coinsurance amount is not populated. | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3288 | CRX160 | CRX.002.160 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Value must equal '0' if associated Type of Claim is '3', 'C' or 'W' | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3289 | CRX160 | CRX.002.160 | MEDICARE-COMB-DED-IND | Medicare Combined Deductible Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| C2 | 3290 | CRX161 | CRX.002.161 | PROV-LOCATION-ID | Provider Location ID | Mandatory | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| A2 | 3291 | CRX161 | CRX.002.161 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3292 | CRX161 | CRX.002.161 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 |
| X1 | 3293 | CRX108 | CRX.003.108 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3294 | CRX108 | CRX.003.108 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "CRX00003" | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3295 | CRX109 | CRX.003.109 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3296 | CRX109 | CRX.003.109 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3297 | CRX109 | CRX.003.109 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3298 | CRX109 | CRX.003.109 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (CRX.001.007) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3299 | CRX110 | CRX.003.110 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3300 | CRX110 | CRX.003.110 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3301 | CRX110 | CRX.003.110 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3302 | CRX110 | CRX.003.110 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3303 | CRX111 | CRX.003.111 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3304 | CRX111 | CRX.003.111 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3305 | CRX111 | CRX.003.111 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3306 | CRX111 | CRX.003.111 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3307 | CRX111 | CRX.003.111 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3308 | CRX112 | CRX.003.112 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | Value must be 50 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3309 | CRX112 | CRX.003.112 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3310 | CRX112 | CRX.003.112 | ICN-ORIG | Original ICN | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3311 | CRX113 | CRX.003.113 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. | Value must be 50 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3312 | CRX113 | CRX.003.113 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3313 | CRX113 | CRX.003.113 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | If associated Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3314 | CRX113 | CRX.003.113 | ICN-ADJ | Adjustment ICN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3315 | CRX114 | CRX.003.114 | LINE-NUM-ORIG | Original Line Number | Mandatory | A unique number to identify the transaction line number that is being reported on the original claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3316 | CRX114 | CRX.003.114 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3317 | CRX114 | CRX.003.114 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3318 | CRX114 | CRX.003.114 | LINE-NUM-ORIG | Original Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3319 | CRX115 | CRX.003.115 | LINE-NUM-ADJ | Adjustment Line Number | Conditional | A unique number to identify the transaction line number that identifies the line number on the adjustment claim. | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3320 | CRX115 | CRX.003.115 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 0, then value must not be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3321 | CRX115 | CRX.003.115 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3322 | CRX115 | CRX.003.115 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3323 | CRX115 | CRX.003.115 | LINE-NUM-ADJ | Adjustment Line Number | Not Applicable | Not Applicable | When populated, value must be one or greater | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3324 | CRX116 | CRX.003.116 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Conditional | A code to indicate the type of adjustment record claim/encounter represents at claim detail level. | Value must be in Line Adjustment Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3325 | CRX116 | CRX.003.116 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3326 | CRX116 | CRX.003.116 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6] | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3327 | CRX116 | CRX.003.116 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3328 | CRX116 | CRX.003.116 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3329 | CRX116 | CRX.003.116 | LINE-ADJUSTMENT-IND | Line Adjustment Indicator | Not Applicable | Not Applicable | If associated Line Adjustment Number is populated, then value must be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3330 | CRX117 | CRX.003.117 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Conditional | Claim adjustment reason codes communicate why a service line was paid differently than it was billed. | Value must be in Line Adjustment Reason Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3331 | CRX117 | CRX.003.117 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3332 | CRX117 | CRX.003.117 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3333 | CRX117 | CRX.003.117 | LINE-ADJUSTMENT-REASON-CODE | Line Adjustment Reason Code | Not Applicable | Not Applicable | When populated, Line Adjustment Indicator must be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3334 | CRX118 | CRX.003.118 | SUBMITTER-ID | Submitter ID | Mandatory | The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. | Value must be 12 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3335 | CRX118 | CRX.003.118 | SUBMITTER-ID | Submitter ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3336 | CRX119 | CRX.003.119 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The Claim Line Status conveys the status of a specific service line using the X12 Claim Status Codes from the claim adjudication process. | Value must be in Claim Status List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3337 | CRX119 | CRX.003.119 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3338 | CRX119 | CRX.003.119 | CLAIM-LINE-STATUS | Claim Line Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3339 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Mandatory | A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. | Characters 1-5 of value must be numeric | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3340 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 6-9 of value must be numeric | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3341 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Characters 10-12 of value must be numeric or blank | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3342 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be 12 digits or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3343 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must be a valid National Drug Code | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3344 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3345 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must have an associated DTL Metric Decimal Quantity (CRX.003.144) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3346 | CRX120 | CRX.003.120 | NATIONAL-DRUG-CODE | National Drug Code | Not Applicable | Not Applicable | Value must have an associated Unit of Measure (CRX.003.133) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3347 | CRX121 | CRX.003.121 | BILLED-AMT | Billed Amount | Conditional | The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3348 | CRX121 | CRX.003.121 | BILLED-AMT | Billed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3349 | CRX121 | CRX.003.121 | BILLED-AMT | Billed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3350 | CRX122 | CRX.003.122 | ALLOWED-AMT | Allowed Amount | Conditional | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed _x000D_ care encounters the Allowed Amount is determined by the managed care organization. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3351 | CRX122 | CRX.003.122 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3352 | CRX122 | CRX.003.122 | ALLOWED-AMT | Allowed Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3353 | CRX123 | CRX.003.123 | COPAY-AMT | Copayment Amount | Conditional | The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. | Value must be 5 digits or less left of the decimal i.e. 99999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3354 | CRX123 | CRX.003.123 | COPAY-AMT | Copayment Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3355 | CRX124 | CRX.003.124 | TPL-AMT | Third Party Liability Amount | Conditional | Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3356 | CRX124 | CRX.003.124 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3357 | CRX124 | CRX.003.124 | TPL-AMT | Third Party Liability Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3358 | CRX125 | CRX.003.125 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Conditional | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire _x000D_ payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3359 | CRX125 | CRX.003.125 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3360 | CRX125 | CRX.003.125 | MEDICAID-PAID-AMT | Medicaid Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3361 | CRX126 | CRX.003.126 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Conditional | The amount that would have been paid had the services been provided on a Fee for Service basis. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3362 | CRX126 | CRX.003.126 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3363 | CRX126 | CRX.003.126 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3364 | CRX126 | CRX.003.126 | MEDICAID-FFS-EQUIVALENT-AMT | Medicaid FFS Equivalent Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3365 | CRX127 | CRX.003.127 | MEDICARE-DEDUCTIBLE-AMT | Medicare Deductible Amount | Conditional | The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and _x000D_ deductible payments cannot be separated, fill this field with the combined payment amount and MEDICARE-COINSURANCE-PAYMENT is not required. |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3366 | CRX127 | CRX.003.127 | MEDICARE-DEDUCTIBLE-AMT | Medicare Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3367 | CRX127 | CRX.003.127 | MEDICARE-DEDUCTIBLE-AMT | Medicare Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3368 | CRX128 | CRX.003.128 | MEDICARE-COINS-AMT | Medicare Coinsurance Amount | Conditional | The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and _x000D_ deductible payments cannot be separated, populate the MEDICARE-DEDUCTIBLE-AMT. See US Dollar Amount (DT) |
Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3369 | CRX128 | CRX.003.128 | MEDICARE-COINS-AMT | Medicare Coinsurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3370 | CRX128 | CRX.003.128 | MEDICARE-COINS-AMT | Medicare Coinsurance Amount | Not Applicable | Not Applicable | (payments can't be separated) value 99998 is an exception to the US Dollar Amount requirements | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3371 | CRX128 | CRX.003.128 | MEDICARE-COINS-AMT | Medicare Coinsurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3372 | CRX129 | CRX.003.129 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim or adjustment. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3373 | CRX129 | CRX.003.129 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3374 | CRX129 | CRX.003.129 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated. | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3375 | CRX129 | CRX.003.129 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3376 | CRX129 | CRX.003.129 | MEDICARE-PAID-AMT | Medicare Paid Amount | Not Applicable | Not Applicable | If value is populated, Crossover Indicator must be equal to "1" | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3377 | CRX131 | CRX.003.131 | OT-RX-CLAIM-QUANTITY-ALLOWED | OT RX Claim Quantity Allowed | Conditional | The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. | Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3378 | CRX131 | CRX.003.131 | OT-RX-CLAIM-QUANTITY-ALLOWED | OT RX Claim Quantity Allowed | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3379 | CRX131 | CRX.003.131 | OT-RX-CLAIM-QUANTITY-ALLOWED | OT RX Claim Quantity Allowed | Not Applicable | Not Applicable | If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported. | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3380 | CRX132 | CRX.003.132 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Conditional | The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span. 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 _x000D_ 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 _x000D_ filled vials, use 1 as the number of units. |
Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C1 | 3381 | CRX132 | CRX.003.132 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3382 | CRX132 | CRX.003.132 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Not Applicable | Not Applicable | If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported. | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3383 | CRX132 | CRX.003.132 | OT-RX-CLAIM-QUANTITY-ACTUAL | OT RX Claim Quantity Actual | Not Applicable | Not Applicable | When populated, corresponding Unit of Measure must be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3384 | CRX133 | CRX.003.133 | UNIT-OF-MEASURE | Unit of Measure | Conditional | A code to indicate the basis by which the quantity of the drug or supply is expressed. | Value must be in NDC Unit of Measure List (VVL). | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3385 | CRX133 | CRX.003.133 | UNIT-OF-MEASURE | Unit of Measure | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3386 | CRX133 | CRX.003.133 | UNIT-OF-MEASURE | Unit of Measure | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3387 | CRX134 | CRX.003.134 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | Value must be 3 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3388 | CRX134 | CRX.003.134 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3389 | CRX134 | CRX.003.134 | TYPE-OF-SERVICE | Type of Service | Not Applicable | Not Applicable | Value must satisfy the requirements of Type of Service (RX Claim) List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3390 | CRX135 | CRX.003.135 | HCBS-SERVICE-CODE | HCBS Service Code | Conditional | A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. _x000D_ 1915(c), 1915(i), 1915(j), and 1915(k) services). |
Value must be in HCBS Service Code List (VVL). | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3391 | CRX135 | CRX.003.135 | HCBS-SERVICE-CODE | HCBS Service Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3392 | CRX135 | CRX.003.135 | HCBS-SERVICE-CODE | HCBS Service Code | Not Applicable | Not Applicable | If value is 1-7, then HCBS Taxonomy must be populated. | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3393 | CRX135 | CRX.003.135 | HCBS-SERVICE-CODE | HCBS Service Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3394 | CRX136 | CRX.003.136 | HCBS-TAXONOMY | HCBS Taxonomy | Conditional | A code to classify the home and community based services listed on the claim into the HCBS taxonomy. | Value must be in HCBS Taxonomy Code List (VVL). | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3395 | CRX136 | CRX.003.136 | HCBS-TAXONOMY | HCBS Taxonomy | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3396 | CRX136 | CRX.003.136 | HCBS-TAXONOMY | HCBS Taxonomy | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3397 | CRX137 | CRX.003.137 | OTHER-TPL-COLLECTION | Other TPL Collection | Conditional | This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. | Value must be in Other TPL Collection List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3398 | CRX137 | CRX.003.137 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3399 | CRX137 | CRX.003.137 | OTHER-TPL-COLLECTION | Other TPL Collection | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3400 | CRX138 | CRX.003.138 | DAYS-SUPPLY | Days Supply | Mandatory | Number of days supply dispensed. | Value must be 5 digits or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3401 | CRX138 | CRX.003.138 | DAYS-SUPPLY | Days Supply | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3402 | CRX138 | CRX.003.138 | DAYS-SUPPLY | Days Supply | Not Applicable | Not Applicable | Value should be between -365 and 365 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3403 | CRX139 | CRX.003.139 | NEW-REFILL-IND | New Refill Indicator | Mandatory | 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. | Value must be in New Refill Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3404 | CRX139 | CRX.003.139 | NEW-REFILL-IND | New Refill Indicator | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3405 | CRX139 | CRX.003.139 | NEW-REFILL-IND | New Refill Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3406 | CRX140 | CRX.003.140 | BRAND-GENERIC-IND | Brand Generic Indicator | Mandatory | Indicates whether the drug is a brand name, generic, single-source, or multi-source drug. | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3407 | CRX140 | CRX.003.140 | BRAND-GENERIC-IND | Brand Generic Indicator | Not Applicable | Not Applicable | Value must be in Brand Generic Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3408 | CRX140 | CRX.003.140 | BRAND-GENERIC-IND | Brand Generic Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3409 | CRX141 | CRX.003.141 | DISPENSE-FEE | Dispense Fee | Mandatory | The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription. Dispense Fee reflects the amount billed by the provider towards the professional dispensing fee._x000D_ If the provider does not break out the professional dispensing fee on the NCPDP transaction, this field should be left blank in T-MSIS._x000D_ There is currently no specific field in T-MSIS to capture either the professional dispensing fee amount paid, or the amount billed or paid towards ingredient costs. |
Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3410 | CRX141 | CRX.003.141 | DISPENSE-FEE | Dispense Fee | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3411 | CRX142 | CRX.003.142 | PRESCRIPTION-NUM | Prescription Number | Mandatory | The unique identification number assigned by the pharmacy or supplier to the prescription. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3412 | CRX142 | CRX.003.142 | PRESCRIPTION-NUM | Prescription Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3413 | CRX142 | CRX.003.142 | PRESCRIPTION-NUM | Prescription Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3414 | CRX143 | CRX.003.143 | DRUG-UTILIZATION-CODE | Drug Utilization Code | Mandatory | A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment._x000D_ The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (44-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and _x000D_ independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the _x000D_ information affects payment for, or documentation of, professional pharmacy service. _x000D_ The NCPDP "Results of Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the _x000D_ pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. _x000D_ _x000D_ Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. _x000D_ _x000D_ see Drug Utilization Professional Service Code List (VVL.044)_x000D_ see Drug Utilization Reason For Service Code List (VVL.045)_x000D_ see Drug Utilization Result of Service Code List (VVL.046) |
Value must be 6 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3415 | CRX143 | CRX.003.143 | DRUG-UTILIZATION-CODE | Drug Utilization Code | Not Applicable | Not Applicable | Characters 1 and 2 (2-character string) may be in Drug Utilization Result of Service Code List (VVL), or spaces in cases where code is unused or not available | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3416 | CRX143 | CRX.003.143 | DRUG-UTILIZATION-CODE | Drug Utilization Code | Not Applicable | Not Applicable | Characters 3 and 4 (2-character string) may be in Drug Utilization Professional Service Code List (VVL), or spaces in cases where code is unused or not available | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3417 | CRX143 | CRX.003.143 | DRUG-UTILIZATION-CODE | Drug Utilization Code | Not Applicable | Not Applicable | Characters 5 and 6 (2-character string) may be in Drug Utilization Reason For Service Code List (VVL), or not populated in cases where code is unused or not available | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3418 | CRX143 | CRX.003.143 | DRUG-UTILIZATION-CODE | Drug Utilization Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3419 | CRX145 | CRX.003.145 | COMPOUND-DOSAGE-FORM | Compound Dosage Form | Conditional | The physical form of a dose of medication, such as a capsule or injection. see Compound Dosage Form List (VVL.037) | Value must be in Compound Dosage Form List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3420 | CRX145 | CRX.003.145 | COMPOUND-DOSAGE-FORM | Compound Dosage Form | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3421 | CRX145 | CRX.003.145 | COMPOUND-DOSAGE-FORM | Compound Dosage Form | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3422 | CRX146 | CRX.003.146 | REBATE-ELIGIBLE-INDICATOR | Rebate Eligible Indicator | Conditional | An indicator to identify claim lines with an NDC that is eligible for the drug rebate program. | Value must be in Rebate Eligible Indicator List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3423 | CRX146 | CRX.003.146 | REBATE-ELIGIBLE-INDICATOR | Rebate Eligible Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3424 | CRX146 | CRX.003.146 | REBATE-ELIGIBLE-INDICATOR | Rebate Eligible Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| D1 | 3425 | CRX147 | CRX.003.147 | IMMUNIZATION-TYPE | Immunization Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3426 | CRX148 | CRX.003.148 | BENEFIT-TYPE | Benefit Type | Mandatory | The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types | Value must be in Benefit Type Code List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3427 | CRX148 | CRX.003.148 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3428 | CRX148 | CRX.003.148 | BENEFIT-TYPE | Benefit Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3429 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | Value must be in CMS 64 Category for Federal Reimbursement List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3430 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3431 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3'] | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3432 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1' | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C1 | 3433 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3434 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3435 | CRX149 | CRX.003.149 | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CMS 64 Category for Federal Reimbursement | Not Applicable | Not Applicable | If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3436 | CRX150 | CRX.003.150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Conditional | A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation. | Value must be in XIX MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3437 | CRX150 | CRX.003.150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3438 | CRX150 | CRX.003.150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3439 | CRX150 | CRX.003.150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3440 | CRX150 | CRX.003.150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3441 | CRX150 | CRX.003.150 | XIX-MBESCBES-CATEGORY-OF-SERVICE | XIX MBESCBES Category of Service | Not Applicable | Not Applicable | If XXI MBESCBES Category of Service is populated then must not be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3442 | CRX151 | CRX.003.151 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Conditional | A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation. | Value must be in XXI MBESCBES Category of Service List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3443 | CRX151 | CRX.003.151 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3444 | CRX151 | CRX.003.151 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3445 | CRX151 | CRX.003.151 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | If XIX MBESCBES Category of Service is populated then value must not be populated | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3446 | CRX151 | CRX.003.151 | XXI-MBESCBES-CATEGORY-OF-SERVICE | XXI MBESCBES Category of Service | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3447 | CRX152 | CRX.003.152 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3448 | CRX152 | CRX.003.152 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3449 | CRX152 | CRX.003.152 | OTHER-INSURANCE-AMT | Other Insurance Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3450 | CRX153 | CRX.003.153 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3451 | CRX153 | CRX.003.153 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3452 | CRX153 | CRX.003.153 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| D1 | 3453 | CRX154 | CRX.003.154 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3454 | CRX157 | CRX.003.157 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3455 | CRX157 | CRX.003.157 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3456 | CRX157 | CRX.003.157 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Value should be on or before End of Time Period value found in associated T-MSIS File Header Record | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3457 | CRX157 | CRX.003.157 | ADJUDICATION-DATE | Adjudication Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3458 | CRX158 | CRX.003.158 | SELF-DIRECTION-TYPE | Self Direction Type | Conditional | This data element is not applicable to this file type. | Value must be in Self Direction Type List (VVL) | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3459 | CRX158 | CRX.003.158 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3460 | CRX158 | CRX.003.158 | SELF-DIRECTION-TYPE | Self Direction Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| A2 | 3461 | CRX159 | CRX.003.159 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Conditional | A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). | Value must be 18 characters or less | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| C2 | 3462 | CRX159 | CRX.003.159 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3463 | CRX159 | CRX.003.159 | PRE-AUTHORIZATION-NUM | Preauthorization Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 |
| X1 | 3464 | ELG001 | ELG.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3465 | ELG001 | ELG.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00001" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3466 | ELG002 | ELG.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3467 | ELG002 | ELG.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3468 | ELG002 | ELG.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3469 | ELG003 | ELG.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3470 | ELG003 | ELG.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3471 | ELG003 | ELG.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3472 | ELG004 | ELG.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3473 | ELG004 | ELG.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3474 | ELG004 | ELG.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3475 | ELG005 | ELG.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3476 | ELG005 | ELG.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3477 | ELG006 | ELG.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'ELIGIBLE' | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3478 | ELG007 | ELG.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3479 | ELG007 | ELG.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3480 | ELG007 | ELG.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3481 | ELG007 | ELG.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same for all records | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3482 | ELG008 | ELG.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3483 | ELG008 | ELG.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3484 | ELG008 | ELG.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3485 | ELG008 | ELG.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3486 | ELG008 | ELG.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3487 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3488 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3489 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3490 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3491 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3492 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3493 | ELG009 | ELG.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3494 | ELG010 | ELG.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3495 | ELG010 | ELG.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3496 | ELG010 | ELG.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3497 | ELG010 | ELG.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3498 | ELG010 | ELG.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3499 | ELG010 | ELG.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3500 | ELG011 | ELG.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3501 | ELG011 | ELG.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3502 | ELG011 | ELG.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3503 | ELG012 | ELG.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability _x000D_ files. |
Value must be in SSN Indicator List (VVL) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3504 | ELG012 | ELG.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3505 | ELG012 | ELG.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3506 | ELG013 | ELG.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3507 | ELG013 | ELG.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3508 | ELG013 | ELG.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3509 | ELG013 | ELG.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3510 | ELG013 | ELG.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3511 | ELG014 | ELG.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3512 | ELG014 | ELG.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3513 | ELG014 | ELG.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| D1 | 3514 | ELG015 | ELG.001.015 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3515 | ELG247 | ELG.001.247 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the _x000D_ original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject _x000D_ area). |
Value must between 1 and 9999 | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3516 | ELG247 | ELG.001.247 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| C2 | 3517 | ELG247 | ELG.001.247 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| A2 | 3518 | ELG247 | ELG.001.247 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3519 | ELG247 | ELG.001.247 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 |
| X1 | 3520 | ELG016 | ELG.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3521 | ELG016 | ELG.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00002" | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3522 | ELG017 | ELG.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3523 | ELG017 | ELG.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3524 | ELG017 | ELG.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3525 | ELG017 | ELG.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3526 | ELG018 | ELG.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3527 | ELG018 | ELG.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3528 | ELG018 | ELG.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3529 | ELG018 | ELG.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3530 | ELG019 | ELG.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3531 | ELG019 | ELG.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3532 | ELG019 | ELG.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3533 | ELG019 | ELG.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3534 | ELG020 | ELG.002.020 | ELIGIBLE-FIRST-NAME | Eligible First Name | Mandatory | Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). | Value must be 30 characters or less | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3535 | ELG020 | ELG.002.020 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C1 | 3536 | ELG020 | ELG.002.020 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3537 | ELG021 | ELG.002.021 | ELIGIBLE-LAST-NAME | Eligible Last Name | Mandatory | Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). | Value must be 30 characters or less | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3538 | ELG021 | ELG.002.021 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3539 | ELG021 | ELG.002.021 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3540 | ELG022 | ELG.002.022 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3541 | ELG022 | ELG.002.022 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3542 | ELG022 | ELG.002.022 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3543 | ELG022 | ELG.002.022 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3544 | ELG023 | ELG.002.023 | SEX | Sex | Mandatory | Either individual's biological sex or their self-identified sex. | Value must be in Sex List (VVL) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3545 | ELG023 | ELG.002.023 | SEX | Sex | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3546 | ELG023 | ELG.002.023 | SEX | Sex | Not Applicable | Not Applicable | (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal '1' | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3547 | ELG023 | ELG.002.023 | SEX | Sex | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3548 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3549 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3550 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3551 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3552 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Value must be less than or equal to associated Date File Created (ELG.001.008) value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3553 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3554 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3555 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Conditional | The date an individual died on. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3556 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3557 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3558 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | If populated, value must be on or after individual's Date of Birth | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3559 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | Value must be less than or equal to associated Date File Created (ELG.001.008) value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3560 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | There must never be more than one Date of Death value reported across Primary Demographic segments that have the same MSIS Identification number | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3561 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, Procedure Code Dates on a claim must be less than or equal to this value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3562 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, Admission Date on a claim must be less than or equal to this value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3563 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, Discharge Date on a claim must be less than or equal to this value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3564 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, Ending Date of Service on a claim must be less than or equal to this value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3565 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, value must be less than or equal to Enrollment End Date (ELG.021.254) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3566 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, value minus Date of Birth (ELG.002.024) is less than or equal to 125 years | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3567 | ELG026 | ELG.002.026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Primary Demographic Element Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3568 | ELG026 | ELG.002.026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Primary Demographic Element Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3569 | ELG026 | ELG.002.026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Primary Demographic Element Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3570 | ELG026 | ELG.002.026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Primary Demographic Element Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3571 | ELG026 | ELG.002.026 | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | Primary Demographic Element Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3572 | ELG027 | ELG.002.027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Primary Demographic Element End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3573 | ELG027 | ELG.002.027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Primary Demographic Element End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3574 | ELG027 | ELG.002.027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Primary Demographic Element End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3575 | ELG027 | ELG.002.027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Primary Demographic Element End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3576 | ELG027 | ELG.002.027 | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | Primary Demographic Element End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| A2 | 3577 | ELG028 | ELG.002.028 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| C2 | 3578 | ELG028 | ELG.002.028 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3579 | ELG028 | ELG.002.028 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| D1 | 3580 | ELG029 | ELG.002.029 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 |
| X1 | 3581 | ELG030 | ELG.003.030 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3582 | ELG030 | ELG.003.030 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00003" | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3583 | ELG031 | ELG.003.031 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3584 | ELG031 | ELG.003.031 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3585 | ELG031 | ELG.003.031 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3586 | ELG031 | ELG.003.031 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3587 | ELG032 | ELG.003.032 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3588 | ELG032 | ELG.003.032 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3589 | ELG032 | ELG.003.032 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3590 | ELG032 | ELG.003.032 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3591 | ELG033 | ELG.003.033 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3592 | ELG033 | ELG.003.033 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3593 | ELG033 | ELG.003.033 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3594 | ELG033 | ELG.003.033 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3595 | ELG034 | ELG.003.034 | MARITAL-STATUS | Marital Status | Mandatory | A code to classify eligible individual's marital/domestic-relationship status. An eligible individual who is younger than 12 years should have a marital status of never married or _x000D_ unknown. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). |
Value must be in Marital Status List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3596 | ELG034 | ELG.003.034 | MARITAL-STATUS | Marital Status | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3597 | ELG034 | ELG.003.034 | MARITAL-STATUS | Marital Status | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3598 | ELG035 | ELG.003.035 | MARITAL-STATUS-OTHER-EXPLANATION | Marital Status Other Explanation | Conditional | A free-text field to capture the description of the marital/domestic-relationship status when Marital Status =14 (Other) is selected. | If associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3599 | ELG035 | ELG.003.035 | MARITAL-STATUS-OTHER-EXPLANATION | Marital Status Other Explanation | Not Applicable | Not Applicable | Value must be 50 characters or less | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3600 | ELG035 | ELG.003.035 | MARITAL-STATUS-OTHER-EXPLANATION | Marital Status Other Explanation | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3601 | ELG036 | ELG.003.036 | SSN | SSN | Conditional | The eligible individual's social security number. For newborns when value is unknown it is not required. For SSN states, in instances where the social security number is not known and a temporary MSIS Identification Number is used, the MSIS Identification Number field should be populated _x000D_ with the temporary MSIS Identification Number and the SSN field should be space-filled, or blank. When the SSN becomes known, the MSIS Identification Number field should continue to be populated with the temporary MSIS Identification Number and the SSN field should be populated with the _x000D_ newly acquired SSN for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS Identification Number and the social security number. |
Value must be 9-digit number | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3602 | ELG036 | ELG.003.036 | SSN | SSN | Not Applicable | Not Applicable | For any individual, the value must be the same over all segment effective and end dates | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3603 | ELG036 | ELG.003.036 | SSN | SSN | Not Applicable | Not Applicable | (SSN State) if associated SSN Indicator (ELG.001.012) value is coded as "1", then value must equal MSIS Identification Number (ELG.002.019) value | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3604 | ELG036 | ELG.003.036 | SSN | SSN | Not Applicable | Not Applicable | Value can only be reported with one MSIS Identification Number (ELG.002.019) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3605 | ELG036 | ELG.003.036 | SSN | SSN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3606 | ELG036 | ELG.003.036 | SSN | SSN | Not Applicable | Not Applicable | (Non-SSN State) if associated SSN Indicator (ELG.001.012) value is coded as "0", then value must not equal MSIS Identification Number (ELG.002.019) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3607 | ELG037 | ELG.003.037 | SSN-VERIFICATION-FLAG | SSN Verification Flag | Mandatory | A code describing whether the state has verified the social security number (SSN) with the Social Security Administration (SSA). | Value must be in SSN Verification Flag List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3608 | ELG037 | ELG.003.037 | SSN-VERIFICATION-FLAG | SSN Verification Flag | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3609 | ELG037 | ELG.003.037 | SSN-VERIFICATION-FLAG | SSN Verification Flag | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3610 | ELG038 | ELG.003.038 | INCOME-CODE | Income Code | Mandatory | A code indicating the family income level. | Value must be in Income Code List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3611 | ELG038 | ELG.003.038 | INCOME-CODE | Income Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3612 | ELG038 | ELG.003.038 | INCOME-CODE | Income Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3613 | ELG039 | ELG.003.039 | VETERAN-IND | Veteran Indicator | Conditional | A flag indicating if a non-citizen is exempt from the 5-year bar on benefits because they are a veteran or an active member of the military, naval or air service. | Value must be in Veteran Indicator List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3614 | ELG039 | ELG.003.039 | VETERAN-IND | Veteran Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3615 | ELG039 | ELG.003.039 | VETERAN-IND | Veteran Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3616 | ELG039 | ELG.003.039 | VETERAN-IND | Veteran Indicator | Not Applicable | Not Applicable | Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3617 | ELG040 | ELG.003.040 | CITIZENSHIP-IND | Citizenship Indicator | Mandatory | Indicates if the individual is identified as a U.S. Citizen. | Value must be in Citizenship Indicator List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3618 | ELG040 | ELG.003.040 | CITIZENSHIP-IND | Citizenship Indicator | Not Applicable | Not Applicable | If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3619 | ELG040 | ELG.003.040 | CITIZENSHIP-IND | Citizenship Indicator | Not Applicable | Not Applicable | If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8' | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3620 | ELG040 | ELG.003.040 | CITIZENSHIP-IND | Citizenship Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3621 | ELG040 | ELG.003.040 | CITIZENSHIP-IND | Citizenship Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3622 | ELG041 | ELG.003.041 | CITIZENSHIP-VERIFICATION-FLAG | Citizenship Verification Flag | Conditional | Indicates the individual is enrolled in Medicaid pending citizenship verification. | Value must be in Citizenship Verification Flag List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3623 | ELG041 | ELG.003.041 | CITIZENSHIP-VERIFICATION-FLAG | Citizenship Verification Flag | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3624 | ELG041 | ELG.003.041 | CITIZENSHIP-VERIFICATION-FLAG | Citizenship Verification Flag | Not Applicable | Not Applicable | Value must be populated when Citizenship Indicator (ELG.003.040) equals '1' (Yes) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3625 | ELG041 | ELG.003.041 | CITIZENSHIP-VERIFICATION-FLAG | Citizenship Verification Flag | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3626 | ELG042 | ELG.003.042 | IMMIGRATION-STATUS | Immigration Status | Mandatory | The immigration status of the individual. | Value must be in Immigration Status List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3627 | ELG042 | ELG.003.042 | IMMIGRATION-STATUS | Immigration Status | Not Applicable | Not Applicable | If associated Citizenship Indicator (ELG.003.040) value is coded as '0', then value must be in [ 1, 2, 3 ] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3628 | ELG042 | ELG.003.042 | IMMIGRATION-STATUS | Immigration Status | Not Applicable | Not Applicable | If associated Citizenship Indicator (ELG.003.040) value is coded as '1', then value must equal '8' | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3629 | ELG042 | ELG.003.042 | IMMIGRATION-STATUS | Immigration Status | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3630 | ELG042 | ELG.003.042 | IMMIGRATION-STATUS | Immigration Status | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3631 | ELG043 | ELG.003.043 | IMMIGRATION-VERIFICATION-FLAG | Immigration Verification Flag | Conditional | Indicates the individual is enrolled in Medicaid pending immigration verification. | Value must be in Immigration Verification Flag List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3632 | ELG043 | ELG.003.043 | IMMIGRATION-VERIFICATION-FLAG | Immigration Verification Flag | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3633 | ELG043 | ELG.003.043 | IMMIGRATION-VERIFICATION-FLAG | Immigration Verification Flag | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3634 | ELG044 | ELG.003.044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Immigration Status Five Year Bar End Date | Conditional | The date the five-year bar for an individual ends._x000D_ Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's _x000D_ Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified alien." |
(U.S. Citizen) if associated Citizenship Indicator (ELG.003.040) value is '1', then value should not be populated | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3635 | ELG044 | ELG.003.044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Immigration Status Five Year Bar End Date | Not Applicable | Not Applicable | (Non U.S. Citizen) if associated Citizenship Indicator (ELG.003.040) value is '0', then value should be populated | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3636 | ELG044 | ELG.003.044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Immigration Status Five Year Bar End Date | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3637 | ELG044 | ELG.003.044 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Immigration Status Five Year Bar End Date | Not Applicable | Not Applicable | (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3638 | ELG045 | ELG.003.045 | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Primary Language English Proficiency Code | Conditional | A code indicating the level of spoken English proficiency by the individual. | Value must be in Primary Language English Proficiency Code List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3639 | ELG045 | ELG.003.045 | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Primary Language English Proficiency Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3640 | ELG045 | ELG.003.045 | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Primary Language English Proficiency Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3641 | ELG046 | ELG.003.046 | PRIMARY-LANGUAGE-CODE | Primary Language Code | Conditional | A code indicating the language the individual speaks other than English at home. | Value must be in Primary Language Code List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3642 | ELG046 | ELG.003.046 | PRIMARY-LANGUAGE-CODE | Primary Language Code | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3643 | ELG046 | ELG.003.046 | PRIMARY-LANGUAGE-CODE | Primary Language Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3644 | ELG047 | ELG.003.047 | HOUSEHOLD-SIZE | Household Size | Mandatory | Household Size used in the Medicaid or CHIP eligibility determination process. | Value must be in Household Size List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3645 | ELG047 | ELG.003.047 | HOUSEHOLD-SIZE | Household Size | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3646 | ELG047 | ELG.003.047 | HOUSEHOLD-SIZE | Household Size | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3647 | ELG049 | ELG.003.049 | PREGNANCY-IND | Pregnancy Indicator | Conditional | A flag indicating the individual is pregnant at the time of application based on self-attestation. | Value must be in Pregnancy Indicator List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3648 | ELG049 | ELG.003.049 | PREGNANCY-IND | Pregnancy Indicator | Not Applicable | Not Applicable | If value equals '1', then Sex (ELG.002.023) value must equal 'F" | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3649 | ELG049 | ELG.003.049 | PREGNANCY-IND | Pregnancy Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3650 | ELG049 | ELG.003.049 | PREGNANCY-IND | Pregnancy Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3651 | ELG050 | ELG.003.050 | MEDICARE-HIC-NUM | Medicare HIC Number | Conditional | The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the _x000D_ Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & _x000D_ alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) |
Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3652 | ELG050 | ELG.003.050 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3653 | ELG050 | ELG.003.050 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3654 | ELG050 | ELG.003.050 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated. | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3655 | ELG050 | ELG.003.050 | MEDICARE-HIC-NUM | Medicare HIC Number | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then value for either HICN or MBI is mandatory and must be provided | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3656 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Conditional | The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI _x000D_ over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. |
Conditional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3657 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must be an 11-character string | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3658 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 1 must be numeric values 1 thru 9 | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3659 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3660 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3661 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 4 must be numeric values 0 thru 9 | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3662 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3663 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3664 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 7 must be numeric values 0 thru 9 | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3665 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3666 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3667 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 10 must be numeric values 0 thru 9 | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3668 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Character 11 must be numeric values 0 thru 9 | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3669 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3670 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | When Dual Eligible Code (ELG.005.085) equals '00' and End of Time Period (ELG.001.010) greater than or equal to '2015-11-01', value should not be populated | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3671 | ELG051 | ELG.003.051 | MEDICARE-BENEFICIARY-IDENTIFIER | Medicare Beneficiary Identifier | Not Applicable | Not Applicable | (Medicare Enrolled) if associated Dual Eligible Code value (ELG.005.085) is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then the value for either HICN or MBI is mandatory and must be provided | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3672 | ELG054 | ELG.003.054 | CHIP-CODE | CHIP Code | Mandatory | A code used to distinguish among Medicaid, Medicaid Expansion CHIP, and Separate CHIP populations. | Value must be in CHIP Code List (VVL) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3673 | ELG054 | ELG.003.054 | CHIP-CODE | CHIP Code | Not Applicable | Not Applicable | If value is in [ 2, 3 ], then associated Eligibility Group (ELG.005.087) value must be in [ "07", "31", "61", 62", "63", "64", "65", "66", "67", or "68" ] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3674 | ELG054 | ELG.003.054 | CHIP-CODE | CHIP Code | Not Applicable | Not Applicable | If value is "1", then associated Eligibility Group (ELG.005.087) value must not be in [ "61", 62", "63", "64", "65", "66", "67", or "68" ] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3675 | ELG054 | ELG.003.054 | CHIP-CODE | CHIP Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3676 | ELG054 | ELG.003.054 | CHIP-CODE | CHIP Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3677 | ELG057 | ELG.003.057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Variable Demographic Element Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3678 | ELG057 | ELG.003.057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Variable Demographic Element Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3679 | ELG057 | ELG.003.057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Variable Demographic Element Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3680 | ELG057 | ELG.003.057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Variable Demographic Element Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3681 | ELG057 | ELG.003.057 | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | Variable Demographic Element Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3682 | ELG058 | ELG.003.058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Variable Demographic Element End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3683 | ELG058 | ELG.003.058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Variable Demographic Element End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3684 | ELG058 | ELG.003.058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Variable Demographic Element End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3685 | ELG058 | ELG.003.058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Variable Demographic Element End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3686 | ELG058 | ELG.003.058 | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | Variable Demographic Element End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| A2 | 3687 | ELG059 | ELG.003.059 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| C2 | 3688 | ELG059 | ELG.003.059 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3689 | ELG059 | ELG.003.059 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| D1 | 3690 | ELG060 | ELG.003.060 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| X1 | 3691 | ELG061 | ELG.004.061 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3692 | ELG061 | ELG.004.061 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00004" | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3693 | ELG062 | ELG.004.062 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3694 | ELG062 | ELG.004.062 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3695 | ELG062 | ELG.004.062 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3696 | ELG062 | ELG.004.062 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3697 | ELG063 | ELG.004.063 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3698 | ELG063 | ELG.004.063 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3699 | ELG063 | ELG.004.063 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3700 | ELG063 | ELG.004.063 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3701 | ELG064 | ELG.004.064 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3702 | ELG064 | ELG.004.064 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3703 | ELG064 | ELG.004.064 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3704 | ELG064 | ELG.004.064 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3705 | ELG065 | ELG.004.065 | ADDR-TYPE | Eligible Address Type | Mandatory | The type of address and contact information for the eligible submitted in the record segment. | Value must be in Eligible Address Type List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3706 | ELG065 | ELG.004.065 | ADDR-TYPE | Eligible Address Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3707 | ELG065 | ELG.004.065 | ADDR-TYPE | Eligible Address Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3708 | ELG066 | ELG.004.066 | ELIGIBLE-ADDR-LN1 | Eligible Address Line 1 | Mandatory | The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3709 | ELG066 | ELG.004.066 | ELIGIBLE-ADDR-LN1 | Eligible Address Line 1 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 2 or Address Line 3 value(s) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3710 | ELG066 | ELG.004.066 | ELIGIBLE-ADDR-LN1 | Eligible Address Line 1 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3711 | ELG066 | ELG.004.066 | ELIGIBLE-ADDR-LN1 | Eligible Address Line 1 | Not Applicable | Not Applicable | When populated, the associated Address Type is required | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3712 | ELG066 | ELG.004.066 | ELIGIBLE-ADDR-LN1 | Eligible Address Line 1 | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3713 | ELG067 | ELG.004.067 | ELIGIBLE-ADDR-LN2 | Eligible Address Line 2 | Conditional | The second line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3714 | ELG067 | ELG.004.067 | ELIGIBLE-ADDR-LN2 | Eligible Address Line 2 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 3 value(s) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3715 | ELG067 | ELG.004.067 | ELIGIBLE-ADDR-LN2 | Eligible Address Line 2 | Not Applicable | Not Applicable | There must be an Address Line 1 in order to have an Address Line 2 | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3716 | ELG067 | ELG.004.067 | ELIGIBLE-ADDR-LN2 | Eligible Address Line 2 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3717 | ELG067 | ELG.004.067 | ELIGIBLE-ADDR-LN2 | Eligible Address Line 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3718 | ELG068 | ELG.004.068 | ELIGIBLE-ADDR-LN3 | Eligible Address Line 3 | Conditional | The third line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3719 | ELG068 | ELG.004.068 | ELIGIBLE-ADDR-LN3 | Eligible Address Line 3 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 2 value(s) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3720 | ELG068 | ELG.004.068 | ELIGIBLE-ADDR-LN3 | Eligible Address Line 3 | Not Applicable | Not Applicable | If Address Line 2 is not populated, then value should not be populated | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3721 | ELG068 | ELG.004.068 | ELIGIBLE-ADDR-LN3 | Eligible Address Line 3 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3722 | ELG068 | ELG.004.068 | ELIGIBLE-ADDR-LN3 | Eligible Address Line 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3723 | ELG069 | ELG.004.069 | ELIGIBLE-CITY | Eligible City | Mandatory | The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). | Value must be 28 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3724 | ELG069 | ELG.004.069 | ELIGIBLE-CITY | Eligible City | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3725 | ELG069 | ELG.004.069 | ELIGIBLE-CITY | Eligible City | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3726 | ELG070 | ELG.004.070 | ELIGIBLE-STATE | Eligible State | Mandatory | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code for where the individual _x000D_ eligible to receive healthcare services resides. (The state for the type of address indicated in Address Type.) |
Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3727 | ELG070 | ELG.004.070 | ELIGIBLE-STATE | Eligible State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3728 | ELG070 | ELG.004.070 | ELIGIBLE-STATE | Eligible State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3729 | ELG071 | ELG.004.071 | ELIGIBLE-ZIP-CODE | Eligible Zip Code | Mandatory | U.S. Zip Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) | Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3730 | ELG071 | ELG.004.071 | ELIGIBLE-ZIP-CODE | Eligible Zip Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3731 | ELG072 | ELG.004.072 | ELIGIBLE-COUNTY-CODE | Eligible County Code | Mandatory | Standard ANSI code used to identify a specific U.S. County. | Value must be in US County Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3732 | ELG072 | ELG.004.072 | ELIGIBLE-COUNTY-CODE | Eligible County Code | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3733 | ELG072 | ELG.004.072 | ELIGIBLE-COUNTY-CODE | Eligible County Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3734 | ELG073 | ELG.004.073 | ELIGIBLE-PHONE-NUM | Eligible Phone Number | Optional | Phone number for a given entity (e.g. person, organization, agency). | Value must be 10 characters, digits (0-9) only | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3735 | ELG073 | ELG.004.073 | ELIGIBLE-PHONE-NUM | Eligible Phone Number | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3736 | ELG074 | ELG.004.074 | TYPE-OF-LIVING-ARRANGEMENT | Type Of Living Arrangement | Conditional | A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid value lists. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3737 | ELG074 | ELG.004.074 | TYPE-OF-LIVING-ARRANGEMENT | Type Of Living Arrangement | Not Applicable | Not Applicable | Value must be 100 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3738 | ELG074 | ELG.004.074 | TYPE-OF-LIVING-ARRANGEMENT | Type Of Living Arrangement | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3739 | ELG075 | ELG.004.075 | ELIGIBLE-ADDR-EFF-DATE | Eligible Address Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3740 | ELG075 | ELG.004.075 | ELIGIBLE-ADDR-EFF-DATE | Eligible Address Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3741 | ELG075 | ELG.004.075 | ELIGIBLE-ADDR-EFF-DATE | Eligible Address Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3742 | ELG075 | ELG.004.075 | ELIGIBLE-ADDR-EFF-DATE | Eligible Address Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3743 | ELG075 | ELG.004.075 | ELIGIBLE-ADDR-EFF-DATE | Eligible Address Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3744 | ELG076 | ELG.004.076 | ELIGIBLE-ADDR-END-DATE | Eligible Address End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3745 | ELG076 | ELG.004.076 | ELIGIBLE-ADDR-END-DATE | Eligible Address End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3746 | ELG076 | ELG.004.076 | ELIGIBLE-ADDR-END-DATE | Eligible Address End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3747 | ELG076 | ELG.004.076 | ELIGIBLE-ADDR-END-DATE | Eligible Address End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3748 | ELG076 | ELG.004.076 | ELIGIBLE-ADDR-END-DATE | Eligible Address End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| A2 | 3749 | ELG077 | ELG.004.077 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| C2 | 3750 | ELG077 | ELG.004.077 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3751 | ELG077 | ELG.004.077 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| D1 | 3752 | ELG078 | ELG.004.078 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 |
| X1 | 3753 | ELG079 | ELG.005.079 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3754 | ELG079 | ELG.005.079 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00005" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3755 | ELG080 | ELG.005.080 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3756 | ELG080 | ELG.005.080 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3757 | ELG080 | ELG.005.080 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3758 | ELG080 | ELG.005.080 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3759 | ELG081 | ELG.005.081 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3760 | ELG081 | ELG.005.081 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3761 | ELG081 | ELG.005.081 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3762 | ELG081 | ELG.005.081 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3763 | ELG082 | ELG.005.082 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3764 | ELG082 | ELG.005.082 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3765 | ELG082 | ELG.005.082 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3766 | ELG082 | ELG.005.082 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3767 | ELG083 | ELG.005.083 | MSIS-CASE-NUM | MSIS Case Num | Mandatory | The state-assigned number which uniquely identifies the Medicaid case to which the enrollee belongs. The definition of a case varies. There are single-person cases (mostly aged and blind/disabled) and multi-person cases (mostly TANF) in which all members of the case have the same case _x000D_ number, but a unique identification number. A warning for longitudinal research efforts: a case numbers associated with an individual may change over time. |
Value must not contain a pipe symbol | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3768 | ELG083 | ELG.005.083 | MSIS-CASE-NUM | MSIS Case Num | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3769 | ELG083 | ELG.005.083 | MSIS-CASE-NUM | MSIS Case Num | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| D1 | 3770 | ELG084 | ELG.005.084 | MEDICAID-BASIS-OF-ELIGIBILITY | Medicaid Basis Of Eligibility | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3771 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Conditional | Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits. | Value must be in Dual Eligible Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3772 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value is "05", then Eligibility Group (ELG.005.087) must be "24" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3773 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value is "06", then Eligibility Group (ELG.005.087) must be "26" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3774 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3775 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3776 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3777 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated. | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3778 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3779 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3780 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3781 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3782 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value is "01", then Eligibility Group (ELG.005.087) must be "23" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3783 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Not Applicable | Not Applicable | If value is "03", then Eligibility Group (ELG.005.087) must be "25" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3784 | ELG086 | ELG.005.086 | PRIMARY-ELIGIBILITY-GROUP-IND | Primary Eligibility Group Indicator | Mandatory | A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and _x000D_ end dates. |
Value must be in Primary Eligibility Group Indicator List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3785 | ELG086 | ELG.005.086 | PRIMARY-ELIGIBILITY-GROUP-IND | Primary Eligibility Group Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3786 | ELG086 | ELG.005.086 | PRIMARY-ELIGIBILITY-GROUP-IND | Primary Eligibility Group Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3787 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Conditional | 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). | Value must be in Eligibility Group List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C1 | 3788 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If value is "26", then Dual Eligible Code value must be "06" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3789 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3790 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014. | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3791 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "7" and State Plan Option Type must equal "06" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3792 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ] | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C1 | 3793 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ] | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3794 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3795 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If value is "23", then Dual Eligible Code value must be in ["01", "02"] | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3796 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If value is "25", then Dual Eligible Code value must be in ["03", "04"] | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3797 | ELG087 | ELG.005.087 | ELIGIBILITY-GROUP | Eligibility Group | Not Applicable | Not Applicable | If value is "24", then Dual Eligible Code value must be "05" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3798 | ELG088 | ELG.005.088 | LEVEL-OF-CARE-STATUS | Level Of Care Status | Conditional | The level of care required to meet an individual's needs and to determine LTSS program eligibility. | Value must be in Level of Care Status List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3799 | ELG088 | ELG.005.088 | LEVEL-OF-CARE-STATUS | Level Of Care Status | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3800 | ELG088 | ELG.005.088 | LEVEL-OF-CARE-STATUS | Level Of Care Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3801 | ELG089 | ELG.005.089 | SSDI-IND | SSDI Indicator | Conditional | A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA). | Value must be in SSDI Indicator List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3802 | ELG089 | ELG.005.089 | SSDI-IND | SSDI Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3803 | ELG089 | ELG.005.089 | SSDI-IND | SSDI Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3804 | ELG090 | ELG.005.090 | SSI-IND | SSI Indicator | Conditional | A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA). | Value must be in SSI Indicator List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3805 | ELG090 | ELG.005.090 | SSI-IND | SSI Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3806 | ELG090 | ELG.005.090 | SSI-IND | SSI Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3807 | ELG090 | ELG.005.090 | SSI-IND | SSI Indicator | Not Applicable | Not Applicable | Value must equal '0' when SSI Status equals '003' or is not populated | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3808 | ELG091 | ELG.005.091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | SSI State Supplement Status Code | Conditional | Indicates the individual's State Supplemental Income Status. | Value must be in SSI State Supplement Status Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3809 | ELG091 | ELG.005.091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | SSI State Supplement Status Code | Not Applicable | Not Applicable | (individual not receiving Federal SSI) If SSI State Supplemental Status Code is "001" or "002", then SSI Status cannot be "000" or "003" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3810 | ELG091 | ELG.005.091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | SSI State Supplement Status Code | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3811 | ELG091 | ELG.005.091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | SSI State Supplement Status Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3812 | ELG091 | ELG.005.091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | SSI State Supplement Status Code | Not Applicable | Not Applicable | Value must not be populated when SSI Status is not populated | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3813 | ELG092 | ELG.005.092 | SSI-STATUS | SSI Status | Conditional | Indicates the individual's SSI Status. | Value must be in SSI Status List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3814 | ELG092 | ELG.005.092 | SSI-STATUS | SSI Status | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3815 | ELG092 | ELG.005.092 | SSI-STATUS | SSI Status | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3816 | ELG092 | ELG.005.092 | SSI-STATUS | SSI Status | Not Applicable | Not Applicable | Value must be populated when SSI Indicator equals '1' | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3817 | ELG093 | ELG.005.093 | STATE-SPEC-ELIG-GROUP | State Specific Eligibility Group | Mandatory | The composite of eligibility mapping factors used to create the corresponding Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) values (before January 1, 2014) and ELIGIBILITY-GROUP values (on or after January 1, 2014). This field should not include information _x000D_ that already appears elsewhere on the Eligible File record even if it is part of the MAS and BOE or Eligibility Group algorithm (e.g., age information computed from Date of Birth or County Code). |
If value is in the range [ 000000 .. 999999 ], then associated Date of Death value must not be before the start of the reporting period. | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3818 | ELG093 | ELG.005.093 | STATE-SPEC-ELIG-GROUP | State Specific Eligibility Group | Not Applicable | Not Applicable | Value must be 6 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3819 | ELG093 | ELG.005.093 | STATE-SPEC-ELIG-GROUP | State Specific Eligibility Group | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3820 | ELG094 | ELG.005.094 | CONCEPTION-TO-BIRTH-IND | Conception To Birth Indicator | Conditional | A flag to identify children eligible through the conception to birth option, which is available only through a Separate CHIP Program. | Value must be in Conception to Birth Indicator List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3821 | ELG094 | ELG.005.094 | CONCEPTION-TO-BIRTH-IND | Conception To Birth Indicator | Not Applicable | Not Applicable | If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3822 | ELG094 | ELG.005.094 | CONCEPTION-TO-BIRTH-IND | Conception To Birth Indicator | Not Applicable | Not Applicable | If the value is equal to "1", then any associated claims must indicate the Program Type ='14' (State Plan CHIP) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3823 | ELG094 | ELG.005.094 | CONCEPTION-TO-BIRTH-IND | Conception To Birth Indicator | Not Applicable | Not Applicable | If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3824 | ELG094 | ELG.005.094 | CONCEPTION-TO-BIRTH-IND | Conception To Birth Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3825 | ELG094 | ELG.005.094 | CONCEPTION-TO-BIRTH-IND | Conception To Birth Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3826 | ELG095 | ELG.005.095 | ELIGIBILITY-CHANGE-REASON | Eligibility Change Reason | Conditional | The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status. | Value must be in Eligibility Change Reason List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3827 | ELG095 | ELG.005.095 | ELIGIBILITY-CHANGE-REASON | Eligibility Change Reason | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3828 | ELG095 | ELG.005.095 | ELIGIBILITY-CHANGE-REASON | Eligibility Change Reason | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| D1 | 3829 | ELG096 | ELG.005.096 | MAINTENANCE-ASSISTANCE-STATUS | Maintenance Assistance Status | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3830 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Mandatory | A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to. | Value must be in Restricted Benefits Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3831 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3832 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3833 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3834 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3835 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3836 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | If value is populated, then Eligibility Group (ELG.005.087) must be populated. | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3837 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | If value is "6" then ELIGIBILITY-GROUP(ELG.DE.087) must be in ("35", "70")" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3838 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be 'F' | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3839 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3840 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3841 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3842 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3843 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3844 | ELG097 | ELG.005.097 | RESTRICTED-BENEFITS-CODE | Restricted Benefits Code | Not Applicable | Not Applicable | (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3845 | ELG098 | ELG.005.098 | TANF-CASH-CODE | TANF Cash Code | Conditional | A flag that indicates whether the individual received Federal Temporary Assistance for Needy Families (TANF) benefits. | Value must be in TANF Cash Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3846 | ELG098 | ELG.005.098 | TANF-CASH-CODE | TANF Cash Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3847 | ELG098 | ELG.005.098 | TANF-CASH-CODE | TANF Cash Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3848 | ELG099 | ELG.005.099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Eligibility Determinant Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3849 | ELG099 | ELG.005.099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Eligibility Determinant Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3850 | ELG099 | ELG.005.099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Eligibility Determinant Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3851 | ELG099 | ELG.005.099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Eligibility Determinant Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3852 | ELG099 | ELG.005.099 | ELIGIBILITY-DETERMINANT-EFF-DATE | Eligibility Determinant Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3853 | ELG100 | ELG.005.100 | ELIGIBILITY-DETERMINANT-END-DATE | Eligibility Determinant End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3854 | ELG100 | ELG.005.100 | ELIGIBILITY-DETERMINANT-END-DATE | Eligibility Determinant End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3855 | ELG100 | ELG.005.100 | ELIGIBILITY-DETERMINANT-END-DATE | Eligibility Determinant End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3856 | ELG100 | ELG.005.100 | ELIGIBILITY-DETERMINANT-END-DATE | Eligibility Determinant End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3857 | ELG100 | ELG.005.100 | ELIGIBILITY-DETERMINANT-END-DATE | Eligibility Determinant End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| A2 | 3858 | ELG101 | ELG.005.101 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| C2 | 3859 | ELG101 | ELG.005.101 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3860 | ELG101 | ELG.005.101 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| D1 | 3861 | ELG102 | ELG.005.102 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 |
| X1 | 3862 | ELG103 | ELG.006.103 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3863 | ELG103 | ELG.006.103 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00006" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3864 | ELG104 | ELG.006.104 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3865 | ELG104 | ELG.006.104 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3866 | ELG104 | ELG.006.104 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3867 | ELG104 | ELG.006.104 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3868 | ELG105 | ELG.006.105 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3869 | ELG105 | ELG.006.105 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3870 | ELG105 | ELG.006.105 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3871 | ELG105 | ELG.006.105 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3872 | ELG106 | ELG.006.106 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3873 | ELG106 | ELG.006.106 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3874 | ELG106 | ELG.006.106 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3875 | ELG106 | ELG.006.106 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A1 | 3876 | ELG107 | ELG.006.107 | HEALTH-HOME-SPA-NAME | Health Home SPA Name | Mandatory | A free-form text field for the name of the health home program approved by CMS. This name needs to be consistent across files to be used for linking. | Value must be 100 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3877 | ELG107 | ELG.006.107 | HEALTH-HOME-SPA-NAME | Health Home SPA Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C1 | 3878 | ELG107 | ELG.006.107 | HEALTH-HOME-SPA-NAME | Health Home SPA Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3879 | ELG108 | ELG.006.108 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Mandatory | A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead. | Value must 100 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3880 | ELG108 | ELG.006.108 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C1 | 3881 | ELG108 | ELG.006.108 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3882 | ELG109 | ELG.006.109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Health Home SPA Participation Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3883 | ELG109 | ELG.006.109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Health Home SPA Participation Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3884 | ELG109 | ELG.006.109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Health Home SPA Participation Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3885 | ELG109 | ELG.006.109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Health Home SPA Participation Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3886 | ELG109 | ELG.006.109 | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | Health Home SPA Participation Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3887 | ELG110 | ELG.006.110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Health Home SPA Participation End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3888 | ELG110 | ELG.006.110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Health Home SPA Participation End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3889 | ELG110 | ELG.006.110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Health Home SPA Participation End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3890 | ELG110 | ELG.006.110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Health Home SPA Participation End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3891 | ELG110 | ELG.006.110 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | Health Home SPA Participation End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3892 | ELG111 | ELG.006.111 | HEALTH-HOME-ENTITY-EFF-DATE | Health Home Entity Effective Date | Not Applicable | The date on which the health home entity was approved by CMS to participate in the Health Home Program. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3893 | ELG111 | ELG.006.111 | HEALTH-HOME-ENTITY-EFF-DATE | Health Home Entity Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| A2 | 3894 | ELG112 | ELG.006.112 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| C2 | 3895 | ELG112 | ELG.006.112 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3896 | ELG112 | ELG.006.112 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| D1 | 3897 | ELG113 | ELG.006.113 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 |
| X1 | 3898 | ELG114 | ELG.007.114 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3899 | ELG114 | ELG.007.114 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00007" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3900 | ELG115 | ELG.007.115 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3901 | ELG115 | ELG.007.115 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3902 | ELG115 | ELG.007.115 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3903 | ELG115 | ELG.007.115 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3904 | ELG116 | ELG.007.116 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3905 | ELG116 | ELG.007.116 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3906 | ELG116 | ELG.007.116 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3907 | ELG116 | ELG.007.116 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3908 | ELG117 | ELG.007.117 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3909 | ELG117 | ELG.007.117 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3910 | ELG117 | ELG.007.117 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3911 | ELG117 | ELG.007.117 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3912 | ELG118 | ELG.007.118 | HEALTH-HOME-SPA-NAME | Health Home SPA Name | Mandatory | A free-form text field for the name of the health home program approved by CMS. This name needs to be consistent across files to be used for linking. | Value must be 100 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3913 | ELG118 | ELG.007.118 | HEALTH-HOME-SPA-NAME | Health Home SPA Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C1 | 3914 | ELG118 | ELG.007.118 | HEALTH-HOME-SPA-NAME | Health Home SPA Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3915 | ELG119 | ELG.007.119 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Mandatory | A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead. | Value must 100 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3916 | ELG119 | ELG.007.119 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C1 | 3917 | ELG119 | ELG.007.119 | HEALTH-HOME-ENTITY-NAME | Health Home Entity Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3918 | ELG120 | ELG.007.120 | HEALTH-HOME-PROV-NUM | Health Home Provider Number | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3919 | ELG120 | ELG.007.120 | HEALTH-HOME-PROV-NUM | Health Home Provider Number | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3920 | ELG120 | ELG.007.120 | HEALTH-HOME-PROV-NUM | Health Home Provider Number | Not Applicable | Not Applicable | Value must match Provider Identifier (PRV.005.081) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C1 | 3921 | ELG120 | ELG.007.120 | HEALTH-HOME-PROV-NUM | Health Home Provider Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3922 | ELG121 | ELG.007.121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Health Home SPA Provider Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3923 | ELG121 | ELG.007.121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Health Home SPA Provider Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3924 | ELG121 | ELG.007.121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Health Home SPA Provider Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3925 | ELG121 | ELG.007.121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Health Home SPA Provider Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3926 | ELG121 | ELG.007.121 | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | Health Home SPA Provider Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3927 | ELG122 | ELG.007.122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Health Home Spa Provider End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3928 | ELG122 | ELG.007.122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Health Home Spa Provider End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3929 | ELG122 | ELG.007.122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Health Home Spa Provider End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3930 | ELG122 | ELG.007.122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Health Home Spa Provider End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3931 | ELG122 | ELG.007.122 | HEALTH-HOME-SPA-PROVIDER-END-DATE | Health Home Spa Provider End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3932 | ELG123 | ELG.007.123 | HEALTH-HOME-ENTITY-EFF-DATE | Health Home Entity Effective Date | Mandatory | The date on which the health home entity was approved by CMS to participate in the Health Home Program. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3933 | ELG123 | ELG.007.123 | HEALTH-HOME-ENTITY-EFF-DATE | Health Home Entity Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C1 | 3934 | ELG123 | ELG.007.123 | HEALTH-HOME-ENTITY-EFF-DATE | Health Home Entity Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| A2 | 3935 | ELG124 | ELG.007.124 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| C2 | 3936 | ELG124 | ELG.007.124 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3937 | ELG124 | ELG.007.124 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| D1 | 3938 | ELG125 | ELG.007.125 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 |
| X1 | 3939 | ELG126 | ELG.008.126 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3940 | ELG126 | ELG.008.126 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00008" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3941 | ELG127 | ELG.008.127 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3942 | ELG127 | ELG.008.127 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3943 | ELG127 | ELG.008.127 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3944 | ELG127 | ELG.008.127 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3945 | ELG128 | ELG.008.128 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3946 | ELG128 | ELG.008.128 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3947 | ELG128 | ELG.008.128 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3948 | ELG128 | ELG.008.128 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3949 | ELG129 | ELG.008.129 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3950 | ELG129 | ELG.008.129 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3951 | ELG129 | ELG.008.129 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3952 | ELG129 | ELG.008.129 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3953 | ELG130 | ELG.008.130 | HEALTH-HOME-CHRONIC-CONDITION | Health Home Chronic Condition | Mandatory | The chronic condition used to determine the individual's eligibility for the health home provision. | Value must be in Health Home Chronic Condition List (VVL) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3954 | ELG130 | ELG.008.130 | HEALTH-HOME-CHRONIC-CONDITION | Health Home Chronic Condition | Not Applicable | Not Applicable | If value equals "H, associated Health Home Chronic Condition Other Explanation must be provided | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3955 | ELG130 | ELG.008.130 | HEALTH-HOME-CHRONIC-CONDITION | Health Home Chronic Condition | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C1 | 3956 | ELG130 | ELG.008.130 | HEALTH-HOME-CHRONIC-CONDITION | Health Home Chronic Condition | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3957 | ELG131 | ELG.008.131 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Health Home Chronic Condition Other Explanation | Conditional | A free-text field to capture the description of the other chronic condition (or conditions) when value "H" (Other) appears in the HEALTH-HOME-CHRONIC-CONDITION. | Value must be 50 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3958 | ELG131 | ELG.008.131 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Health Home Chronic Condition Other Explanation | Not Applicable | Not Applicable | If associated Health Home Chronic Condition (ELG.008.130) value equals "H", then value is mandatory and must be provided | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3959 | ELG131 | ELG.008.131 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Health Home Chronic Condition Other Explanation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C1 | 3960 | ELG131 | ELG.008.131 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Health Home Chronic Condition Other Explanation | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3961 | ELG132 | ELG.008.132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Health Home Chronic Condition Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3962 | ELG132 | ELG.008.132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Health Home Chronic Condition Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3963 | ELG132 | ELG.008.132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Health Home Chronic Condition Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C1 | 3964 | ELG132 | ELG.008.132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Health Home Chronic Condition Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3965 | ELG132 | ELG.008.132 | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | Health Home Chronic Condition Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3966 | ELG133 | ELG.008.133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Health Home Chronic Condition End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3967 | ELG133 | ELG.008.133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Health Home Chronic Condition End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3968 | ELG133 | ELG.008.133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Health Home Chronic Condition End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C1 | 3969 | ELG133 | ELG.008.133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Health Home Chronic Condition End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3970 | ELG133 | ELG.008.133 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | Health Home Chronic Condition End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| A2 | 3971 | ELG134 | ELG.008.134 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| C2 | 3972 | ELG134 | ELG.008.134 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3973 | ELG134 | ELG.008.134 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| D1 | 3974 | ELG135 | ELG.008.135 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 |
| X1 | 3975 | ELG136 | ELG.009.136 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3976 | ELG136 | ELG.009.136 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00009" | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3977 | ELG137 | ELG.009.137 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3978 | ELG137 | ELG.009.137 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3979 | ELG137 | ELG.009.137 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3980 | ELG137 | ELG.009.137 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3981 | ELG138 | ELG.009.138 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3982 | ELG138 | ELG.009.138 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3983 | ELG138 | ELG.009.138 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3984 | ELG138 | ELG.009.138 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3985 | ELG139 | ELG.009.139 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 3986 | ELG139 | ELG.009.139 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 3987 | ELG139 | ELG.009.139 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3988 | ELG139 | ELG.009.139 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3989 | ELG140 | ELG.009.140 | LOCKIN-PROV-NUM | Lockin Provider Num | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3990 | ELG140 | ELG.009.140 | LOCKIN-PROV-NUM | Lockin Provider Num | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C1 | 3991 | ELG140 | ELG.009.140 | LOCKIN-PROV-NUM | Lockin Provider Num | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3992 | ELG140 | ELG.009.140 | LOCKIN-PROV-NUM | Lockin Provider Num | Not Applicable | Not Applicable | Value must match Provider Identifier (PRV.005.081) | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3993 | ELG141 | ELG.009.141 | LOCKIN-PROV-TYPE | Lockin Provider Type | Mandatory | A code describing the provider type classification for which the provider/beneficiary lock-in relationship exists. | Value must be in Lockin Provider Type List (VVL) | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 3994 | ELG141 | ELG.009.141 | LOCKIN-PROV-TYPE | Lockin Provider Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C1 | 3995 | ELG141 | ELG.009.141 | LOCKIN-PROV-TYPE | Lockin Provider Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 3996 | ELG142 | ELG.009.142 | LOCKIN-EFF-DATE | Lockin Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 3997 | ELG142 | ELG.009.142 | LOCKIN-EFF-DATE | Lockin Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 3998 | ELG142 | ELG.009.142 | LOCKIN-EFF-DATE | Lockin Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C1 | 3999 | ELG142 | ELG.009.142 | LOCKIN-EFF-DATE | Lockin Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 4000 | ELG142 | ELG.009.142 | LOCKIN-EFF-DATE | Lockin Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 4001 | ELG143 | ELG.009.143 | LOCKIN-END-DATE | Lockin End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 4002 | ELG143 | ELG.009.143 | LOCKIN-END-DATE | Lockin End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 4003 | ELG143 | ELG.009.143 | LOCKIN-END-DATE | Lockin End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 4004 | ELG143 | ELG.009.143 | LOCKIN-END-DATE | Lockin End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 4005 | ELG143 | ELG.009.143 | LOCKIN-END-DATE | Lockin End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| A2 | 4006 | ELG144 | ELG.009.144 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 4007 | ELG144 | ELG.009.144 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| X1 | 4008 | ELG144 | ELG.009.144 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| D1 | 4009 | ELG145 | ELG.009.145 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 |
| C2 | 4010 | ELG146 | ELG.010.146 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4011 | ELG146 | ELG.010.146 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00010" | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4012 | ELG147 | ELG.010.147 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4013 | ELG147 | ELG.010.147 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4014 | ELG147 | ELG.010.147 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4015 | ELG147 | ELG.010.147 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4016 | ELG148 | ELG.010.148 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4017 | ELG148 | ELG.010.148 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4018 | ELG148 | ELG.010.148 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4019 | ELG148 | ELG.010.148 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4020 | ELG149 | ELG.010.149 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4021 | ELG149 | ELG.010.149 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4022 | ELG149 | ELG.010.149 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4023 | ELG149 | ELG.010.149 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4024 | ELG150 | ELG.010.150 | MFP-LIVES-WITH-FAMILY | MFP Lives with Family | Mandatory | A code indicating if the individual lives with his/her family or is not a participant in the MFP program. | Value must be in MFP Lives with Family List (VVL) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4025 | ELG150 | ELG.010.150 | MFP-LIVES-WITH-FAMILY | MFP Lives with Family | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C1 | 4026 | ELG150 | ELG.010.150 | MFP-LIVES-WITH-FAMILY | MFP Lives with Family | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4027 | ELG151 | ELG.010.151 | MFP-QUALIFIED-INSTITUTION | MFP Qualified Institution | Mandatory | A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant. | Value must be in MFP Qualified Institution List (VVL) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4028 | ELG151 | ELG.010.151 | MFP-QUALIFIED-INSTITUTION | MFP Qualified Institution | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C1 | 4029 | ELG151 | ELG.010.151 | MFP-QUALIFIED-INSTITUTION | MFP Qualified Institution | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4030 | ELG152 | ELG.010.152 | MFP-QUALIFIED-RESIDENCE | MFP Qualified Residence | Mandatory | A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant. | Value must be in MFP Qualified Residence List (VVL) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4031 | ELG152 | ELG.010.152 | MFP-QUALIFIED-RESIDENCE | MFP Qualified Residence | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C1 | 4032 | ELG152 | ELG.010.152 | MFP-QUALIFIED-RESIDENCE | MFP Qualified Residence | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4033 | ELG153 | ELG.010.153 | MFP-REASON-PARTICIPATION-ENDED | MFP Reason Participation Ended | Conditional | A code describing why an individual's participation in Money Follows the Person demonstration ended. | Value must be in MFP Reason Participation Ended List (VVL) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4034 | ELG153 | ELG.010.153 | MFP-REASON-PARTICIPATION-ENDED | MFP Reason Participation Ended | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4035 | ELG153 | ELG.010.153 | MFP-REASON-PARTICIPATION-ENDED | MFP Reason Participation Ended | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4036 | ELG153 | ELG.010.153 | MFP-REASON-PARTICIPATION-ENDED | MFP Reason Participation Ended | Not Applicable | Not Applicable | Value must not be populated when Enrollment End Date equals '9999-12-31' | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4037 | ELG154 | ELG.010.154 | MFP-REINSTITUTIONALIZED-REASON | MFP Reinstitutionalized Reason | Conditional | A code describing why the individual was reinstitutionalized after participation in the Money Follows the Person Demonstration. | Value must be in MFP Reinstitutionalized Reason (VVL) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4038 | ELG154 | ELG.010.154 | MFP-REINSTITUTIONALIZED-REASON | MFP Reinstitutionalized Reason | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4039 | ELG154 | ELG.010.154 | MFP-REINSTITUTIONALIZED-REASON | MFP Reinstitutionalized Reason | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4040 | ELG155 | ELG.010.155 | MFP-ENROLLMENT-EFF-DATE | MFP Enrollment Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4041 | ELG155 | ELG.010.155 | MFP-ENROLLMENT-EFF-DATE | MFP Enrollment Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4042 | ELG155 | ELG.010.155 | MFP-ENROLLMENT-EFF-DATE | MFP Enrollment Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C1 | 4043 | ELG155 | ELG.010.155 | MFP-ENROLLMENT-EFF-DATE | MFP Enrollment Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4044 | ELG155 | ELG.010.155 | MFP-ENROLLMENT-EFF-DATE | MFP Enrollment Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4045 | ELG156 | ELG.010.156 | MFP-ENROLLMENT-END-DATE | MFP Enrollment End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4046 | ELG156 | ELG.010.156 | MFP-ENROLLMENT-END-DATE | MFP Enrollment End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4047 | ELG156 | ELG.010.156 | MFP-ENROLLMENT-END-DATE | MFP Enrollment End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4048 | ELG156 | ELG.010.156 | MFP-ENROLLMENT-END-DATE | MFP Enrollment End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4049 | ELG156 | ELG.010.156 | MFP-ENROLLMENT-END-DATE | MFP Enrollment End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| A2 | 4050 | ELG157 | ELG.010.157 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4051 | ELG157 | ELG.010.157 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| X1 | 4052 | ELG157 | ELG.010.157 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| D1 | 4053 | ELG158 | ELG.010.158 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | MFP-INFORMATION-ELG00010 |
| C2 | 4054 | ELG159 | ELG.011.159 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4055 | ELG159 | ELG.011.159 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00011" | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4056 | ELG160 | ELG.011.160 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4057 | ELG160 | ELG.011.160 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4058 | ELG160 | ELG.011.160 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4059 | ELG160 | ELG.011.160 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4060 | ELG161 | ELG.011.161 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4061 | ELG161 | ELG.011.161 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4062 | ELG161 | ELG.011.161 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4063 | ELG161 | ELG.011.161 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4064 | ELG162 | ELG.011.162 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4065 | ELG162 | ELG.011.162 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4066 | ELG162 | ELG.011.162 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4067 | ELG162 | ELG.011.162 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4068 | ELG163 | ELG.011.163 | STATE-PLAN-OPTION-TYPE | State Plan Option Type | Mandatory | This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment. | Value must be in State Plan Option Type List (VVL) | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4069 | ELG163 | ELG.011.163 | STATE-PLAN-OPTION-TYPE | State Plan Option Type | Not Applicable | Not Applicable | If associated Eligibility Group (ELG.005.087) value is in [ "72", "73", "74", "75" ], then value must be "06" | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4070 | ELG163 | ELG.011.163 | STATE-PLAN-OPTION-TYPE | State Plan Option Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C1 | 4071 | ELG163 | ELG.011.163 | STATE-PLAN-OPTION-TYPE | State Plan Option Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4072 | ELG163 | ELG.011.163 | STATE-PLAN-OPTION-TYPE | State Plan Option Type | Not Applicable | Not Applicable | Value must equal '02' when Program Type (CIP.002.129) equals '13' | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4073 | ELG163 | ELG.011.163 | STATE-PLAN-OPTION-TYPE | State Plan Option Type | Not Applicable | Not Applicable | Value must equal '02' when Program Type (COT.002.065) equals '13' | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4074 | ELG164 | ELG.011.164 | STATE-PLAN-OPTION-EFF-DATE | State Plan Option Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4075 | ELG164 | ELG.011.164 | STATE-PLAN-OPTION-EFF-DATE | State Plan Option Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4076 | ELG164 | ELG.011.164 | STATE-PLAN-OPTION-EFF-DATE | State Plan Option Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4077 | ELG164 | ELG.011.164 | STATE-PLAN-OPTION-EFF-DATE | State Plan Option Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4078 | ELG164 | ELG.011.164 | STATE-PLAN-OPTION-EFF-DATE | State Plan Option Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4079 | ELG165 | ELG.011.165 | STATE-PLAN-OPTION-END-DATE | State Plan Option End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4080 | ELG165 | ELG.011.165 | STATE-PLAN-OPTION-END-DATE | State Plan Option End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4081 | ELG165 | ELG.011.165 | STATE-PLAN-OPTION-END-DATE | State Plan Option End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4082 | ELG165 | ELG.011.165 | STATE-PLAN-OPTION-END-DATE | State Plan Option End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4083 | ELG165 | ELG.011.165 | STATE-PLAN-OPTION-END-DATE | State Plan Option End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| A2 | 4084 | ELG166 | ELG.011.166 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4085 | ELG166 | ELG.011.166 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| X1 | 4086 | ELG166 | ELG.011.166 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| D1 | 4087 | ELG167 | ELG.011.167 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 |
| C2 | 4088 | ELG168 | ELG.012.168 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4089 | ELG168 | ELG.012.168 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00012" | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4090 | ELG169 | ELG.012.169 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4091 | ELG169 | ELG.012.169 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4092 | ELG169 | ELG.012.169 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4093 | ELG169 | ELG.012.169 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4094 | ELG170 | ELG.012.170 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4095 | ELG170 | ELG.012.170 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4096 | ELG170 | ELG.012.170 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4097 | ELG170 | ELG.012.170 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4098 | ELG171 | ELG.012.171 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4099 | ELG171 | ELG.012.171 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4100 | ELG171 | ELG.012.171 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4101 | ELG171 | ELG.012.171 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4102 | ELG172 | ELG.012.172 | WAIVER-ID | Waiver ID | Mandatory | Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the_x000D_ "core" part of the waiver IDs, without including suffixes for renewals or amendments. |
Value must be associated with a populated Waiver Type | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4103 | ELG172 | ELG.012.172 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4104 | ELG172 | ELG.012.172 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4105 | ELG172 | ELG.012.172 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4106 | ELG172 | ELG.012.172 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Value must have a corresponding value in Waiver Type (ELG.012.173) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4107 | ELG172 | ELG.012.172 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4108 | ELG173 | ELG.012.173 | WAIVER-TYPE | Eligible Waiver Type | Mandatory | Code for specifying waiver types under which the eligible individual is covered during the month. | Value must be in Waiver Type List (VVL) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4109 | ELG173 | ELG.012.173 | WAIVER-TYPE | Eligible Waiver Type | Not Applicable | Not Applicable | Value must have a corresponding value in Waiver ID (ELG.012.172) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C1 | 4110 | ELG173 | ELG.012.173 | WAIVER-TYPE | Eligible Waiver Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4111 | ELG173 | ELG.012.173 | WAIVER-TYPE | Eligible Waiver Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4112 | ELG174 | ELG.012.174 | WAIVER-ENROLLMENT-EFF-DATE | Waiver Enrollment Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4113 | ELG174 | ELG.012.174 | WAIVER-ENROLLMENT-EFF-DATE | Waiver Enrollment Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4114 | ELG174 | ELG.012.174 | WAIVER-ENROLLMENT-EFF-DATE | Waiver Enrollment Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C1 | 4115 | ELG174 | ELG.012.174 | WAIVER-ENROLLMENT-EFF-DATE | Waiver Enrollment Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4116 | ELG174 | ELG.012.174 | WAIVER-ENROLLMENT-EFF-DATE | Waiver Enrollment Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4117 | ELG175 | ELG.012.175 | WAIVER-ENROLLMENT-END-DATE | Waiver Enrollment End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4118 | ELG175 | ELG.012.175 | WAIVER-ENROLLMENT-END-DATE | Waiver Enrollment End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4119 | ELG175 | ELG.012.175 | WAIVER-ENROLLMENT-END-DATE | Waiver Enrollment End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C1 | 4120 | ELG175 | ELG.012.175 | WAIVER-ENROLLMENT-END-DATE | Waiver Enrollment End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4121 | ELG175 | ELG.012.175 | WAIVER-ENROLLMENT-END-DATE | Waiver Enrollment End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| A2 | 4122 | ELG176 | ELG.012.176 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4123 | ELG176 | ELG.012.176 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| X1 | 4124 | ELG176 | ELG.012.176 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| D1 | 4125 | ELG177 | ELG.012.177 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 |
| C2 | 4126 | ELG178 | ELG.013.178 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4127 | ELG178 | ELG.013.178 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00013" | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4128 | ELG179 | ELG.013.179 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4129 | ELG179 | ELG.013.179 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4130 | ELG179 | ELG.013.179 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4131 | ELG179 | ELG.013.179 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4132 | ELG180 | ELG.013.180 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4133 | ELG180 | ELG.013.180 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4134 | ELG180 | ELG.013.180 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4135 | ELG180 | ELG.013.180 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4136 | ELG181 | ELG.013.181 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4137 | ELG181 | ELG.013.181 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4138 | ELG181 | ELG.013.181 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4139 | ELG181 | ELG.013.181 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4140 | ELG182 | ELG.013.182 | LTSS-LEVEL-CARE | LTSS Level Care | Mandatory | The level of care provided to the individual by the long term care facility. | Value must be in LTSS Level Care List (VVL) | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4141 | ELG182 | ELG.013.182 | LTSS-LEVEL-CARE | LTSS Level Care | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C1 | 4142 | ELG182 | ELG.013.182 | LTSS-LEVEL-CARE | LTSS Level Care | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4143 | ELG183 | ELG.013.183 | LTSS-PROV-NUM | LTSS Provider Num | Mandatory | A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual. | Value must be 30 characters or less | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4144 | ELG183 | ELG.013.183 | LTSS-PROV-NUM | LTSS Provider Num | Not Applicable | Not Applicable | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C1 | 4145 | ELG183 | ELG.013.183 | LTSS-PROV-NUM | LTSS Provider Num | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4146 | ELG183 | ELG.013.183 | LTSS-PROV-NUM | LTSS Provider Num | Not Applicable | Not Applicable | Value must match Provider Identifier (PRV.005.081) | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4147 | ELG184 | ELG.013.184 | LTSS-ELIGIBILITY-EFF-DATE | LTSS Eligibility Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4148 | ELG184 | ELG.013.184 | LTSS-ELIGIBILITY-EFF-DATE | LTSS Eligibility Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4149 | ELG184 | ELG.013.184 | LTSS-ELIGIBILITY-EFF-DATE | LTSS Eligibility Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C1 | 4150 | ELG184 | ELG.013.184 | LTSS-ELIGIBILITY-EFF-DATE | LTSS Eligibility Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4151 | ELG184 | ELG.013.184 | LTSS-ELIGIBILITY-EFF-DATE | LTSS Eligibility Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4152 | ELG185 | ELG.013.185 | LTSS-ELIGIBILITY-END-DATE | LTSS Eligibility End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4153 | ELG185 | ELG.013.185 | LTSS-ELIGIBILITY-END-DATE | LTSS Eligibility End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4154 | ELG185 | ELG.013.185 | LTSS-ELIGIBILITY-END-DATE | LTSS Eligibility End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4155 | ELG185 | ELG.013.185 | LTSS-ELIGIBILITY-END-DATE | LTSS Eligibility End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4156 | ELG185 | ELG.013.185 | LTSS-ELIGIBILITY-END-DATE | LTSS Eligibility End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| A2 | 4157 | ELG186 | ELG.013.186 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4158 | ELG186 | ELG.013.186 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| X1 | 4159 | ELG186 | ELG.013.186 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| D1 | 4160 | ELG187 | ELG.013.187 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | LTSS-PARTICIPATION-ELG00013 |
| C2 | 4161 | ELG188 | ELG.014.188 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4162 | ELG188 | ELG.014.188 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00014" | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4163 | ELG189 | ELG.014.189 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4164 | ELG189 | ELG.014.189 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4165 | ELG189 | ELG.014.189 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4166 | ELG189 | ELG.014.189 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4167 | ELG190 | ELG.014.190 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4168 | ELG190 | ELG.014.190 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4169 | ELG190 | ELG.014.190 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4170 | ELG190 | ELG.014.190 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4171 | ELG191 | ELG.014.191 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4172 | ELG191 | ELG.014.191 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4173 | ELG191 | ELG.014.191 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4174 | ELG191 | ELG.014.191 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4175 | ELG192 | ELG.014.192 | MANAGED-CARE-PLAN-ID | Managed Care Plan ID | Mandatory | The managed care plan identification number under which the eligible individual is enrolled. _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible _x000D_ File". _x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47565_x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management _x000D_ Reporting"._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/52896 |
Value must not contain a pipe or asterisk symbol | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4176 | ELG192 | ELG.014.192 | MANAGED-CARE-PLAN-ID | Managed Care Plan ID | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4177 | ELG192 | ELG.014.192 | MANAGED-CARE-PLAN-ID | Managed Care Plan ID | Not Applicable | Not Applicable | Value reported must match the value reported on State Plan Identification Number (MCR.002.019) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C1 | 4178 | ELG192 | ELG.014.192 | MANAGED-CARE-PLAN-ID | Managed Care Plan ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4179 | ELG193 | ELG.014.193 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Mandatory | A model of health care delivery organized to provide a defined set of services._x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File"_x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47540_x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File"_x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47564 |
Value must be in Managed Care Plan Type List (VVL) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4180 | ELG193 | ELG.014.193 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C1 | 4181 | ELG193 | ELG.014.193 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4182 | ELG193 | ELG.014.193 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Not Applicable | Not Applicable | Value must not be populated when Managed Care Plan ID (ELG.014.192) is not populated | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4183 | ELG193 | ELG.014.193 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Not Applicable | Not Applicable | Value must equal the Managed Care Plan Type (MCR.002.024) associated with the State Plan Identification Number (MCR.002.018) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| D1 | 4184 | ELG194 | ELG.014.194 | NATIONAL-HEALTH-CARE-ENTITY-ID | National Health Care Entity ID | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| D1 | 4185 | ELG195 | ELG.014.195 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | National Health Care Entity ID Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4186 | ELG196 | ELG.014.196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Managed Care Plan Enrollment Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4187 | ELG196 | ELG.014.196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Managed Care Plan Enrollment Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4188 | ELG196 | ELG.014.196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Managed Care Plan Enrollment Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C1 | 4189 | ELG196 | ELG.014.196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Managed Care Plan Enrollment Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4190 | ELG196 | ELG.014.196 | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | Managed Care Plan Enrollment Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4191 | ELG197 | ELG.014.197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Managed Care Plan Enrollment End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4192 | ELG197 | ELG.014.197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Managed Care Plan Enrollment End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4193 | ELG197 | ELG.014.197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Managed Care Plan Enrollment End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4194 | ELG197 | ELG.014.197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Managed Care Plan Enrollment End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4195 | ELG197 | ELG.014.197 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | Managed Care Plan Enrollment End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| A2 | 4196 | ELG198 | ELG.014.198 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4197 | ELG198 | ELG.014.198 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| X1 | 4198 | ELG198 | ELG.014.198 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| D1 | 4199 | ELG199 | ELG.014.199 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 |
| C2 | 4200 | ELG200 | ELG.015.200 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4201 | ELG200 | ELG.015.200 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00015" | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| X1 | 4202 | ELG201 | ELG.015.201 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4203 | ELG201 | ELG.015.201 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| X1 | 4204 | ELG201 | ELG.015.201 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4205 | ELG201 | ELG.015.201 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4206 | ELG202 | ELG.015.202 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4207 | ELG202 | ELG.015.202 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4208 | ELG202 | ELG.015.202 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| X1 | 4209 | ELG202 | ELG.015.202 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4210 | ELG203 | ELG.015.203 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4211 | ELG203 | ELG.015.203 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4212 | ELG203 | ELG.015.203 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4213 | ELG203 | ELG.015.203 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| X1 | 4214 | ELG204 | ELG.015.204 | ETHNICITY-CODE | Ethnicity Code | Mandatory | A code indicating that the individual's ethnicity is Hispanic, Latino/a, or Spanish ethnicity of a Medicaid/CHIP enrolled individual.._x000D_ _x000D_ Ethnicity Code clarifications:_x000D_ If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified."_x000D_ _x000D_ NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. |
Value must be in Ethnicity Code List (VVL) | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4215 | ELG204 | ELG.015.204 | ETHNICITY-CODE | Ethnicity Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C1 | 4216 | ELG204 | ELG.015.204 | ETHNICITY-CODE | Ethnicity Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4217 | ELG205 | ELG.015.205 | ETHNICITY-DECLARATION-EFF-DATE | Ethnicity Declaration Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4218 | ELG205 | ELG.015.205 | ETHNICITY-DECLARATION-EFF-DATE | Ethnicity Declaration Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4219 | ELG205 | ELG.015.205 | ETHNICITY-DECLARATION-EFF-DATE | Ethnicity Declaration Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C1 | 4220 | ELG205 | ELG.015.205 | ETHNICITY-DECLARATION-EFF-DATE | Ethnicity Declaration Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4221 | ELG205 | ELG.015.205 | ETHNICITY-DECLARATION-EFF-DATE | Ethnicity Declaration Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4222 | ELG206 | ELG.015.206 | ETHNICITY-DECLARATION-END-DATE | Ethnicity Declaration End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4223 | ELG206 | ELG.015.206 | ETHNICITY-DECLARATION-END-DATE | Ethnicity Declaration End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| X1 | 4224 | ELG206 | ELG.015.206 | ETHNICITY-DECLARATION-END-DATE | Ethnicity Declaration End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C1 | 4225 | ELG206 | ELG.015.206 | ETHNICITY-DECLARATION-END-DATE | Ethnicity Declaration End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4226 | ELG206 | ELG.015.206 | ETHNICITY-DECLARATION-END-DATE | Ethnicity Declaration End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| A2 | 4227 | ELG207 | ELG.015.207 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4228 | ELG207 | ELG.015.207 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| X1 | 4229 | ELG207 | ELG.015.207 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| D1 | 4230 | ELG208 | ELG.015.208 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 |
| C2 | 4231 | ELG209 | ELG.016.209 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4232 | ELG209 | ELG.016.209 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00016" | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4233 | ELG210 | ELG.016.210 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4234 | ELG210 | ELG.016.210 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4235 | ELG210 | ELG.016.210 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4236 | ELG210 | ELG.016.210 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4237 | ELG211 | ELG.016.211 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4238 | ELG211 | ELG.016.211 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4239 | ELG211 | ELG.016.211 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4240 | ELG211 | ELG.016.211 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4241 | ELG212 | ELG.016.212 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4242 | ELG212 | ELG.016.212 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4243 | ELG212 | ELG.016.212 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4244 | ELG212 | ELG.016.212 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4245 | ELG213 | ELG.016.213 | RACE | Race | Mandatory | A code indicating the individual's race either in accordance with requirements of Section 4302 of the Affordable Care Act classifications _x000D_ _x000D_ Race Code clarifications:_x000D_ If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown." _x000D_ If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," _x000D_ "Unspecified" or "Unknown." _x000D_ _x000D_ NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese)._x000D_ _x000D_ NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question. |
Value must be in Race List (VVL) | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4246 | ELG213 | ELG.016.213 | RACE | Race | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C1 | 4247 | ELG213 | ELG.016.213 | RACE | Race | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4248 | ELG214 | ELG.016.214 | RACE-OTHER | Race Other | Conditional | A freeform field to document the race of the beneficiary when the beneficiary identifies themselves as Other Asian, Other Pacific Islander (race codes 010 or 015). | If associated Race (ELG.016.213) value is in [ "010", "015" ], then value must be populated. | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4249 | ELG214 | ELG.016.214 | RACE-OTHER | Race Other | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4250 | ELG214 | ELG.016.214 | RACE-OTHER | Race Other | Not Applicable | Not Applicable | Value must be 25 characters or less | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4251 | ELG214 | ELG.016.214 | RACE-OTHER | Race Other | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4252 | ELG215 | ELG.016.215 | AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR | American Indian Alaskan Native Indicator | Conditional | "American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual:_x000D_ a. Is a member of a Federally-recognized Indian tribe;_x000D_ b. Resides in an urban center and meets one or more of the following four criteria:_x000D_ i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member;_x000D_ ii. Is an Eskimo or Aleut or other Alaska Native;_x000D_ iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or_x000D_ iv. Is determined to be an Indian under regulations promulgated by the `Secretary of Health and Human Services;_x000D_ c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or _x000D_ d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native._x000D_ _x000D_ NOTE_x000D_ Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native._x000D_ Are you a member of a federally recognized tribe?_x000D_ Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
Value must be in American Indian Alaskan Native Indicator List (VVL) | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4253 | ELG215 | ELG.016.215 | AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR | American Indian Alaskan Native Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4254 | ELG215 | ELG.016.215 | AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR | American Indian Alaskan Native Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4255 | ELG216 | ELG.016.216 | RACE-DECLARATION-EFF-DATE | Race Declaration Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4256 | ELG216 | ELG.016.216 | RACE-DECLARATION-EFF-DATE | Race Declaration Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4257 | ELG216 | ELG.016.216 | RACE-DECLARATION-EFF-DATE | Race Declaration Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C1 | 4258 | ELG216 | ELG.016.216 | RACE-DECLARATION-EFF-DATE | Race Declaration Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4259 | ELG216 | ELG.016.216 | RACE-DECLARATION-EFF-DATE | Race Declaration Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4260 | ELG217 | ELG.016.217 | RACE-DECLARATION-END-DATE | Race Declaration End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4261 | ELG217 | ELG.016.217 | RACE-DECLARATION-END-DATE | Race Declaration End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4262 | ELG217 | ELG.016.217 | RACE-DECLARATION-END-DATE | Race Declaration End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C1 | 4263 | ELG217 | ELG.016.217 | RACE-DECLARATION-END-DATE | Race Declaration End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4264 | ELG217 | ELG.016.217 | RACE-DECLARATION-END-DATE | Race Declaration End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| A2 | 4265 | ELG218 | ELG.016.218 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4266 | ELG218 | ELG.016.218 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| X1 | 4267 | ELG218 | ELG.016.218 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| D1 | 4268 | ELG219 | ELG.016.219 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | RACE-INFORMATION-ELG00016 |
| C2 | 4269 | ELG220 | ELG.017.220 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4270 | ELG220 | ELG.017.220 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00017" | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4271 | ELG221 | ELG.017.221 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4272 | ELG221 | ELG.017.221 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| X1 | 4273 | ELG221 | ELG.017.221 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4274 | ELG221 | ELG.017.221 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4275 | ELG222 | ELG.017.222 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4276 | ELG222 | ELG.017.222 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4277 | ELG222 | ELG.017.222 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| X1 | 4278 | ELG222 | ELG.017.222 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4279 | ELG223 | ELG.017.223 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4280 | ELG223 | ELG.017.223 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4281 | ELG223 | ELG.017.223 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4282 | ELG223 | ELG.017.223 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| D1 | 4283 | ELG224 | ELG.017.224 | DISABILITY-TYPE-CODE | Disability Type Code | Conditional | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4284 | ELG224 | ELG.017.224 | DISABILITY-TYPE-CODE | Disability Type Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| X1 | 4285 | ELG224 | ELG.017.224 | DISABILITY-TYPE-CODE | Disability Type Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4286 | ELG225 | ELG.017.225 | DISABILITY-TYPE-EFF-DATE | Disability Type Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4287 | ELG225 | ELG.017.225 | DISABILITY-TYPE-EFF-DATE | Disability Type Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4288 | ELG225 | ELG.017.225 | DISABILITY-TYPE-EFF-DATE | Disability Type Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| X1 | 4289 | ELG225 | ELG.017.225 | DISABILITY-TYPE-EFF-DATE | Disability Type Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4290 | ELG225 | ELG.017.225 | DISABILITY-TYPE-EFF-DATE | Disability Type Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4291 | ELG226 | ELG.017.226 | DISABILITY-TYPE-END-DATE | Disability Type End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4292 | ELG226 | ELG.017.226 | DISABILITY-TYPE-END-DATE | Disability Type End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4293 | ELG226 | ELG.017.226 | DISABILITY-TYPE-END-DATE | Disability Type End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| X1 | 4294 | ELG226 | ELG.017.226 | DISABILITY-TYPE-END-DATE | Disability Type End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4295 | ELG226 | ELG.017.226 | DISABILITY-TYPE-END-DATE | Disability Type End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| A2 | 4296 | ELG227 | ELG.017.227 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4297 | ELG227 | ELG.017.227 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| X1 | 4298 | ELG227 | ELG.017.227 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| D1 | 4299 | ELG228 | ELG.017.228 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | DISABILITY-INFORMATION-ELG00017 |
| C2 | 4300 | ELG229 | ELG.018.229 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4301 | ELG229 | ELG.018.229 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00018" | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4302 | ELG230 | ELG.018.230 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4303 | ELG230 | ELG.018.230 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4304 | ELG230 | ELG.018.230 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4305 | ELG230 | ELG.018.230 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4306 | ELG231 | ELG.018.231 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4307 | ELG231 | ELG.018.231 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4308 | ELG231 | ELG.018.231 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4309 | ELG231 | ELG.018.231 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4310 | ELG232 | ELG.018.232 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4311 | ELG232 | ELG.018.232 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4312 | ELG232 | ELG.018.232 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4313 | ELG232 | ELG.018.232 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4314 | ELG233 | ELG.018.233 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | Indicates that the individual participates in an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | Value must be in 1115A Demonstration Indicator List (VVL) | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4315 | ELG233 | ELG.018.233 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4316 | ELG233 | ELG.018.233 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4317 | ELG234 | ELG.018.234 | 1115A-EFF-DATE | 1115A Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4318 | ELG234 | ELG.018.234 | 1115A-EFF-DATE | 1115A Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4319 | ELG234 | ELG.018.234 | 1115A-EFF-DATE | 1115A Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C1 | 4320 | ELG234 | ELG.018.234 | 1115A-EFF-DATE | 1115A Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4321 | ELG234 | ELG.018.234 | 1115A-EFF-DATE | 1115A Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4322 | ELG235 | ELG.018.235 | 1115A-END-DATE | 1115A End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4323 | ELG235 | ELG.018.235 | 1115A-END-DATE | 1115A End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4324 | ELG235 | ELG.018.235 | 1115A-END-DATE | 1115A End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4325 | ELG235 | ELG.018.235 | 1115A-END-DATE | 1115A End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4326 | ELG235 | ELG.018.235 | 1115A-END-DATE | 1115A End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| A2 | 4327 | ELG236 | ELG.018.236 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4328 | ELG236 | ELG.018.236 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| X1 | 4329 | ELG236 | ELG.018.236 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| D1 | 4330 | ELG237 | ELG.018.237 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 |
| C2 | 4331 | ELG238 | ELG.020.238 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4332 | ELG238 | ELG.020.238 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00020" | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4333 | ELG239 | ELG.020.239 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4334 | ELG239 | ELG.020.239 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4335 | ELG239 | ELG.020.239 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4336 | ELG239 | ELG.020.239 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4337 | ELG240 | ELG.020.240 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4338 | ELG240 | ELG.020.240 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4339 | ELG240 | ELG.020.240 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4340 | ELG240 | ELG.020.240 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4341 | ELG241 | ELG.020.241 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4342 | ELG241 | ELG.020.241 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4343 | ELG241 | ELG.020.241 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4344 | ELG241 | ELG.020.241 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4345 | ELG242 | ELG.020.242 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | HCBS Chronic Condition Non Health Home Code | Mandatory | The chronic condition for which the eligible person is receiving non-Health-Home home and community based care. | Value must be in HCBS Chronic Condition Non Health Home Code List (VVL) | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4346 | ELG242 | ELG.020.242 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | HCBS Chronic Condition Non Health Home Code | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C1 | 4347 | ELG242 | ELG.020.242 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | HCBS Chronic Condition Non Health Home Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4348 | ELG243 | ELG.020.243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | HCBS Chronic Condition Non Health Home Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4349 | ELG243 | ELG.020.243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | HCBS Chronic Condition Non Health Home Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4350 | ELG243 | ELG.020.243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | HCBS Chronic Condition Non Health Home Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C1 | 4351 | ELG243 | ELG.020.243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | HCBS Chronic Condition Non Health Home Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4352 | ELG243 | ELG.020.243 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | HCBS Chronic Condition Non Health Home Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4353 | ELG244 | ELG.020.244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | HCBS Chronic Condition Non Health Home End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4354 | ELG244 | ELG.020.244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | HCBS Chronic Condition Non Health Home End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4355 | ELG244 | ELG.020.244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | HCBS Chronic Condition Non Health Home End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| X1 | 4356 | ELG244 | ELG.020.244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | HCBS Chronic Condition Non Health Home End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4357 | ELG244 | ELG.020.244 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | HCBS Chronic Condition Non Health Home End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| A2 | 4358 | ELG245 | ELG.020.245 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4359 | ELG245 | ELG.020.245 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4360 | ELG245 | ELG.020.245 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| D1 | 4361 | ELG246 | ELG.020.246 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 |
| C2 | 4362 | ELG248 | ELG.021.248 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4363 | ELG248 | ELG.021.248 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00021" | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4364 | ELG249 | ELG.021.249 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4365 | ELG249 | ELG.021.249 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4366 | ELG249 | ELG.021.249 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4367 | ELG249 | ELG.021.249 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4368 | ELG250 | ELG.021.250 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4369 | ELG250 | ELG.021.250 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4370 | ELG250 | ELG.021.250 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4371 | ELG250 | ELG.021.250 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4372 | ELG251 | ELG.021.251 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4373 | ELG251 | ELG.021.251 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4374 | ELG251 | ELG.021.251 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4375 | ELG251 | ELG.021.251 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4376 | ELG252 | ELG.021.252 | ENROLLMENT-TYPE | Enrollment Type | Mandatory | Identify the type of enrollment that the eligible person has been enrolled into as either Medicaid/Medicaid Expansion CHIP or Separate CHIP. | Value must be in Enrollment Type List (VVL) | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4377 | ELG252 | ELG.021.252 | ENROLLMENT-TYPE | Enrollment Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4378 | ELG252 | ELG.021.252 | ENROLLMENT-TYPE | Enrollment Type | Not Applicable | Not Applicable | If value equals 1, then associated CHIP Code (ELG.003.054) value must be in [1, 2] | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4379 | ELG252 | ELG.021.252 | ENROLLMENT-TYPE | Enrollment Type | Not Applicable | Not Applicable | If value equals 2, then associated CHIP Code (ELG.003.054) value must be "3" | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4380 | ELG252 | ELG.021.252 | ENROLLMENT-TYPE | Enrollment Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4381 | ELG253 | ELG.021.253 | ENROLLMENT-EFF-DATE | Enrollment Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4382 | ELG253 | ELG.021.253 | ENROLLMENT-EFF-DATE | Enrollment Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4383 | ELG253 | ELG.021.253 | ENROLLMENT-EFF-DATE | Enrollment Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4384 | ELG253 | ELG.021.253 | ENROLLMENT-EFF-DATE | Enrollment Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4385 | ELG253 | ELG.021.253 | ENROLLMENT-EFF-DATE | Enrollment Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4386 | ELG254 | ELG.021.254 | ENROLLMENT-END-DATE | Enrollment End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4387 | ELG254 | ELG.021.254 | ENROLLMENT-END-DATE | Enrollment End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4388 | ELG254 | ELG.021.254 | ENROLLMENT-END-DATE | Enrollment End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4389 | ELG254 | ELG.021.254 | ENROLLMENT-END-DATE | Enrollment End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4390 | ELG254 | ELG.021.254 | ENROLLMENT-END-DATE | Enrollment End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A2 | 4391 | ELG255 | ELG.021.255 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| C2 | 4392 | ELG255 | ELG.021.255 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| X1 | 4393 | ELG255 | ELG.021.255 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ENROLLMENT-TIME-SPAN-ELG00021 |
| A1 | 4394 | ELG257 | ELG.022.257 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4395 | ELG257 | ELG.022.257 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "ELG00022" | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4396 | ELG258 | ELG.022.258 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4397 | ELG258 | ELG.022.258 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4398 | ELG258 | ELG.022.258 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4399 | ELG258 | ELG.022.258 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (ELG.001.007) | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4400 | ELG259 | ELG.022.259 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4401 | ELG259 | ELG.022.259 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4402 | ELG259 | ELG.022.259 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4403 | ELG259 | ELG.022.259 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4404 | ELG260 | ELG.022.260 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4405 | ELG260 | ELG.022.260 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4406 | ELG260 | ELG.022.260 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4407 | ELG260 | ELG.022.260 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4408 | ELG261 | ELG.022.261 | ELG-IDENTIFIER-TYPE | Eligible Identifier Type | Mandatory | A code to identify the kind of eligible identifier that is captured in the Eligible Identifier data element. | Value must be in Eligible Identifier Type List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4409 | ELG261 | ELG.022.261 | ELG-IDENTIFIER-TYPE | Eligible Identifier Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4410 | ELG261 | ELG.022.261 | ELG-IDENTIFIER-TYPE | Eligible Identifier Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4411 | ELG262 | ELG.022.262 | ELG-IDENTIFIER-ISSUING-ENTITY-ID | Eligible Identifier Issuing Entity Identifier | Optional | This data element is reserved for future use. | Value must be 18 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4412 | ELG262 | ELG.022.262 | ELG-IDENTIFIER-ISSUING-ENTITY-ID | Eligible Identifier Issuing Entity Identifier | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4413 | ELG263 | ELG.022.263 | ELG-IDENTIFIER-EFF-DATE | Eligible Identifier Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4414 | ELG263 | ELG.022.263 | ELG-IDENTIFIER-EFF-DATE | Eligible Identifier Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4415 | ELG263 | ELG.022.263 | ELG-IDENTIFIER-EFF-DATE | Eligible Identifier Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4416 | ELG263 | ELG.022.263 | ELG-IDENTIFIER-EFF-DATE | Eligible Identifier Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4417 | ELG263 | ELG.022.263 | ELG-IDENTIFIER-EFF-DATE | Eligible Identifier Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4418 | ELG264 | ELG.022.264 | ELG-IDENTIFIER-END-DATE | Eligible Identifier End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4419 | ELG264 | ELG.022.264 | ELG-IDENTIFIER-END-DATE | Eligible Identifier End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4420 | ELG264 | ELG.022.264 | ELG-IDENTIFIER-END-DATE | Eligible Identifier End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4421 | ELG264 | ELG.022.264 | ELG-IDENTIFIER-END-DATE | Eligible Identifier End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4422 | ELG264 | ELG.022.264 | ELG-IDENTIFIER-END-DATE | Eligible Identifier End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4423 | ELG265 | ELG.022.265 | ELG-IDENTIFIER | Eligible Identifier | Mandatory | A data element to capture the various identifiers assigned to Medicaid and CHIP beneficiary by various entities. The specific type of identifier is shown in the corresponding value in the Eligible Identifier Type data element. States should provide all Old MSIS Identification Number with _x000D_ Eligible Identifier Type = 2 to T-MSIS in case the state changes the MSIS Identification Number of a beneficiary. The state should submit updates to T-MSIS whenever an identifier is retired or issued. _x000D_ _x000D_ States should provide Old MSIS Identification Number with Reason for Change = 'MERGE' to T-MSIS if the state was reporting multiple MSIS Identification Numbers for a single beneficiary and merges them under a single MSIS Identification Number. _x000D_ _x000D_ States should provide Old MSIS Identification Number with Reason for Change = 'UNMERGE' to T-MSIS if the state unmerges a beneficiary from another beneficiary. For example, if a newborn child is originally reported with the mother's MSIS Identification Number and is then _x000D_ assigned a different MSIS Identification Number. _x000D_ _x000D_ States should provide Old MSIS Identification Number with Reason for Change = 'LSE' to T-MSIS if the state assigns a new MSIS Identification Number to any beneficiaries during large system enhancement in state MMIS._x000D_ _x000D_ States should provide Old MSIS Identification Number with Reason for Change = 'TCAM' to T-MSIS if the Medicaid and Separate CHIP programs use different MSIS Identifier Number schemas and beneficiaries are transferred from CHIP to Medicaid or from Medicaid to CHIP and a _x000D_ new MSIS Identification Number is issued. |
Value must be 20 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4424 | ELG265 | ELG.022.265 | ELG-IDENTIFIER | Eligible Identifier | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4425 | ELG265 | ELG.022.265 | ELG-IDENTIFIER | Eligible Identifier | Not Applicable | Not Applicable | Must not contain a pipe symbol | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4426 | ELG266 | ELG.022.266 | REASON-FOR-CHANGE | Reason for Change | Conditional | A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for ELG-IDENTIFIER-TYPE '2-Old MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID' or _x000D_ 'Unmerge'. |
Value must be in Reason for Change List (VVL) | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4427 | ELG266 | ELG.022.266 | REASON-FOR-CHANGE | Reason for Change | Not Applicable | Not Applicable | Value must be 10 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4428 | ELG266 | ELG.022.266 | REASON-FOR-CHANGE | Reason for Change | Not Applicable | Not Applicable | Conditional | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4429 | ELG266 | ELG.022.266 | REASON-FOR-CHANGE | Reason for Change | Not Applicable | Not Applicable | (Old MSIS Identification Number) value must be populated when Eligible Identifier Type (ELG.022.261) equals '2' | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A2 | 4430 | ELG267 | ELG.022.267 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4431 | ELG267 | ELG.022.267 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| A1 | 4432 | ELG267 | ELG.022.267 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | ELIGIBLE | ELIGIBLE-IDENTIFIER-ELG00022 |
| C2 | 4433 | MCR001 | MCR.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4434 | MCR001 | MCR.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00001" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4435 | MCR002 | MCR.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4436 | MCR002 | MCR.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4437 | MCR002 | MCR.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4438 | MCR003 | MCR.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4439 | MCR003 | MCR.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4440 | MCR003 | MCR.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4441 | MCR004 | MCR.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4442 | MCR004 | MCR.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4443 | MCR004 | MCR.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4444 | MCR005 | MCR.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4445 | MCR005 | MCR.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4446 | MCR006 | MCR.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'MNGDCARE' | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4447 | MCR007 | MCR.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4448 | MCR007 | MCR.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4449 | MCR007 | MCR.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4450 | MCR007 | MCR.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same for all records | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4451 | MCR008 | MCR.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4452 | MCR008 | MCR.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4453 | MCR008 | MCR.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4454 | MCR008 | MCR.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4455 | MCR008 | MCR.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4456 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4457 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4458 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4459 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4460 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4461 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4462 | MCR009 | MCR.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4463 | MCR010 | MCR.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4464 | MCR010 | MCR.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4465 | MCR010 | MCR.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4466 | MCR010 | MCR.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4467 | MCR010 | MCR.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4468 | MCR010 | MCR.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4469 | MCR011 | MCR.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4470 | MCR011 | MCR.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4471 | MCR011 | MCR.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4472 | MCR013 | MCR.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4473 | MCR013 | MCR.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4474 | MCR013 | MCR.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4475 | MCR013 | MCR.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4476 | MCR013 | MCR.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4477 | MCR014 | MCR.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4478 | MCR014 | MCR.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4479 | MCR014 | MCR.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4480 | MCR112 | MCR.001.112 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, _x000D_ replacement files). This should begin with 1 for the original Create submission type and be incremented by one for _x000D_ each Replacement or Update submission for the same reporting period and file type (subject area). |
Value must between 1 and 9999 | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4481 | MCR112 | MCR.001.112 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4482 | MCR112 | MCR.001.112 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| A2 | 4483 | MCR112 | MCR.001.112 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| X1 | 4484 | MCR112 | MCR.001.112 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 |
| C2 | 4485 | MCR016 | MCR.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4486 | MCR016 | MCR.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00002" | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4487 | MCR017 | MCR.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4488 | MCR017 | MCR.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4489 | MCR017 | MCR.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4490 | MCR017 | MCR.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (MCR.001.007) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4491 | MCR018 | MCR.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4492 | MCR018 | MCR.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4493 | MCR018 | MCR.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4494 | MCR018 | MCR.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4495 | MCR019 | MCR.002.019 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | Value must be 12 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4496 | MCR019 | MCR.002.019 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4497 | MCR019 | MCR.002.019 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4498 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4499 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Mandatory | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4500 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4501 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4502 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4503 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4504 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Not Applicable | Not Applicable | Value must occur before Managed Care Contract End Date (MCR.002.021) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4505 | MCR021 | MCR.002.021 | MANAGED-CARE-CONTRACT-END-DATE | Managed Care Contract End Date | Mandatory | The expiration date of the managed care contract period with the state. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4506 | MCR021 | MCR.002.021 | MANAGED-CARE-CONTRACT-END-DATE | Managed Care Contract End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4507 | MCR021 | MCR.002.021 | MANAGED-CARE-CONTRACT-END-DATE | Managed Care Contract End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4508 | MCR022 | MCR.002.022 | MANAGED-CARE-NAME | Managed Care Name | Mandatory | The name of the managed care entity under contract with the State Medicaid Agency. The name _x000D_ should be as it appears on the contract. |
Value must not contain a pipe or asterisk symbol | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4509 | MCR022 | MCR.002.022 | MANAGED-CARE-NAME | Managed Care Name | Not Applicable | Not Applicable | Value must be 55 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4510 | MCR022 | MCR.002.022 | MANAGED-CARE-NAME | Managed Care Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4511 | MCR023 | MCR.002.023 | MANAGED-CARE-PROGRAM | Managed Care Program | Mandatory | The state program through which a managed care plan is approved to operate. | Value must be in Managed Care Program List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4512 | MCR023 | MCR.002.023 | MANAGED-CARE-PROGRAM | Managed Care Program | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4513 | MCR023 | MCR.002.023 | MANAGED-CARE-PROGRAM | Managed Care Program | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4514 | MCR024 | MCR.002.024 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Mandatory | The type of managed care plan that corresponds to the State Plan Identification Number. The value reported in this data element should match the Managed Care Plan Type value reported on the Eligible file for the corresponding managed care plan number._x000D_ Assign plan type value "15" for plans that primarily cover non-emergency medical transportation (NEMT)._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File"_x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47540 _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting MANAGED-CARE-PLAN-TYPE in the T-MSIS Managed Care File" _x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47564 |
Value must be in Managed Care Plan Type List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4515 | MCR024 | MCR.002.024 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4516 | MCR024 | MCR.002.024 | MANAGED-CARE-PLAN-TYPE | Managed Care Plan Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4517 | MCR025 | MCR.002.025 | REIMBURSEMENT-ARRANGEMENT | Reimbursement Arrangement | Mandatory | A code indicating the how the managed care entity is reimbursed. | Value must be in Reimbursement Arrangement List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4518 | MCR025 | MCR.002.025 | REIMBURSEMENT-ARRANGEMENT | Reimbursement Arrangement | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4519 | MCR025 | MCR.002.025 | REIMBURSEMENT-ARRANGEMENT | Reimbursement Arrangement | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4520 | MCR026 | MCR.002.026 | MANAGED-CARE-PROFIT-STATUS | Managed Care Profit Status | Mandatory | A code denoting the profit status of managed care entity. | Value must be in Managed Care Profit Status List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4521 | MCR026 | MCR.002.026 | MANAGED-CARE-PROFIT-STATUS | Managed Care Profit Status | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4522 | MCR026 | MCR.002.026 | MANAGED-CARE-PROFIT-STATUS | Managed Care Profit Status | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4523 | MCR027 | MCR.002.027 | CORE-BASED-STATISTICAL-AREA-CODE | Core Based Statistical Area Code | Mandatory | A code signifying whether the Managed Care Organization's (MCO) service area falls into one or more metropolitan or micropolitan statistical areas. Whenever a service area straddles two types of areas (e.g., metropolitan & micropolitan, metropolitan & non-CBSA area) classify the _x000D_ service area based on the denser classification. Metropolitan and micropolitan statistical areas (metro and micro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB). The term "Core Based Statistical Area" (CBSA) is a collective term for both _x000D_ metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties _x000D_ containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core._x000D_ The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the _x000D_ definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009. _x000D_ See the hyperlink below for further information._x000D_ http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf |
Value must be in Core Based Statistical Area Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4524 | MCR027 | MCR.002.027 | CORE-BASED-STATISTICAL-AREA-CODE | Core Based Statistical Area Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4525 | MCR027 | MCR.002.027 | CORE-BASED-STATISTICAL-AREA-CODE | Core Based Statistical Area Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4526 | MCR028 | MCR.002.028 | PERCENT-BUSINESS | Percent Business | Mandatory | The percentage of the managed care entity's total revenue that is derived from contracts with Medicare (Part C and D) in the state and State Medicaid agency contract(s) prior calendar year. Include Medicaid and Medicare in calculation of percentage of business in public programs for IRS health insurer tax exemption as required in ACA. | Value must be between 0 and 100 inclusively | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4527 | MCR028 | MCR.002.028 | PERCENT-BUSINESS | Percent Business | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4528 | MCR029 | MCR.002.029 | MANAGED-CARE-SERVICE-AREA | Managed Care Service Area | Mandatory | Identifies the geographic unit under which the managed care entity is under contract to provide services. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name_x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File"_x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47542 |
Value must be in Managed Care Service Area List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4529 | MCR029 | MCR.002.029 | MANAGED-CARE-SERVICE-AREA | Managed Care Service Area | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4530 | MCR029 | MCR.002.029 | MANAGED-CARE-SERVICE-AREA | Managed Care Service Area | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4531 | MCR029 | MCR.002.029 | MANAGED-CARE-SERVICE-AREA | Managed Care Service Area | Not Applicable | Not Applicable | When value equals '2', the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4532 | MCR030 | MCR.002.030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Managed Care Main Record Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4533 | MCR030 | MCR.002.030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Managed Care Main Record Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4534 | MCR030 | MCR.002.030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Managed Care Main Record Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4535 | MCR030 | MCR.002.030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Managed Care Main Record Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4536 | MCR030 | MCR.002.030 | MANAGED-CARE-MAIN-REC-EFF-DATE | Managed Care Main Record Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4537 | MCR031 | MCR.002.031 | MANAGED-CARE-MAIN-REC-END-DATE | Managed Care Main Record End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4538 | MCR031 | MCR.002.031 | MANAGED-CARE-MAIN-REC-END-DATE | Managed Care Main Record End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4539 | MCR031 | MCR.002.031 | MANAGED-CARE-MAIN-REC-END-DATE | Managed Care Main Record End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4540 | MCR031 | MCR.002.031 | MANAGED-CARE-MAIN-REC-END-DATE | Managed Care Main Record End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4541 | MCR031 | MCR.002.031 | MANAGED-CARE-MAIN-REC-END-DATE | Managed Care Main Record End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| A2 | 4542 | MCR032 | MCR.002.032 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| C2 | 4543 | MCR032 | MCR.002.032 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4544 | MCR032 | MCR.002.032 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| D1 | 4545 | MCR033 | MCR.002.033 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | MANAGED-CARE-MAIN-MCR00002 |
| X1 | 4546 | MCR034 | MCR.003.034 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4547 | MCR034 | MCR.003.034 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00003" | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4548 | MCR035 | MCR.003.035 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4549 | MCR035 | MCR.003.035 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4550 | MCR035 | MCR.003.035 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4551 | MCR035 | MCR.003.035 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (MCR.001.007) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4552 | MCR036 | MCR.003.036 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4553 | MCR036 | MCR.003.036 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4554 | MCR036 | MCR.003.036 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4555 | MCR036 | MCR.003.036 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4556 | MCR037 | MCR.003.037 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | Value must be 12 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4557 | MCR037 | MCR.003.037 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4558 | MCR037 | MCR.003.037 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4559 | MCR038 | MCR.003.038 | MANAGED-CARE-LOCATION-ID | Managed Care Location ID | Mandatory | A field to differentiate a managed care entity's service locations through adding a sequential number in this data element identifier field. Use sequential numbers to indicate additional services locations. | Value must not contain a pipe symbol | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4560 | MCR038 | MCR.003.038 | MANAGED-CARE-LOCATION-ID | Managed Care Location ID | Not Applicable | Not Applicable | Each managed care entity's locations must have a unique identifier | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4561 | MCR038 | MCR.003.038 | MANAGED-CARE-LOCATION-ID | Managed Care Location ID | Not Applicable | Not Applicable | (Managed care entity's service location address) value must be populated if associated Managed Care Address Type (MCR.003.041) equals 3 | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4562 | MCR038 | MCR.003.038 | MANAGED-CARE-LOCATION-ID | Managed Care Location ID | Not Applicable | Not Applicable | Value must be 15 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4563 | MCR038 | MCR.003.038 | MANAGED-CARE-LOCATION-ID | Managed Care Location ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4564 | MCR039 | MCR.003.039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Managed Care Location and Contract Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4565 | MCR039 | MCR.003.039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Managed Care Location and Contract Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4566 | MCR039 | MCR.003.039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Managed Care Location and Contract Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4567 | MCR039 | MCR.003.039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Managed Care Location and Contract Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4568 | MCR039 | MCR.003.039 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | Managed Care Location and Contract Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4569 | MCR040 | MCR.003.040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Managed Care Location and Contract End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4570 | MCR040 | MCR.003.040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Managed Care Location and Contract End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4571 | MCR040 | MCR.003.040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Managed Care Location and Contract End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4572 | MCR040 | MCR.003.040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Managed Care Location and Contract End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4573 | MCR040 | MCR.003.040 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | Managed Care Location and Contract End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4574 | MCR041 | MCR.003.041 | MANAGED-CARE-ADDR-TYPE | Managed Care Address Type | Mandatory | The type of address for the managed care organization submitted in the record segment. | Value must be in Managed Care Address Type List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4575 | MCR041 | MCR.003.041 | MANAGED-CARE-ADDR-TYPE | Managed Care Address Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4576 | MCR041 | MCR.003.041 | MANAGED-CARE-ADDR-TYPE | Managed Care Address Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4577 | MCR042 | MCR.003.042 | MANAGED-CARE-ADDR-LN1 | Managed Care Address Line 1 | Mandatory | The managed care entity's address listed on the contract with the state. | Value must be 60 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4578 | MCR042 | MCR.003.042 | MANAGED-CARE-ADDR-LN1 | Managed Care Address Line 1 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 2 or Address Line 3 value(s) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4579 | MCR042 | MCR.003.042 | MANAGED-CARE-ADDR-LN1 | Managed Care Address Line 1 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4580 | MCR042 | MCR.003.042 | MANAGED-CARE-ADDR-LN1 | Managed Care Address Line 1 | Not Applicable | Not Applicable | When populated, the associated Address Type is required | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4581 | MCR042 | MCR.003.042 | MANAGED-CARE-ADDR-LN1 | Managed Care Address Line 1 | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4582 | MCR043 | MCR.003.043 | MANAGED-CARE-ADDR-LN2 | Managed Care Address Line 2 | Conditional | The managed care entity's address listed on the contract with the state. | Value must be 60 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4583 | MCR043 | MCR.003.043 | MANAGED-CARE-ADDR-LN2 | Managed Care Address Line 2 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 3 value(s) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4584 | MCR043 | MCR.003.043 | MANAGED-CARE-ADDR-LN2 | Managed Care Address Line 2 | Not Applicable | Not Applicable | There must be an Address Line 1 in order to have an Address Line 2 | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4585 | MCR043 | MCR.003.043 | MANAGED-CARE-ADDR-LN2 | Managed Care Address Line 2 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4586 | MCR043 | MCR.003.043 | MANAGED-CARE-ADDR-LN2 | Managed Care Address Line 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4587 | MCR044 | MCR.003.044 | MANAGED-CARE-ADDR-LN3 | Managed Care Address Line 3 | Conditional | The managed care entity's address listed on the contract with the state. | Value must be 60 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4588 | MCR044 | MCR.003.044 | MANAGED-CARE-ADDR-LN3 | Managed Care Address Line 3 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 2 value(s) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4589 | MCR044 | MCR.003.044 | MANAGED-CARE-ADDR-LN3 | Managed Care Address Line 3 | Not Applicable | Not Applicable | If Address Line 2 is not populated, then value should not be populated | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4590 | MCR044 | MCR.003.044 | MANAGED-CARE-ADDR-LN3 | Managed Care Address Line 3 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4591 | MCR044 | MCR.003.044 | MANAGED-CARE-ADDR-LN3 | Managed Care Address Line 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4592 | MCR045 | MCR.003.045 | MANAGED-CARE-CITY | Managed Care City | Mandatory | The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). | Value must be 28 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4593 | MCR045 | MCR.003.045 | MANAGED-CARE-CITY | Managed Care City | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4594 | MCR045 | MCR.003.045 | MANAGED-CARE-CITY | Managed Care City | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4595 | MCR046 | MCR.003.046 | MANAGED-CARE-STATE | Managed Care State | Mandatory | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the of the managed care entity's address as listed on the contract with the state. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4596 | MCR046 | MCR.003.046 | MANAGED-CARE-STATE | Managed Care State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4597 | MCR046 | MCR.003.046 | MANAGED-CARE-STATE | Managed Care State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4598 | MCR047 | MCR.003.047 | MANAGED-CARE-ZIP-CODE | Managed Care Zip Code | Mandatory | U.S. Zip Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) | Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4599 | MCR047 | MCR.003.047 | MANAGED-CARE-ZIP-CODE | Managed Care Zip Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4600 | MCR048 | MCR.003.048 | MANAGED-CARE-COUNTY | Managed Care County | Mandatory | The ANSI County numeric code for the county or county equivalent. One county code should be captured for each of a managed care entity's locations identified. | Value must be in US County Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4601 | MCR048 | MCR.003.048 | MANAGED-CARE-COUNTY | Managed Care County | Not Applicable | Not Applicable | Value must be 3 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4602 | MCR048 | MCR.003.048 | MANAGED-CARE-COUNTY | Managed Care County | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4603 | MCR049 | MCR.003.049 | MANAGED-CARE-TELEPHONE | Managed Care Phone Number | Optional | Phone number for a given entity (e.g. person, organization, agency). | Value must be 10 characters, digits (0-9) only | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4604 | MCR049 | MCR.003.049 | MANAGED-CARE-TELEPHONE | Managed Care Phone Number | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4605 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Optional | The email address of the managed care entity listed on the contract with the state. | Must contain the '@' symbol | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4606 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Not Applicable | Not Applicable | May contain uppercase and lowercase Latin letters A to Z and a to z | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4607 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Not Applicable | Not Applicable | May contain digits 0-9 | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4608 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Not Applicable | Not Applicable | Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4609 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Not Applicable | Not Applicable | Value must be 60 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4610 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4611 | MCR051 | MCR.003.051 | MANAGED-CARE-FAX-NUMBER | Managed Care Fax Number | Optional | A fax number, including area code, as listed on the contract with the state. | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| A2 | 4612 | MCR052 | MCR.003.052 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4613 | MCR052 | MCR.003.052 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| X1 | 4614 | MCR052 | MCR.003.052 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| D1 | 4615 | MCR053 | MCR.003.053 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 |
| C2 | 4616 | MCR054 | MCR.004.054 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4617 | MCR054 | MCR.004.054 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00004" | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4618 | MCR055 | MCR.004.055 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4619 | MCR055 | MCR.004.055 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4620 | MCR055 | MCR.004.055 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4621 | MCR055 | MCR.004.055 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (MCR.001.007) | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4622 | MCR056 | MCR.004.056 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4623 | MCR056 | MCR.004.056 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4624 | MCR056 | MCR.004.056 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4625 | MCR056 | MCR.004.056 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4626 | MCR057 | MCR.004.057 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | Value must be 12 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4627 | MCR057 | MCR.004.057 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4628 | MCR057 | MCR.004.057 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4629 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Conditional | The specific identifiers for the counties, cities, regions, zip codes and/or other geographic areas that the managed care entity serves._x000D_ _x000D_ Put each zip code, city, county, region, or other area descriptor on a separate record._x000D_ Use 5 digit zip codes when service area definition is zip code based._x000D_ Use ANSI codes when service area is defined by counties or cities_x000D_ The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name_x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File"._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47542 |
Value must be in Managed Care Service Area Name List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4630 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Not Applicable | Not Applicable | If associated Managed Care Service Area (MCR.002.029) is in [ 2, 3, 4, 5, 6 ], then value is mandatory and must be provided | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4631 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4632 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Not Applicable | Not Applicable | Value must be 30 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C1 | 4633 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4634 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Not Applicable | Not Applicable | If associated Managed Care Service Area (MCR.002.029) equals '5' (zip code), then value must be a 5-digit zip code | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4635 | MCR058 | MCR.004.058 | MANAGED-CARE-SERVICE-AREA-NAME | Managed Care Service Area Name | Not Applicable | Not Applicable | If associated Managed Care Service Area (MCR.002.029) equals '2' (county code), then value must be a 3-digit number | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4636 | MCR059 | MCR.004.059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Managed Care Service Area Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4637 | MCR059 | MCR.004.059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Managed Care Service Area Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4638 | MCR059 | MCR.004.059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Managed Care Service Area Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4639 | MCR059 | MCR.004.059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Managed Care Service Area Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4640 | MCR059 | MCR.004.059 | MANAGED-CARE-SERVICE-AREA-EFF-DATE | Managed Care Service Area Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4641 | MCR060 | MCR.004.060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Managed Care Service Area End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4642 | MCR060 | MCR.004.060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Managed Care Service Area End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4643 | MCR060 | MCR.004.060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Managed Care Service Area End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4644 | MCR060 | MCR.004.060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Managed Care Service Area End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4645 | MCR060 | MCR.004.060 | MANAGED-CARE-SERVICE-AREA-END-DATE | Managed Care Service Area End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| A2 | 4646 | MCR061 | MCR.004.061 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4647 | MCR061 | MCR.004.061 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| X1 | 4648 | MCR061 | MCR.004.061 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| D1 | 4649 | MCR062 | MCR.004.062 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 |
| C2 | 4650 | MCR063 | MCR.005.063 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4651 | MCR063 | MCR.005.063 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00005" | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4652 | MCR064 | MCR.005.064 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4653 | MCR064 | MCR.005.064 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4654 | MCR064 | MCR.005.064 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4655 | MCR064 | MCR.005.064 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (MCR.001.007) | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4656 | MCR065 | MCR.005.065 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4657 | MCR065 | MCR.005.065 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4658 | MCR065 | MCR.005.065 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4659 | MCR065 | MCR.005.065 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4660 | MCR066 | MCR.005.066 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | Value must be 12 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4661 | MCR066 | MCR.005.066 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4662 | MCR066 | MCR.005.066 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4663 | MCR067 | MCR.005.067 | OPERATING-AUTHORITY | Operating Authority | Mandatory | The type of operating authority through which the managed care entity receives its contract authority. The Managed Care Plan Type assigned to the manage care plan in the Managed Care Main segment should be consistent with the Operating Authority value reported. _x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" _x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47566 |
Value must be in Operating Authority List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4664 | MCR067 | MCR.005.067 | OPERATING-AUTHORITY | Operating Authority | Not Applicable | Not Applicable | Value must be 2 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4665 | MCR067 | MCR.005.067 | OPERATING-AUTHORITY | Operating Authority | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4666 | MCR068 | MCR.005.068 | WAIVER-ID | Waiver ID | Mandatory | Field specifying the ID of the waiver, demonstration or other authority which authorizes the state to operate the managed care program. These IDs must be the approved, full federal ID number assigned during the state submission and CMS approval process. | Value must be 20 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4667 | MCR068 | MCR.005.068 | WAIVER-ID | Waiver ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4668 | MCR069 | MCR.005.069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Managed Care Op Authority Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4669 | MCR069 | MCR.005.069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Managed Care Op Authority Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4670 | MCR069 | MCR.005.069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Managed Care Op Authority Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4671 | MCR069 | MCR.005.069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Managed Care Op Authority Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4672 | MCR069 | MCR.005.069 | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | Managed Care Op Authority Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4673 | MCR070 | MCR.005.070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Managed Care Op Authority End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4674 | MCR070 | MCR.005.070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Managed Care Op Authority End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4675 | MCR070 | MCR.005.070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Managed Care Op Authority End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4676 | MCR070 | MCR.005.070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Managed Care Op Authority End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4677 | MCR070 | MCR.005.070 | MANAGED-CARE-OP-AUTHORITY-END-DATE | Managed Care Op Authority End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| A2 | 4678 | MCR071 | MCR.005.071 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4679 | MCR071 | MCR.005.071 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| X1 | 4680 | MCR071 | MCR.005.071 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| D1 | 4681 | MCR072 | MCR.005.072 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 |
| C2 | 4682 | MCR073 | MCR.006.073 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4683 | MCR073 | MCR.006.073 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00006" | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4684 | MCR074 | MCR.006.074 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4685 | MCR074 | MCR.006.074 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4686 | MCR074 | MCR.006.074 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4687 | MCR074 | MCR.006.074 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (MCR.001.007) | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4688 | MCR075 | MCR.006.075 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4689 | MCR075 | MCR.006.075 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4690 | MCR075 | MCR.006.075 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4691 | MCR075 | MCR.006.075 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4692 | MCR076 | MCR.006.076 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | Value must be 12 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4693 | MCR076 | MCR.006.076 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4694 | MCR076 | MCR.006.076 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4695 | MCR077 | MCR.006.077 | MANAGED-CARE-PLAN-POP | Managed Care Plan Population | Mandatory | The eligibility group(s) the state is authorized to enroll in managed care plans by its operating authority. Submit a separate record segment for each eligibility group that can be enrolled in the managed care program in which the managed care plan is participating. | Value must be in Managed Care Plan Pop List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4696 | MCR077 | MCR.006.077 | MANAGED-CARE-PLAN-POP | Managed Care Plan Population | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4697 | MCR077 | MCR.006.077 | MANAGED-CARE-PLAN-POP | Managed Care Plan Population | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4698 | MCR078 | MCR.006.078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Managed Care Plan Population Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4699 | MCR078 | MCR.006.078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Managed Care Plan Population Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4700 | MCR078 | MCR.006.078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Managed Care Plan Population Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4701 | MCR078 | MCR.006.078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Managed Care Plan Population Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4702 | MCR078 | MCR.006.078 | MANAGED-CARE-PLAN-POP-EFF-DATE | Managed Care Plan Population Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4703 | MCR079 | MCR.006.079 | MANAGED-CARE-PLAN-POP-END-DATE | Managed Care Plan Population End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4704 | MCR079 | MCR.006.079 | MANAGED-CARE-PLAN-POP-END-DATE | Managed Care Plan Population End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4705 | MCR079 | MCR.006.079 | MANAGED-CARE-PLAN-POP-END-DATE | Managed Care Plan Population End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4706 | MCR079 | MCR.006.079 | MANAGED-CARE-PLAN-POP-END-DATE | Managed Care Plan Population End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4707 | MCR079 | MCR.006.079 | MANAGED-CARE-PLAN-POP-END-DATE | Managed Care Plan Population End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| A2 | 4708 | MCR080 | MCR.006.080 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4709 | MCR080 | MCR.006.080 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| X1 | 4710 | MCR080 | MCR.006.080 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| D1 | 4711 | MCR081 | MCR.006.081 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 |
| C2 | 4712 | MCR082 | MCR.007.082 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| A2 | 4713 | MCR082 | MCR.007.082 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "MCR00007" | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4714 | MCR083 | MCR.007.083 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| A2 | 4715 | MCR083 | MCR.007.083 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4716 | MCR083 | MCR.007.083 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4717 | MCR083 | MCR.007.083 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (MCR.001.007) | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4718 | MCR084 | MCR.007.084 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| A2 | 4719 | MCR084 | MCR.007.084 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| A2 | 4720 | MCR084 | MCR.007.084 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4721 | MCR084 | MCR.007.084 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| A2 | 4722 | MCR085 | MCR.007.085 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | Value must be 12 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4723 | MCR085 | MCR.007.085 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4724 | MCR085 | MCR.007.085 | STATE-PLAN-ID-NUM | State Plan ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4725 | MCR086 | MCR.007.086 | ACCREDITATION-ORGANIZATION | Accreditation Organization | Mandatory | Identify the accreditation awarded to the managed care entity. | Value must be in Accreditation Organization List (VVL) | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4726 | MCR086 | MCR.007.086 | ACCREDITATION-ORGANIZATION | Accreditation Organization | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C1 | 4727 | MCR086 | MCR.007.086 | ACCREDITATION-ORGANIZATION | Accreditation Organization | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4728 | MCR087 | MCR.007.087 | DATE-ACCREDITATION-ACHIEVED | Date Accreditation Achieved | Mandatory | The date the organization achieved accreditation. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4729 | MCR087 | MCR.007.087 | DATE-ACCREDITATION-ACHIEVED | Date Accreditation Achieved | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4730 | MCR087 | MCR.007.087 | DATE-ACCREDITATION-ACHIEVED | Date Accreditation Achieved | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4731 | MCR087 | MCR.007.087 | DATE-ACCREDITATION-ACHIEVED | Date Accreditation Achieved | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4732 | MCR087 | MCR.007.087 | DATE-ACCREDITATION-ACHIEVED | Date Accreditation Achieved | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4733 | MCR088 | MCR.007.088 | DATE-ACCREDITATION-END | Date Accreditation End | Mandatory | The date when organization's accreditation ends. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4734 | MCR088 | MCR.007.088 | DATE-ACCREDITATION-END | Date Accreditation End | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4735 | MCR088 | MCR.007.088 | DATE-ACCREDITATION-END | Date Accreditation End | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4736 | MCR088 | MCR.007.088 | DATE-ACCREDITATION-END | Date Accreditation End | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4737 | MCR088 | MCR.007.088 | DATE-ACCREDITATION-END | Date Accreditation End | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| A2 | 4738 | MCR089 | MCR.007.089 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| C2 | 4739 | MCR089 | MCR.007.089 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| X1 | 4740 | MCR089 | MCR.007.089 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| D1 | 4741 | MCR090 | MCR.007.090 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007 |
| D1 | 4742 | MCR091 | MCR.008.091 | RECORD-ID | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4743 | MCR092 | MCR.008.092 | SUBMITTING-STATE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4744 | MCR093 | MCR.008.093 | RECORD-NUMBER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4745 | MCR094 | MCR.008.094 | STATE-PLAN-ID-NUM | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4746 | MCR095 | MCR.008.095 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4747 | MCR096 | MCR.008.096 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4748 | MCR097 | MCR.008.097 | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4749 | MCR098 | MCR.008.098 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4750 | MCR099 | MCR.008.099 | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4751 | MCR100 | MCR.008.100 | STATE-NOTATION | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4752 | MCR101 | MCR.008.101 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
| D1 | 4753 | MCR102 | MCR.009.102 | RECORD-ID | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4754 | MCR103 | MCR.009.103 | SUBMITTING-STATE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4755 | MCR104 | MCR.009.104 | RECORD-NUMBER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4756 | MCR105 | MCR.009.105 | STATE-PLAN-ID-NUM | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4757 | MCR106 | MCR.009.106 | CHPID | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4758 | MCR107 | MCR.009.107 | SHPID | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4759 | MCR108 | MCR.009.108 | CHPID-SHPID-RELATIONSHIP-EFF-DATE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4760 | MCR109 | MCR.009.109 | CHPID-SHPID-RELATIONSHIP-END-DATE | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4761 | MCR110 | MCR.009.110 | STATE-NOTATION | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| D1 | 4762 | MCR111 | MCR.009.111 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 |
| C2 | 4763 | PRV001 | PRV.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4764 | PRV001 | PRV.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00001" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4765 | PRV002 | PRV.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4766 | PRV002 | PRV.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4767 | PRV002 | PRV.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4768 | PRV003 | PRV.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4769 | PRV003 | PRV.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4770 | PRV003 | PRV.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4771 | PRV004 | PRV.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4772 | PRV004 | PRV.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4773 | PRV004 | PRV.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4774 | PRV005 | PRV.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4775 | PRV005 | PRV.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4776 | PRV006 | PRV.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'PROVIDER' | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4777 | PRV007 | PRV.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4778 | PRV007 | PRV.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4779 | PRV007 | PRV.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4780 | PRV007 | PRV.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same for all records | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4781 | PRV008 | PRV.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4782 | PRV008 | PRV.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4783 | PRV008 | PRV.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4784 | PRV008 | PRV.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4785 | PRV008 | PRV.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4786 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4787 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4788 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4789 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4790 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4791 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4792 | PRV009 | PRV.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4793 | PRV010 | PRV.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4794 | PRV010 | PRV.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4795 | PRV010 | PRV.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4796 | PRV010 | PRV.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4797 | PRV010 | PRV.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4798 | PRV010 | PRV.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4799 | PRV011 | PRV.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4800 | PRV011 | PRV.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4801 | PRV011 | PRV.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| D1 | 4802 | PRV012 | PRV.001.012 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4803 | PRV013 | PRV.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4804 | PRV013 | PRV.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4805 | PRV013 | PRV.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4806 | PRV013 | PRV.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4807 | PRV013 | PRV.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4808 | PRV014 | PRV.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4809 | PRV014 | PRV.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4810 | PRV014 | PRV.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4811 | PRV138 | PRV.001.138 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, _x000D_ replacement files). This should begin with 1 for the original Create submission type and be incremented by one for _x000D_ each Replacement or Update submission for the same reporting period and file type (subject area). |
Value must between 1 and 9999 | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4812 | PRV138 | PRV.001.138 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4813 | PRV138 | PRV.001.138 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| A2 | 4814 | PRV138 | PRV.001.138 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| X1 | 4815 | PRV138 | PRV.001.138 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 |
| C2 | 4816 | PRV016 | PRV.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4817 | PRV016 | PRV.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00002" | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4818 | PRV017 | PRV.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4819 | PRV017 | PRV.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4820 | PRV017 | PRV.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4821 | PRV017 | PRV.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4822 | PRV018 | PRV.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4823 | PRV018 | PRV.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4824 | PRV018 | PRV.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4825 | PRV018 | PRV.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4826 | PRV019 | PRV.002.019 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4828 | PRV019 | PRV.002.019 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4829 | PRV020 | PRV.002.020 | PROV-ATTRIBUTES-EFF-DATE | Provider Attributes Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4830 | PRV020 | PRV.002.020 | PROV-ATTRIBUTES-EFF-DATE | Provider Attributes Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4831 | PRV020 | PRV.002.020 | PROV-ATTRIBUTES-EFF-DATE | Provider Attributes Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4832 | PRV020 | PRV.002.020 | PROV-ATTRIBUTES-EFF-DATE | Provider Attributes Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4833 | PRV020 | PRV.002.020 | PROV-ATTRIBUTES-EFF-DATE | Provider Attributes Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4834 | PRV021 | PRV.002.021 | PROV-ATTRIBUTES-END-DATE | Provider Attributes End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4835 | PRV021 | PRV.002.021 | PROV-ATTRIBUTES-END-DATE | Provider Attributes End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4836 | PRV021 | PRV.002.021 | PROV-ATTRIBUTES-END-DATE | Provider Attributes End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4837 | PRV021 | PRV.002.021 | PROV-ATTRIBUTES-END-DATE | Provider Attributes End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4838 | PRV021 | PRV.002.021 | PROV-ATTRIBUTES-END-DATE | Provider Attributes End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4839 | PRV022 | PRV.002.022 | PROV-DOING-BUSINESS-AS-NAME | Provider DBA Name | Conditional | The provider's name that is commonly used by the public when the "doing-business-as" name is different than the _x000D_ legal name. DBA is an abbreviation for "doing business as." Registering a DBA is required to operate a business _x000D_ under a name that differs from the company's legal name. |
Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4840 | PRV022 | PRV.002.022 | PROV-DOING-BUSINESS-AS-NAME | Provider DBA Name | Not Applicable | Not Applicable | Value must be 100 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C1 | 4841 | PRV022 | PRV.002.022 | PROV-DOING-BUSINESS-AS-NAME | Provider DBA Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4842 | PRV023 | PRV.002.023 | PROV-LEGAL-NAME | Provider Legal Name | Mandatory | The name as it appears on the provider agreement between the state and the entity. Both persons and other entities _x000D_ can have a legal name. |
Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4843 | PRV023 | PRV.002.023 | PROV-LEGAL-NAME | Provider Legal Name | Not Applicable | Not Applicable | Value must be 100 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4844 | PRV023 | PRV.002.023 | PROV-LEGAL-NAME | Provider Legal Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4845 | PRV024 | PRV.002.024 | PROV-ORGANIZATION-NAME | Provider Organization Name | Conditional | The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4846 | PRV024 | PRV.002.024 | PROV-ORGANIZATION-NAME | Provider Organization Name | Not Applicable | Not Applicable | Value must be 60 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C1 | 4847 | PRV024 | PRV.002.024 | PROV-ORGANIZATION-NAME | Provider Organization Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4848 | PRV025 | PRV.002.025 | PROV-TAX-NAME | Provider Tax Name | Mandatory | The name that the provider entity uses on IRS filings. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4849 | PRV025 | PRV.002.025 | PROV-TAX-NAME | Provider Tax Name | Not Applicable | Not Applicable | Value must be 100 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4850 | PRV025 | PRV.002.025 | PROV-TAX-NAME | Provider Tax Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4851 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Mandatory | A code to identify whether the Submitting State Provider Identifier is assigned to an individual, group, or a facility. | Value must be in Facility Group Individual Code List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4852 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4853 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4854 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4855 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4856 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4857 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4858 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | (individual) if value equals '03', then Provider Date of Birth (PRV.002.034)must be populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4859 | PRV026 | PRV.002.026 | FACILITY-GROUP-INDIVIDUAL-CODE | Facility Group Individual Code | Not Applicable | Not Applicable | (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4860 | PRV027 | PRV.002.027 | TEACHING-IND | Teaching Indicator | Conditional | A code indicating if the provider's organization is a teaching facility. | Value must be in Teaching Indicator List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4861 | PRV027 | PRV.002.027 | TEACHING-IND | Teaching Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4862 | PRV027 | PRV.002.027 | TEACHING-IND | Teaching Indicator | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4863 | PRV028 | PRV.002.028 | PROV-FIRST-NAME | Provider First Name | Conditional | Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4864 | PRV028 | PRV.002.028 | PROV-FIRST-NAME | Provider First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4865 | PRV028 | PRV.002.028 | PROV-FIRST-NAME | Provider First Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4866 | PRV029 | PRV.002.029 | PROV-MIDDLE-INITIAL | Provider Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4867 | PRV029 | PRV.002.029 | PROV-MIDDLE-INITIAL | Provider Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4868 | PRV029 | PRV.002.029 | PROV-MIDDLE-INITIAL | Provider Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4869 | PRV029 | PRV.002.029 | PROV-MIDDLE-INITIAL | Provider Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4870 | PRV030 | PRV.002.030 | PROV-LAST-NAME | Provider Last Name | Conditional | Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4871 | PRV030 | PRV.002.030 | PROV-LAST-NAME | Provider Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4872 | PRV030 | PRV.002.030 | PROV-LAST-NAME | Provider Last Name | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4873 | PRV031 | PRV.002.031 | SEX | Sex | Conditional | Either individual's biological sex or their self-identified sex. | Value must be in Sex List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4874 | PRV031 | PRV.002.031 | SEX | Sex | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4875 | PRV031 | PRV.002.031 | SEX | Sex | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4876 | PRV032 | PRV.002.032 | OWNERSHIP-CODE | Ownership Code | Conditional | A code denoting the ownership interest and/or managing control information. The valid values list is a Medicare standard list. | Value must be in Ownership Code List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4877 | PRV032 | PRV.002.032 | OWNERSHIP-CODE | Ownership Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4878 | PRV032 | PRV.002.032 | OWNERSHIP-CODE | Ownership Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4879 | PRV032 | PRV.002.032 | OWNERSHIP-CODE | Ownership Code | Not Applicable | Not Applicable | Value is mandatory when associated Facility Group Individual Code (PRV.002.026) is in ['01, '02'] (organization) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4880 | PRV033 | PRV.002.033 | PROV-PROFIT-STATUS | Provider Profit Status | Mandatory | A code denoting the profit status of the provider. | Value must be in Provider Profit Status List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4881 | PRV033 | PRV.002.033 | PROV-PROFIT-STATUS | Provider Profit Status | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4882 | PRV033 | PRV.002.033 | PROV-PROFIT-STATUS | Provider Profit Status | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4883 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Conditional | An individual's date of birth. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4884 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4885 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Value must be less than or equal to associated End of Time Period (PRV.001.010) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4886 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Value must be less than or equal to associated Date File Created (PRV.001.008) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4887 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4888 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Not Applicable | Not Applicable | The difference between current value and Start of Time Period (PRV.001.009) must be between 18 and 85 years | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4889 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Conditional | The date an individual died on. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4890 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4891 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4892 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | If populated, value must be on or after individual's Date of Birth | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4893 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | Value must be less than or equal to associated End of Time Period (PRV.001.010) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4894 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | There can only be one value on all records when the value is populated | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4895 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Not Applicable | Not Applicable | When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4896 | PRV036 | PRV.002.036 | ACCEPTING-NEW-PATIENTS-IND | Accepting New Patients Indicator | Mandatory | An indicator to identify providers who are accepting new patients. | Value must be in Accepting New Patients Indicator List (VVL) | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4897 | PRV036 | PRV.002.036 | ACCEPTING-NEW-PATIENTS-IND | Accepting New Patients Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4898 | PRV036 | PRV.002.036 | ACCEPTING-NEW-PATIENTS-IND | Accepting New Patients Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| A2 | 4899 | PRV037 | PRV.002.037 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4900 | PRV037 | PRV.002.037 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| X1 | 4901 | PRV037 | PRV.002.037 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| D1 | 4902 | PRV038 | PRV.002.038 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 |
| C2 | 4903 | PRV039 | PRV.003.039 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4904 | PRV039 | PRV.003.039 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00003" | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4905 | PRV040 | PRV.003.040 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4906 | PRV040 | PRV.003.040 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4907 | PRV040 | PRV.003.040 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4908 | PRV040 | PRV.003.040 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4909 | PRV041 | PRV.003.041 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4910 | PRV041 | PRV.003.041 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4911 | PRV041 | PRV.003.041 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4912 | PRV041 | PRV.003.041 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4913 | PRV042 | PRV.003.042 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4915 | PRV042 | PRV.003.042 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4916 | PRV043 | PRV.003.043 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe symbol | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4917 | PRV043 | PRV.003.043 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4918 | PRV044 | PRV.003.044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Provider Location & Contact Info Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4919 | PRV044 | PRV.003.044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Provider Location & Contact Info Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4920 | PRV044 | PRV.003.044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Provider Location & Contact Info Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4921 | PRV044 | PRV.003.044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Provider Location & Contact Info Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4922 | PRV044 | PRV.003.044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Provider Location & Contact Info Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4923 | PRV045 | PRV.003.045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Provider Location & Contact Info End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4924 | PRV045 | PRV.003.045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Provider Location & Contact Info End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4925 | PRV045 | PRV.003.045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Provider Location & Contact Info End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4926 | PRV045 | PRV.003.045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Provider Location & Contact Info End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4927 | PRV045 | PRV.003.045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Provider Location & Contact Info End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4928 | PRV046 | PRV.003.046 | ADDR-TYPE | Provider Address Type | Mandatory | The type of address and contact information for the provider submitted in the record segment. | Value must be in Provider Address Type List (VVL) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4929 | PRV046 | PRV.003.046 | ADDR-TYPE | Provider Address Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4930 | PRV046 | PRV.003.046 | ADDR-TYPE | Provider Address Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4931 | PRV047 | PRV.003.047 | ADDR-LN1 | Provider Address Line 1 | Mandatory | The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4932 | PRV047 | PRV.003.047 | ADDR-LN1 | Provider Address Line 1 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 2 or Address Line 3 value(s) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4933 | PRV047 | PRV.003.047 | ADDR-LN1 | Provider Address Line 1 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4934 | PRV047 | PRV.003.047 | ADDR-LN1 | Provider Address Line 1 | Not Applicable | Not Applicable | When populated, the associated Address Type is required | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4935 | PRV047 | PRV.003.047 | ADDR-LN1 | Provider Address Line 1 | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4936 | PRV048 | PRV.003.048 | ADDR-LN2 | Provider Address Line 2 | Conditional | The second line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4937 | PRV048 | PRV.003.048 | ADDR-LN2 | Provider Address Line 2 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 3 value(s) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4938 | PRV048 | PRV.003.048 | ADDR-LN2 | Provider Address Line 2 | Not Applicable | Not Applicable | There must be an Address Line 1 in order to have an Address Line 2 | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4939 | PRV048 | PRV.003.048 | ADDR-LN2 | Provider Address Line 2 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4940 | PRV048 | PRV.003.048 | ADDR-LN2 | Provider Address Line 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4941 | PRV049 | PRV.003.049 | ADDR-LN3 | Provider Address Line 3 | Conditional | The third line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4942 | PRV049 | PRV.003.049 | ADDR-LN3 | Provider Address Line 3 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 2 value(s) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4943 | PRV049 | PRV.003.049 | ADDR-LN3 | Provider Address Line 3 | Not Applicable | Not Applicable | If Address Line 2 is not populated, then value should not be populated | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4944 | PRV049 | PRV.003.049 | ADDR-LN3 | Provider Address Line 3 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4945 | PRV049 | PRV.003.049 | ADDR-LN3 | Provider Address Line 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4946 | PRV050 | PRV.003.050 | ADDR-CITY | Provider City | Mandatory | The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). | Value must be 28 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4947 | PRV050 | PRV.003.050 | ADDR-CITY | Provider City | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4948 | PRV050 | PRV.003.050 | ADDR-CITY | Provider City | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4949 | PRV051 | PRV.003.051 | ADDR-STATE | Provider State | Mandatory | The ANSI numeric state code component of an address associated with a given entity (e.g. person, organization, agency, etc.) | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4950 | PRV051 | PRV.003.051 | ADDR-STATE | Provider State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4951 | PRV051 | PRV.003.051 | ADDR-STATE | Provider State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4952 | PRV052 | PRV.003.052 | ADDR-ZIP-CODE | Provider Zip Code | Mandatory | U.S. Zip Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) | Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4953 | PRV052 | PRV.003.052 | ADDR-ZIP-CODE | Provider Zip Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4954 | PRV053 | PRV.003.053 | ADDR-TELEPHONE | Provider Phone Number | Optional | Phone number for a given entity (e.g. person, organization, agency). | Value must be 10 characters, digits (0-9) only | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4955 | PRV053 | PRV.003.053 | ADDR-TELEPHONE | Provider Phone Number | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4956 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Optional | The email address of the provider for the location being captured on this record | Must contain the '@' symbol | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4957 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Not Applicable | Not Applicable | May contain uppercase and lowercase Latin letters A to Z and a to z | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4958 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Not Applicable | Not Applicable | May contain digits 0-9 | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4959 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Not Applicable | Not Applicable | Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4960 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Not Applicable | Not Applicable | Value must be 60 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4961 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4962 | PRV055 | PRV.003.055 | ADDR-FAX-NUM | Provider Address Fax | Optional | The fax number of the provider for the location being captured on this record. | Value must be 10 characters, digits (0-9) only | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4963 | PRV055 | PRV.003.055 | ADDR-FAX-NUM | Provider Address Fax | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4964 | PRV056 | PRV.003.056 | ADDR-BORDER-STATE-IND | Address Border State Indicator | Mandatory | A code identify an out of state provider enrolled with the state (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) | Value must be in Address Border State Indicator List (VVL) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4965 | PRV056 | PRV.003.056 | ADDR-BORDER-STATE-IND | Address Border State Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4966 | PRV057 | PRV.003.057 | ADDR-COUNTY | Provider County Code | Mandatory | Standard ANSI code used to identify a specific U.S. County. | Value must be in US County Code List (VVL) | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4967 | PRV057 | PRV.003.057 | ADDR-COUNTY | Provider County Code | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4968 | PRV057 | PRV.003.057 | ADDR-COUNTY | Provider County Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| A2 | 4969 | PRV058 | PRV.003.058 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4970 | PRV058 | PRV.003.058 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| X1 | 4971 | PRV058 | PRV.003.058 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| D1 | 4972 | PRV059 | PRV.003.059 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 |
| C2 | 4973 | PRV060 | PRV.004.060 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4974 | PRV060 | PRV.004.060 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00004" | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4975 | PRV061 | PRV.004.061 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4976 | PRV061 | PRV.004.061 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4977 | PRV061 | PRV.004.061 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4978 | PRV061 | PRV.004.061 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4979 | PRV062 | PRV.004.062 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4980 | PRV062 | PRV.004.062 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4981 | PRV062 | PRV.004.062 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4982 | PRV062 | PRV.004.062 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4983 | PRV063 | PRV.004.063 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4985 | PRV063 | PRV.004.063 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4986 | PRV064 | PRV.004.064 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe symbol | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4987 | PRV064 | PRV.004.064 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4988 | PRV065 | PRV.004.065 | PROV-LICENSE-EFF-DATE | Provider License Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4989 | PRV065 | PRV.004.065 | PROV-LICENSE-EFF-DATE | Provider License Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4990 | PRV065 | PRV.004.065 | PROV-LICENSE-EFF-DATE | Provider License Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4991 | PRV065 | PRV.004.065 | PROV-LICENSE-EFF-DATE | Provider License Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4992 | PRV065 | PRV.004.065 | PROV-LICENSE-EFF-DATE | Provider License Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4993 | PRV066 | PRV.004.066 | PROV-LICENSE-END-DATE | Provider License End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4994 | PRV066 | PRV.004.066 | PROV-LICENSE-END-DATE | Provider License End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4995 | PRV066 | PRV.004.066 | PROV-LICENSE-END-DATE | Provider License End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4996 | PRV066 | PRV.004.066 | PROV-LICENSE-END-DATE | Provider License End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 4997 | PRV066 | PRV.004.066 | PROV-LICENSE-END-DATE | Provider License End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 4998 | PRV067 | PRV.004.067 | LICENSE-TYPE | License Type | Mandatory | A code to identify the kind of license or accreditation number that is captured in the LICENSE-OR-ACCREDITATION-NUMBER data element. | Value must be in License Type List (VVL) | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 4999 | PRV067 | PRV.004.067 | LICENSE-TYPE | License Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C1 | 5000 | PRV067 | PRV.004.067 | LICENSE-TYPE | License Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5001 | PRV068 | PRV.004.068 | LICENSE-ISSUING-ENTITY-ID | License Issuing Entity ID | Mandatory | A free text field to capture the identity of the entity issuing the license or accreditation. Enter the applicable state code, county code, municipality name, "DEA", professional society's name, or the CLIA accreditation body's name. _x000D_ (county) if associated License Type is equal to 1 and issuing authority is a State, then value must be a 5-digit, concatenated code consisting of the ANSI 2-digit state code plus the ANSI county 3-digit code of the applicable. _x000D_ If associated License Type is equal to 1 and the issuing authority is the State, then value must be a 5-digit, concatenated code consisting of the ANSI 2 digit state code plus the ANSI 3 digit county code._x000D_ For example, Orange County, CA would be 06059 Orange County, NC 37135. A list of codes can be found here: https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/home/?cid=nrcs143_013697 _x000D_ (CLIA) if associated License Type is equal to 4, then value must be the text string identifying the CLIA accreditation body's name._x000D_ (Professional society accreditation) if associated License Type is equal to three, then enter the text string identifying the professional society issuing the accreditation. _x000D_ (DEA) if associated License Type is equal to 2 , then value must be the text string "DEA"_x000D_ (state) if associated License Type is equal to 1 and issuing authority is a State, then value must be a 2 digit ANSI State abbreviation code. |
Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 5002 | PRV068 | PRV.004.068 | LICENSE-ISSUING-ENTITY-ID | License Issuing Entity ID | Not Applicable | Not Applicable | Value must be 60 characters or less | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5003 | PRV068 | PRV.004.068 | LICENSE-ISSUING-ENTITY-ID | License Issuing Entity ID | Not Applicable | Not Applicable | (required) if associated License or Accreditation Number (PRV.005.069) value is populated, then value is mandatory and must be provided | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C1 | 5004 | PRV068 | PRV.004.068 | LICENSE-ISSUING-ENTITY-ID | License Issuing Entity ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5005 | PRV068 | PRV.004.068 | LICENSE-ISSUING-ENTITY-ID | License Issuing Entity ID | Not Applicable | Not Applicable | Value must equal 'DEA' when associated License Type equals '2' | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5006 | PRV069 | PRV.004.069 | LICENSE-OR-ACCREDITATION-NUMBER | License or Accreditation Number | Mandatory | A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the LICENSE-ISSUING-ENTITY-ID data element. | Value must not contain a pipe and asterisk symbol | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5007 | PRV069 | PRV.004.069 | LICENSE-OR-ACCREDITATION-NUMBER | License or Accreditation Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 5008 | PRV069 | PRV.004.069 | LICENSE-OR-ACCREDITATION-NUMBER | License or Accreditation Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| A2 | 5009 | PRV070 | PRV.004.070 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5010 | PRV070 | PRV.004.070 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| X1 | 5011 | PRV070 | PRV.004.070 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| D1 | 5012 | PRV071 | PRV.004.071 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-LICENSING-INFO-PRV00004 |
| C2 | 5013 | PRV072 | PRV.005.072 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5014 | PRV072 | PRV.005.072 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00005" | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5015 | PRV073 | PRV.005.073 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5016 | PRV073 | PRV.005.073 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5017 | PRV073 | PRV.005.073 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5018 | PRV073 | PRV.005.073 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5019 | PRV074 | PRV.005.074 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5020 | PRV074 | PRV.005.074 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5021 | PRV074 | PRV.005.074 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5022 | PRV074 | PRV.005.074 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5023 | PRV075 | PRV.005.075 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5025 | PRV075 | PRV.005.075 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5026 | PRV076 | PRV.005.076 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe symbol | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5027 | PRV076 | PRV.005.076 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5028 | PRV077 | PRV.005.077 | PROV-IDENTIFIER-TYPE | Provider Identifier Type | Mandatory | A code to identify the kind of provider identifier that is captured in the Provider Identifier data element. The state should _x000D_ submit updates to T-MSIS whenever an identifier is retired or issued. see Provider Identifier Type List (VVL.146) |
Value must be in Provider Identifier Type List (VVL) | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5029 | PRV077 | PRV.005.077 | PROV-IDENTIFIER-TYPE | Provider Identifier Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5030 | PRV077 | PRV.005.077 | PROV-IDENTIFIER-TYPE | Provider Identifier Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5031 | PRV077 | PRV.005.077 | PROV-IDENTIFIER-TYPE | Provider Identifier Type | Not Applicable | Not Applicable | When value equals '2', the associated Provider Identifier (PRV.005.081) must be a valid NPI | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5032 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Mandatory | A free text field to capture the identity of the entity that issued the provider identifier in the PROV-IDENTIFIER data element. For (State Tax ID), if associated Provider Identifier Type (DE) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (DE) value is equal to 8, then _x000D_ value must be the name of the entity that issued the identifier. |
Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5033 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | (State-specific Medicaid Provider) if associated Provider Identifier Type (PRV.005.077) value is equal to 1, then value must equal (PRV.005.073) Submitting State | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5034 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | (NPI) if associated Provider Identifier Type (PRV.005.077) value is equal to 2, then value must equal 'NPI' | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5035 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | (Medicare) if associated Provider Identifier Type (PRV.005.077) value is equal to 3, then value must equal 'CMS' | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5036 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | (NCPDP) if associated Provider Identifier Type (PRV.005.077) value is equal to 4, then value must equal 'NCPDP' | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5037 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | (Federal Tax ID) if associated Provider Identifier Type (PRV.005.077) value is equal to 5, then value must equal 'IRS' | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5038 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | (SSN) if associated Provider Identifier Type (PRV.005.077) value is equal to 7, then value must be equal to 'SSA' | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5039 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | Value must be 18 characters or less | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5040 | PRV078 | PRV.005.078 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Provider Identifier Issuing Entity ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5041 | PRV079 | PRV.005.079 | PROV-IDENTIFIER-EFF-DATE | Provider Identifier Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5042 | PRV079 | PRV.005.079 | PROV-IDENTIFIER-EFF-DATE | Provider Identifier Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5043 | PRV079 | PRV.005.079 | PROV-IDENTIFIER-EFF-DATE | Provider Identifier Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5044 | PRV079 | PRV.005.079 | PROV-IDENTIFIER-EFF-DATE | Provider Identifier Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5045 | PRV079 | PRV.005.079 | PROV-IDENTIFIER-EFF-DATE | Provider Identifier Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5046 | PRV080 | PRV.005.080 | PROV-IDENTIFIER-END-DATE | Provider Identifier End Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5047 | PRV080 | PRV.005.080 | PROV-IDENTIFIER-END-DATE | Provider Identifier End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5048 | PRV080 | PRV.005.080 | PROV-IDENTIFIER-END-DATE | Provider Identifier End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5049 | PRV080 | PRV.005.080 | PROV-IDENTIFIER-END-DATE | Provider Identifier End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5050 | PRV080 | PRV.005.080 | PROV-IDENTIFIER-END-DATE | Provider Identifier End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5051 | PRV081 | PRV.005.081 | PROV-IDENTIFIER | Provider Identifier | Mandatory | A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is defined in the corresponding value in the PROVIDER-IDENTIFIER-TYPE data element. | Mandatory | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5052 | PRV081 | PRV.005.081 | PROV-IDENTIFIER | Provider Identifier | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbol | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5053 | PRV081 | PRV.005.081 | PROV-IDENTIFIER | Provider Identifier | Not Applicable | Not Applicable | Value must have an associated Provider Identifier Type (PRV.005.077) | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5054 | PRV081 | PRV.005.081 | PROV-IDENTIFIER | Provider Identifier | Not Applicable | Not Applicable | One record must have a Provider Identifier Type (PRV.005.077) equal to "1" | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5055 | PRV081 | PRV.005.081 | PROV-IDENTIFIER | Provider Identifier | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| A2 | 5056 | PRV082 | PRV.005.082 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5057 | PRV082 | PRV.005.082 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| X1 | 5058 | PRV082 | PRV.005.082 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| D1 | 5059 | PRV083 | PRV.005.083 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-IDENTIFIERS-PRV00005 |
| C2 | 5060 | PRV084 | PRV.006.084 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5061 | PRV084 | PRV.006.084 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00006" | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5062 | PRV085 | PRV.006.085 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5063 | PRV085 | PRV.006.085 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5064 | PRV085 | PRV.006.085 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5065 | PRV085 | PRV.006.085 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5066 | PRV086 | PRV.006.086 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5067 | PRV086 | PRV.006.086 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5068 | PRV086 | PRV.006.086 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5069 | PRV086 | PRV.006.086 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5070 | PRV087 | PRV.006.087 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5072 | PRV087 | PRV.006.087 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5073 | PRV088 | PRV.006.088 | PROV-CLASSIFICATION-TYPE | Provider Classification Type | Mandatory | A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" _x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47562_x000D_ A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
Value must be in Provider Classification Type List (VVL) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5074 | PRV088 | PRV.006.088 | PROV-CLASSIFICATION-TYPE | Provider Classification Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5075 | PRV088 | PRV.006.088 | PROV-CLASSIFICATION-TYPE | Provider Classification Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5076 | PRV089 | PRV.006.089 | PROV-CLASSIFICATION-CODE | Provider Classification Code | Mandatory | The code values from the categorization schema identified in the Provider Classification Type data element. Note: States should apply these classification schemas consistently across all providers. | If associated Provider Classification Type equals 1, value must be in Provider Taxonomy List (VVL) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5077 | PRV089 | PRV.006.089 | PROV-CLASSIFICATION-CODE | Provider Classification Code | Not Applicable | Not Applicable | If associated Provider Classification Type equals 2, value must be in Provider Specialty Code List (VVL) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5078 | PRV089 | PRV.006.089 | PROV-CLASSIFICATION-CODE | Provider Classification Code | Not Applicable | Not Applicable | If associated Provider Classification Type equals 3, value must be in Provider Type Code List (VVL) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5079 | PRV089 | PRV.006.089 | PROV-CLASSIFICATION-CODE | Provider Classification Code | Not Applicable | Not Applicable | If associated Provider Classification Type equals 4, value must be in Provider Authorized Category of Service Code List (VVL) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5080 | PRV089 | PRV.006.089 | PROV-CLASSIFICATION-CODE | Provider Classification Code | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5081 | PRV089 | PRV.006.089 | PROV-CLASSIFICATION-CODE | Provider Classification Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5082 | PRV090 | PRV.006.090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Provider Taxonomy Classification Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5083 | PRV090 | PRV.006.090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Provider Taxonomy Classification Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5084 | PRV090 | PRV.006.090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Provider Taxonomy Classification Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5085 | PRV090 | PRV.006.090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Provider Taxonomy Classification Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5086 | PRV090 | PRV.006.090 | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | Provider Taxonomy Classification Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5087 | PRV091 | PRV.006.091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Provider Taxonomy Classification End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5088 | PRV091 | PRV.006.091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Provider Taxonomy Classification End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5089 | PRV091 | PRV.006.091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Provider Taxonomy Classification End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5090 | PRV091 | PRV.006.091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Provider Taxonomy Classification End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5091 | PRV091 | PRV.006.091 | PROV-TAXONOMY-CLASSIFICATION-END-DATE | Provider Taxonomy Classification End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| A2 | 5092 | PRV092 | PRV.006.092 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5093 | PRV092 | PRV.006.092 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| X1 | 5094 | PRV092 | PRV.006.092 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| D1 | 5095 | PRV093 | PRV.006.093 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 |
| C2 | 5096 | PRV094 | PRV.007.094 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5097 | PRV094 | PRV.007.094 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00007" | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5098 | PRV095 | PRV.007.095 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5099 | PRV095 | PRV.007.095 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5100 | PRV095 | PRV.007.095 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5101 | PRV095 | PRV.007.095 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5102 | PRV096 | PRV.007.096 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5103 | PRV096 | PRV.007.096 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5104 | PRV096 | PRV.007.096 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5105 | PRV096 | PRV.007.096 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5106 | PRV097 | PRV.007.097 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5108 | PRV097 | PRV.007.097 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5109 | PRV098 | PRV.007.098 | PROV-MEDICAID-EFF-DATE | Provider Medicaid Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5110 | PRV098 | PRV.007.098 | PROV-MEDICAID-EFF-DATE | Provider Medicaid Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5111 | PRV098 | PRV.007.098 | PROV-MEDICAID-EFF-DATE | Provider Medicaid Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5112 | PRV098 | PRV.007.098 | PROV-MEDICAID-EFF-DATE | Provider Medicaid Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5113 | PRV098 | PRV.007.098 | PROV-MEDICAID-EFF-DATE | Provider Medicaid Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5114 | PRV099 | PRV.007.099 | PROV-MEDICAID-END-DATE | Provider Medicaid End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5115 | PRV099 | PRV.007.099 | PROV-MEDICAID-END-DATE | Provider Medicaid End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5116 | PRV099 | PRV.007.099 | PROV-MEDICAID-END-DATE | Provider Medicaid End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5117 | PRV099 | PRV.007.099 | PROV-MEDICAID-END-DATE | Provider Medicaid End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5118 | PRV099 | PRV.007.099 | PROV-MEDICAID-END-DATE | Provider Medicaid End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5119 | PRV100 | PRV.007.100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Provider Medicaid Enrollment Status Code | Mandatory | A code representing the provider's Medicaid and/or CHIP enrollment status for the time span specified by the PROV-MEDICAID-EFF-DATE and PROV-MEDICAID-END-DATE data elements. Note: The STATE-PLAN-ENROLLMENT data element identifies whether the provider is enrolled in _x000D_ Medicaid, CHIP, or both. |
Value must be in Provider Medicaid Enrollment Status Code List (VVL) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5120 | PRV100 | PRV.007.100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Provider Medicaid Enrollment Status Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5121 | PRV100 | PRV.007.100 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Provider Medicaid Enrollment Status Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5122 | PRV101 | PRV.007.101 | STATE-PLAN-ENROLLMENT | State Plan Enrollment | Mandatory | The state plan with which a provider has an affiliation and is able to provide services to the state's fee for service enrollees. | Value must be in State Plan Enrollment List (VVL) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5123 | PRV101 | PRV.007.101 | STATE-PLAN-ENROLLMENT | State Plan Enrollment | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5124 | PRV101 | PRV.007.101 | STATE-PLAN-ENROLLMENT | State Plan Enrollment | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5125 | PRV102 | PRV.007.102 | PROV-ENROLLMENT-METHOD | Provider Enrollment Method | Mandatory | Process by which a provider was enrolled in Medicaid or CHIP. | Value must be in Provider Enrollment Method List (VVL) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5126 | PRV102 | PRV.007.102 | PROV-ENROLLMENT-METHOD | Provider Enrollment Method | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5127 | PRV102 | PRV.007.102 | PROV-ENROLLMENT-METHOD | Provider Enrollment Method | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5128 | PRV103 | PRV.007.103 | APPL-DATE | Application Date | Mandatory | The date on which the provider applied for enrollment into the State's Medicaid and/or CHIP program. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5129 | PRV103 | PRV.007.103 | APPL-DATE | Application Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5130 | PRV103 | PRV.007.103 | APPL-DATE | Application Date | Not Applicable | Not Applicable | Value must not be earlier than associated Provider Medicaid Effective Date (PRV.007.098) value | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5131 | PRV103 | PRV.007.103 | APPL-DATE | Application Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| A2 | 5132 | PRV104 | PRV.007.104 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5133 | PRV104 | PRV.007.104 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| X1 | 5134 | PRV104 | PRV.007.104 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| D1 | 5135 | PRV105 | PRV.007.105 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 |
| C2 | 5136 | PRV106 | PRV.008.106 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5137 | PRV106 | PRV.008.106 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00008" | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5138 | PRV107 | PRV.008.107 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5139 | PRV107 | PRV.008.107 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| X1 | 5140 | PRV107 | PRV.008.107 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5141 | PRV107 | PRV.008.107 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5142 | PRV108 | PRV.008.108 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5143 | PRV108 | PRV.008.108 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5144 | PRV108 | PRV.008.108 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| X1 | 5145 | PRV108 | PRV.008.108 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5146 | PRV109 | PRV.008.109 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| X1 | 5148 | PRV109 | PRV.008.109 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5149 | PRV110 | PRV.008.110 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Submitting State Provider ID of Affiliated Entity | Mandatory | The unique, state-assigned identification number for the group or subpart with which the individual or subpart is associated. (The submitting state's unique identifier for the group. (Note: The group will also be in the provider data set as a provider (i.e., the group-as-a-provider). | Value must not contain a pipe symbol | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5150 | PRV110 | PRV.008.110 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Submitting State Provider ID of Affiliated Entity | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C1 | 5151 | PRV110 | PRV.008.110 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Submitting State Provider ID of Affiliated Entity | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5152 | PRV111 | PRV.008.111 | PROV-AFFILIATED-GROUP-EFF-DATE | Provider Affiliated Group Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5153 | PRV111 | PRV.008.111 | PROV-AFFILIATED-GROUP-EFF-DATE | Provider Affiliated Group Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5154 | PRV111 | PRV.008.111 | PROV-AFFILIATED-GROUP-EFF-DATE | Provider Affiliated Group Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| X1 | 5155 | PRV111 | PRV.008.111 | PROV-AFFILIATED-GROUP-EFF-DATE | Provider Affiliated Group Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5156 | PRV111 | PRV.008.111 | PROV-AFFILIATED-GROUP-EFF-DATE | Provider Affiliated Group Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5157 | PRV112 | PRV.008.112 | PROV-AFFILIATED-GROUP-END-DATE | Provider Affiliated Group End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5158 | PRV112 | PRV.008.112 | PROV-AFFILIATED-GROUP-END-DATE | Provider Affiliated Group End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5159 | PRV112 | PRV.008.112 | PROV-AFFILIATED-GROUP-END-DATE | Provider Affiliated Group End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| X1 | 5160 | PRV112 | PRV.008.112 | PROV-AFFILIATED-GROUP-END-DATE | Provider Affiliated Group End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5161 | PRV112 | PRV.008.112 | PROV-AFFILIATED-GROUP-END-DATE | Provider Affiliated Group End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| A2 | 5162 | PRV113 | PRV.008.113 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5163 | PRV113 | PRV.008.113 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| X1 | 5164 | PRV113 | PRV.008.113 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| D1 | 5165 | PRV114 | PRV.008.114 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 |
| C2 | 5166 | PRV115 | PRV.009.115 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5167 | PRV115 | PRV.009.115 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00009" | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5168 | PRV116 | PRV.009.116 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5169 | PRV116 | PRV.009.116 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5170 | PRV116 | PRV.009.116 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5171 | PRV116 | PRV.009.116 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5172 | PRV117 | PRV.009.117 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5173 | PRV117 | PRV.009.117 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5174 | PRV117 | PRV.009.117 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5175 | PRV117 | PRV.009.117 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5176 | PRV118 | PRV.009.118 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5178 | PRV118 | PRV.009.118 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5179 | PRV119 | PRV.009.119 | AFFILIATED-PROGRAM-TYPE | Affiliated Program Type | Mandatory | A code to identify the category of program that the provider is affiliated._x000D_ see Affiliated Program Type List (VVL.004)_x000D_ (health plan federal assigned) if associated Affiliated Program Type (DE) value is 1, then value must be the federal-assigned plan ID of the health plan in which a provider is enrolled to provide services._x000D_ (health plan state assigned) if associated Affiliated Program Type (DE) value is 2, then value must be the state-assigned plan ID of the health plan in which a provider is enrolled to provide services._x000D_ (waiver) if associated Affiliated Program Type (DE) value is 3, then value must be the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries._x000D_ (health home entity) if associated Affiliated Program Type (DE) value is 4, then value must be the name of a health home in which a provider is participating._x000D_ (other) if associated Affiliated Program Type (DE) value is 5, then value must be an identifier for something other than a health plan, waiver, or health home entity. |
Value must be in Affiliated Program Type List (VVL) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5180 | PRV119 | PRV.009.119 | AFFILIATED-PROGRAM-TYPE | Affiliated Program Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5181 | PRV119 | PRV.009.119 | AFFILIATED-PROGRAM-TYPE | Affiliated Program Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5182 | PRV120 | PRV.009.120 | AFFILIATED-PROGRAM-ID | Affiliated Program ID | Mandatory | A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates._x000D_ (health plan federal assigned) if associated Affiliated Program Type (DE) value is 1, then value must be the federal-assigned plan ID of the health plan in which a provider is enrolled to provide services._x000D_ (health plan state assigned) if associated Affiliated Program Type (DE) value is 2, then value must be the state-assigned plan ID of the health plan in which a provider is enrolled to provide services._x000D_ (waiver) if associated Affiliated Program Type (DE) value is 3, then value must be the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries._x000D_ (health home entity) if associated Affiliated Program Type (DE) value is 4, then value must be the name of a health home in which a provider is participating._x000D_ (other) if associated Affiliated Program Type (DE) value is 5, then value must be an identifier for something other than a health plan, waiver, or health home entity. |
Value must be 50 characters or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5183 | PRV120 | PRV.009.120 | AFFILIATED-PROGRAM-ID | Affiliated Program ID | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5184 | PRV120 | PRV.009.120 | AFFILIATED-PROGRAM-ID | Affiliated Program ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5185 | PRV121 | PRV.009.121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Provider Affiliated Program Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5186 | PRV121 | PRV.009.121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Provider Affiliated Program Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5187 | PRV121 | PRV.009.121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Provider Affiliated Program Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5188 | PRV121 | PRV.009.121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Provider Affiliated Program Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5189 | PRV121 | PRV.009.121 | PROV-AFFILIATED-PROGRAM-EFF-DATE | Provider Affiliated Program Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5190 | PRV122 | PRV.009.122 | PROV-AFFILIATED-PROGRAM-END-DATE | Provider Affiliated Program End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5191 | PRV122 | PRV.009.122 | PROV-AFFILIATED-PROGRAM-END-DATE | Provider Affiliated Program End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5192 | PRV122 | PRV.009.122 | PROV-AFFILIATED-PROGRAM-END-DATE | Provider Affiliated Program End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5193 | PRV122 | PRV.009.122 | PROV-AFFILIATED-PROGRAM-END-DATE | Provider Affiliated Program End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5194 | PRV122 | PRV.009.122 | PROV-AFFILIATED-PROGRAM-END-DATE | Provider Affiliated Program End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| A2 | 5195 | PRV123 | PRV.009.123 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5196 | PRV123 | PRV.009.123 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| X1 | 5197 | PRV123 | PRV.009.123 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| D1 | 5198 | PRV124 | PRV.009.124 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 |
| C2 | 5199 | PRV125 | PRV.010.125 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5200 | PRV125 | PRV.010.125 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "PRV00010" | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5201 | PRV126 | PRV.010.126 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5202 | PRV126 | PRV.010.126 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5203 | PRV126 | PRV.010.126 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5204 | PRV126 | PRV.010.126 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (PRV.001.007) | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5205 | PRV127 | PRV.010.127 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5206 | PRV127 | PRV.010.127 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5207 | PRV127 | PRV.010.127 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5208 | PRV127 | PRV.010.127 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5209 | PRV128 | PRV.010.128 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Mandatory | The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. | Value must be 30 characters or less | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5211 | PRV128 | PRV.010.128 | SUBMITTING-STATE-PROV-ID | Submitting State Provider ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5212 | PRV129 | PRV.010.129 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier _x000D_ value on a Provider Location & Contact Info (PRV00003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can _x000D_ be used in the PRV00004 or PRV00005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
Value must not contain a pipe symbol | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5213 | PRV129 | PRV.010.129 | PROV-LOCATION-ID | Provider Location ID | Not Applicable | Not Applicable | Value must be 5 characters or less | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5214 | PRV130 | PRV.010.130 | BED-TYPE-EFF-DATE | Bed Type Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5215 | PRV130 | PRV.010.130 | BED-TYPE-EFF-DATE | Bed Type Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5216 | PRV130 | PRV.010.130 | BED-TYPE-EFF-DATE | Bed Type Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5217 | PRV130 | PRV.010.130 | BED-TYPE-EFF-DATE | Bed Type Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5218 | PRV130 | PRV.010.130 | BED-TYPE-EFF-DATE | Bed Type Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5219 | PRV131 | PRV.010.131 | BED-TYPE-END-DATE | Bed Type End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5220 | PRV131 | PRV.010.131 | BED-TYPE-END-DATE | Bed Type End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5221 | PRV131 | PRV.010.131 | BED-TYPE-END-DATE | Bed Type End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5222 | PRV131 | PRV.010.131 | BED-TYPE-END-DATE | Bed Type End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5223 | PRV131 | PRV.010.131 | BED-TYPE-END-DATE | Bed Type End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5224 | PRV134 | PRV.010.134 | BED-TYPE-CODE | Bed Type Code | Mandatory | A code to classify beds available at a facility. | Value must be in Bed Type Code List (VVL) | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5225 | PRV134 | PRV.010.134 | BED-TYPE-CODE | Bed Type Code | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5226 | PRV134 | PRV.010.134 | BED-TYPE-CODE | Bed Type Code | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5227 | PRV135 | PRV.010.135 | BED-COUNT | Bed Count | Mandatory | A count of the number of beds available at the facility for the category of bed identified in the Bed Type Code data element. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T-MSIS Provider File"_x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47561 |
Value must be 5 digits or less | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5228 | PRV135 | PRV.010.135 | BED-COUNT | Bed Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| A2 | 5229 | PRV136 | PRV.010.136 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5230 | PRV136 | PRV.010.136 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| X1 | 5231 | PRV136 | PRV.010.136 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| D1 | 5232 | PRV137 | PRV.010.137 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | PROVIDER | PROV-BED-TYPE-INFO-PRV00010 |
| C2 | 5233 | TPL001 | TPL.001.001 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5234 | TPL001 | TPL.001.001 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "TPL00001" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5235 | TPL002 | TPL.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Mandatory | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary" to V2.4. | Value must be 10 characters or less | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5236 | TPL002 | TPL.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Value must not include the pipe ("|") symbol | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5237 | TPL002 | TPL.001.002 | DATA-DICTIONARY-VERSION | Data Dictionary Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5238 | TPL003 | TPL.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Mandatory | A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects. | Value must be in Submission Transaction Type List (VVL) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5239 | TPL003 | TPL.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5240 | TPL003 | TPL.001.003 | SUBMISSION-TRANSACTION-TYPE | Submission Transaction Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5241 | TPL004 | TPL.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | Value must be in File Encoding Specification List (VVL) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5242 | TPL004 | TPL.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Value must be 3 characters | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5243 | TPL004 | TPL.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5244 | TPL005 | TPL.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Mandatory | Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document | Value must be 9 characters or less | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5245 | TPL005 | TPL.001.005 | DATA-MAPPING-DOCUMENT-VERSION | Data Mapping Document Version | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5246 | TPL006 | TPL.001.006 | FILE-NAME | File Name | Not Applicable | A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only _x000D_ contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, _x000D_ Inpatient, Long-Term Care, Other, and Pharmacy Claim). |
Value must equal 'TPL-FILE' | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5247 | TPL007 | TPL.001.007 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5248 | TPL007 | TPL.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5249 | TPL007 | TPL.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5250 | TPL007 | TPL.001.007 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same for all records | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5251 | TPL008 | TPL.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | Value of the CC component must be "20" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5252 | TPL008 | TPL.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5253 | TPL008 | TPL.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5254 | TPL008 | TPL.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Value must be equal to or after the value of associated End of Time Period | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5255 | TPL008 | TPL.001.008 | DATE-FILE-CREATED | Date File Created | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5256 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. | Value of the CC component must be "20" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5257 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5258 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5259 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be less than current date | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5260 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5261 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Value must be before associated End of Time Period | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5262 | TPL009 | TPL.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5263 | TPL010 | TPL.001.010 | END-OF-TIME-PERIOD | End of Time Period | Mandatory | This value must be the last day of the reporting month, regardless of the actual date span. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5264 | TPL010 | TPL.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value of the CC component must be "20" | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5265 | TPL010 | TPL.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5266 | TPL010 | TPL.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or earlier than associated Date File Created | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5267 | TPL010 | TPL.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Value must be equal to or after associated Start of Time Period | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5268 | TPL010 | TPL.001.010 | END-OF-TIME-PERIOD | End of Time Period | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5269 | TPL011 | TPL.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | For production files, value must be equal to 'P' | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5270 | TPL011 | TPL.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5271 | TPL011 | TPL.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5272 | TPL012 | TPL.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability _x000D_ files. |
Value must be in SSN Indicator List (VVL) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5273 | TPL012 | TPL.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5274 | TPL012 | TPL.001.012 | SSN-INDICATOR | SSN Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5275 | TPL013 | TPL.001.013 | TOT-REC-CNT | Total Record Count | Mandatory | A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. | Value must be a positive integer | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5276 | TPL013 | TPL.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be between 0:99999999999 (inclusive) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5277 | TPL013 | TPL.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5278 | TPL013 | TPL.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Value must equal the number of records included in the file submission except for the file header record. | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5279 | TPL013 | TPL.001.013 | TOT-REC-CNT | Total Record Count | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5280 | TPL014 | TPL.001.014 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5281 | TPL014 | TPL.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5282 | TPL014 | TPL.001.014 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| D1 | 5283 | TPL015 | TPL.001.015 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5284 | TPL088 | TPL.001.088 | SEQUENCE-NUMBER | Sequence Number | Mandatory | To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, _x000D_ replacement files). This should begin with 1 for the original Create submission type and be incremented by one for _x000D_ each Replacement or Update submission for the same reporting period and file type (subject area). |
Value must between 1 and 9999 | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5285 | TPL088 | TPL.001.088 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5286 | TPL088 | TPL.001.088 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must not contain a pipe symbol | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| A2 | 5287 | TPL088 | TPL.001.088 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Value must be 4 characters or less | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| X1 | 5288 | TPL088 | TPL.001.088 | SEQUENCE-NUMBER | Sequence Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | FILE-HEADER-RECORD-TPL-TPL00001 |
| C2 | 5289 | TPL016 | TPL.002.016 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5290 | TPL016 | TPL.002.016 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "TPL00002" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5291 | TPL017 | TPL.002.017 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5292 | TPL017 | TPL.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5293 | TPL017 | TPL.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5294 | TPL017 | TPL.002.017 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (TPL.001.007) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5295 | TPL018 | TPL.002.018 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5296 | TPL018 | TPL.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5297 | TPL018 | TPL.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5298 | TPL018 | TPL.002.018 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5299 | TPL019 | TPL.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5300 | TPL019 | TPL.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5301 | TPL019 | TPL.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5302 | TPL019 | TPL.002.019 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5303 | TPL020 | TPL.002.020 | TPL-HEALTH-INSURANCE-COVERAGE-IND | TPL Health Insurance Coverage Indicator | Mandatory | A flag to indicate that the Medicaid/CHIP eligible person has some form of third party insurance coverage. | Value must be in TPL Health Insurance Coverage Indicator List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5304 | TPL020 | TPL.002.020 | TPL-HEALTH-INSURANCE-COVERAGE-IND | TPL Health Insurance Coverage Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C1 | 5305 | TPL020 | TPL.002.020 | TPL-HEALTH-INSURANCE-COVERAGE-IND | TPL Health Insurance Coverage Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5306 | TPL020 | TPL.002.020 | TPL-HEALTH-INSURANCE-COVERAGE-IND | TPL Health Insurance Coverage Indicator | Not Applicable | Not Applicable | When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5307 | TPL021 | TPL.002.021 | TPL-OTHER-COVERAGE-IND | TPL Other Coverage Indicator | Mandatory | A flag to indicate that the Medicaid/CHIP eligible person has some other form of third party funding besides insurance coverage. | Value must be in TPL Other Coverage Indicator List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5308 | TPL021 | TPL.002.021 | TPL-OTHER-COVERAGE-IND | TPL Other Coverage Indicator | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C1 | 5309 | TPL021 | TPL.002.021 | TPL-OTHER-COVERAGE-IND | TPL Other Coverage Indicator | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5310 | TPL022 | TPL.002.022 | ELIGIBLE-FIRST-NAME | Eligible First Name | Mandatory | The first name of the individual to whom the services were provided. | Value must be 30 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5311 | TPL022 | TPL.002.022 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C1 | 5312 | TPL022 | TPL.002.022 | ELIGIBLE-FIRST-NAME | Eligible First Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5313 | TPL023 | TPL.002.023 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Conditional | Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). | Value may include any alphanumeric characters, digits or symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5314 | TPL023 | TPL.002.023 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5315 | TPL023 | TPL.002.023 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5316 | TPL023 | TPL.002.023 | ELIGIBLE-MIDDLE-INIT | Eligible Middle Initial | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5317 | TPL024 | TPL.002.024 | ELIGIBLE-LAST-NAME | Eligible Last Name | Mandatory | The last name of the individual to whom the services were provided. | Value must be 30 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5318 | TPL024 | TPL.002.024 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C1 | 5319 | TPL024 | TPL.002.024 | ELIGIBLE-LAST-NAME | Eligible Last Name | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5320 | TPL025 | TPL.002.025 | ELIG-PRSN-MAIN-EFF-DATE | Eligible Person Main Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5321 | TPL025 | TPL.002.025 | ELIG-PRSN-MAIN-EFF-DATE | Eligible Person Main Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5322 | TPL025 | TPL.002.025 | ELIG-PRSN-MAIN-EFF-DATE | Eligible Person Main Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5323 | TPL025 | TPL.002.025 | ELIG-PRSN-MAIN-EFF-DATE | Eligible Person Main Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5324 | TPL025 | TPL.002.025 | ELIG-PRSN-MAIN-EFF-DATE | Eligible Person Main Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5325 | TPL025 | TPL.002.025 | ELIG-PRSN-MAIN-EFF-DATE | Eligible Person Main Effective Date | Not Applicable | Not Applicable | Value must be equal to or less than the individual's Date of Death (ELG.002.025) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5326 | TPL026 | TPL.002.026 | ELIG-PRSN-MAIN-END-DATE | Eligible Person Main End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5327 | TPL026 | TPL.002.026 | ELIG-PRSN-MAIN-END-DATE | Eligible Person Main End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5328 | TPL026 | TPL.002.026 | ELIG-PRSN-MAIN-END-DATE | Eligible Person Main End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5329 | TPL026 | TPL.002.026 | ELIG-PRSN-MAIN-END-DATE | Eligible Person Main End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5330 | TPL026 | TPL.002.026 | ELIG-PRSN-MAIN-END-DATE | Eligible Person Main End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| A2 | 5331 | TPL027 | TPL.002.027 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5332 | TPL027 | TPL.002.027 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| X1 | 5333 | TPL027 | TPL.002.027 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| D1 | 5334 | TPL028 | TPL.002.028 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 |
| C2 | 5335 | TPL029 | TPL.003.029 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5336 | TPL029 | TPL.003.029 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "TPL00003" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5337 | TPL030 | TPL.003.030 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5338 | TPL030 | TPL.003.030 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5339 | TPL030 | TPL.003.030 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5340 | TPL030 | TPL.003.030 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (TPL.001.007) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5341 | TPL031 | TPL.003.031 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5342 | TPL031 | TPL.003.031 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5343 | TPL031 | TPL.003.031 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5344 | TPL031 | TPL.003.031 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5345 | TPL032 | TPL.003.032 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5346 | TPL032 | TPL.003.032 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5347 | TPL032 | TPL.003.032 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5348 | TPL032 | TPL.003.032 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5349 | TPL033 | TPL.003.033 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Conditional | The state's internal identification number of the Third Party Liability Insurance carrier. | Value must be 12 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5350 | TPL033 | TPL.003.033 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5351 | TPL033 | TPL.003.033 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5352 | TPL034 | TPL.003.034 | INSURANCE-PLAN-ID | Insurance Plan ID | Conditional | The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. | Value must be 20 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5353 | TPL034 | TPL.003.034 | INSURANCE-PLAN-ID | Insurance Plan ID | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5354 | TPL034 | TPL.003.034 | INSURANCE-PLAN-ID | Insurance Plan ID | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5355 | TPL035 | TPL.003.035 | GROUP-NUM | Group Number | Conditional | The group number of the TPL health insurance policy. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5356 | TPL035 | TPL.003.035 | GROUP-NUM | Group Number | Not Applicable | Not Applicable | Value must be 16 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5357 | TPL035 | TPL.003.035 | GROUP-NUM | Group Number | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5358 | TPL036 | TPL.003.036 | MEMBER-ID | Member ID | Conditional | Member identification number as it appears on the card issued by the TPL insurance carrier. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5359 | TPL036 | TPL.003.036 | MEMBER-ID | Member ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5360 | TPL036 | TPL.003.036 | MEMBER-ID | Member ID | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5361 | TPL037 | TPL.003.037 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Conditional | Code to classify the type of insurance plan providing TPL coverage. | Value must be in Insurance Plan Type List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5362 | TPL037 | TPL.003.037 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5363 | TPL037 | TPL.003.037 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Not Applicable | Not Applicable | Value must be 2 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5364 | TPL037 | TPL.003.037 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Not Applicable | Not Applicable | Value must have an associated Insurance Plan ID | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5365 | TPL038 | TPL.003.038 | ANNUAL-DEDUCTIBLE-AMT | Annual Deductible Amount | Conditional | Annual amount paid each year by the enrollee in the plan before a health plan benefit begins. | Value must be between -99999999999.99 and 99999999999.99 | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5366 | TPL038 | TPL.003.038 | ANNUAL-DEDUCTIBLE-AMT | Annual Deductible Amount | Not Applicable | Not Applicable | Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5367 | TPL038 | TPL.003.038 | ANNUAL-DEDUCTIBLE-AMT | Annual Deductible Amount | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5368 | TPL044 | TPL.003.044 | POLICY-OWNER-FIRST-NAME | Policy Owner First Name | Not Applicable | Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). | Value must be 30 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5369 | TPL044 | TPL.003.044 | POLICY-OWNER-FIRST-NAME | Policy Owner First Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5370 | TPL044 | TPL.003.044 | POLICY-OWNER-FIRST-NAME | Policy Owner First Name | Not Applicable | Not Applicable | If TPL Health Insurance Coverage Indicator (TPL.002.020) equals "1", then value is mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5371 | TPL045 | TPL.003.045 | POLICY-OWNER-LAST-NAME | Policy Owner Last Name | Not Applicable | Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). | Value must be 30 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5372 | TPL045 | TPL.003.045 | POLICY-OWNER-LAST-NAME | Policy Owner Last Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5373 | TPL045 | TPL.003.045 | POLICY-OWNER-LAST-NAME | Policy Owner Last Name | Not Applicable | Not Applicable | If TPL Health Insurance Coverage Indicator (TPL.002.020) equals "1", then value is mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5374 | TPL046 | TPL.003.046 | POLICY-OWNER-SSN | Policy Owner SSN | Conditional | Unique identifier issued to an individual by the SSA for the purpose of identification. | Value must be 9-digit number | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5375 | TPL046 | TPL.003.046 | POLICY-OWNER-SSN | Policy Owner SSN | Not Applicable | Not Applicable | For any individual, the value must be the same over all segment effective and end dates | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5376 | TPL046 | TPL.003.046 | POLICY-OWNER-SSN | Policy Owner SSN | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5377 | TPL047 | TPL.003.047 | POLICY-OWNER-CODE | Policy Owner Code | Conditional | This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary. | Value must be in Policy Owner Code List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5378 | TPL047 | TPL.003.047 | POLICY-OWNER-CODE | Policy Owner Code | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5379 | TPL047 | TPL.003.047 | POLICY-OWNER-CODE | Policy Owner Code | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5380 | TPL048 | TPL.003.048 | INSURANCE-COVERAGE-EFF-DATE | Insurance Coverage Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5381 | TPL048 | TPL.003.048 | INSURANCE-COVERAGE-EFF-DATE | Insurance Coverage Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5382 | TPL048 | TPL.003.048 | INSURANCE-COVERAGE-EFF-DATE | Insurance Coverage Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5383 | TPL048 | TPL.003.048 | INSURANCE-COVERAGE-EFF-DATE | Insurance Coverage Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5384 | TPL048 | TPL.003.048 | INSURANCE-COVERAGE-EFF-DATE | Insurance Coverage Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5385 | TPL049 | TPL.003.049 | INSURANCE-COVERAGE-END-DATE | Insurance Coverage End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5386 | TPL049 | TPL.003.049 | INSURANCE-COVERAGE-END-DATE | Insurance Coverage End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5387 | TPL049 | TPL.003.049 | INSURANCE-COVERAGE-END-DATE | Insurance Coverage End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5388 | TPL049 | TPL.003.049 | INSURANCE-COVERAGE-END-DATE | Insurance Coverage End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5389 | TPL049 | TPL.003.049 | INSURANCE-COVERAGE-END-DATE | Insurance Coverage End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5390 | TPL049 | TPL.003.049 | INSURANCE-COVERAGE-END-DATE | Insurance Coverage End Date | Not Applicable | Not Applicable | When associated Date of Death (ELG.002.025) is populated, data element value must be less than or equal to Date of Death | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5391 | TPL050 | TPL.003.050 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5392 | TPL050 | TPL.003.050 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5393 | TPL050 | TPL.003.050 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| D1 | 5394 | TPL051 | TPL.003.051 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5395 | TPL089 | TPL.003.089 | COVERAGE-TYPE | Coverage Type | Mandatory | A code to indicate the level of coverage being provided under this policy for the insured by the TPL carrier. | Value must be in Coverage Type List (VVL). | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| A2 | 5396 | TPL089 | TPL.003.089 | COVERAGE-TYPE | Coverage Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| X1 | 5397 | TPL089 | TPL.003.089 | COVERAGE-TYPE | Coverage Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 |
| C2 | 5398 | TPL052 | TPL.004.052 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5399 | TPL052 | TPL.004.052 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "TPL00004" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5400 | TPL053 | TPL.004.053 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5401 | TPL053 | TPL.004.053 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5402 | TPL053 | TPL.004.053 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5403 | TPL053 | TPL.004.053 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (TPL.001.007) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5404 | TPL054 | TPL.004.054 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5405 | TPL054 | TPL.004.054 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5406 | TPL054 | TPL.004.054 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5407 | TPL054 | TPL.004.054 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5408 | TPL055 | TPL.004.055 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Mandatory | The state's internal identification number of the Third Party Liability Insurance carrier. | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5409 | TPL055 | TPL.004.055 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Not Applicable | Not Applicable | Value must be 12 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5410 | TPL055 | TPL.004.055 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5411 | TPL056 | TPL.004.056 | INSURANCE-PLAN-ID | Insurance Plan ID | Mandatory | The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiary's insurance card. | Value must not contain a pipe or asterisk symbol | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5412 | TPL056 | TPL.004.056 | INSURANCE-PLAN-ID | Insurance Plan ID | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5413 | TPL056 | TPL.004.056 | INSURANCE-PLAN-ID | Insurance Plan ID | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5414 | TPL057 | TPL.004.057 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Mandatory | Code to classify the entity providing TPL coverage. | Value must be in Insurance Plan Type List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C1 | 5415 | TPL057 | TPL.004.057 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5416 | TPL057 | TPL.004.057 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Not Applicable | Not Applicable | Value must be 2 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5417 | TPL057 | TPL.004.057 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Not Applicable | Not Applicable | Value must have an associated Insurance Plan ID | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5418 | TPL058 | TPL.004.058 | COVERAGE-TYPE | Coverage Type | Mandatory | This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary._x000D_ see Policy Owner Code List (VVL.099) |
Value must be in Coverage Type List (VVL). | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5419 | TPL058 | TPL.004.058 | COVERAGE-TYPE | Coverage Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C1 | 5420 | TPL058 | TPL.004.058 | COVERAGE-TYPE | Coverage Type | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5421 | TPL059 | TPL.004.059 | INSURANCE-CATEGORIES-EFF-DATE | Insurance Categories Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5422 | TPL059 | TPL.004.059 | INSURANCE-CATEGORIES-EFF-DATE | Insurance Categories Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5423 | TPL059 | TPL.004.059 | INSURANCE-CATEGORIES-EFF-DATE | Insurance Categories Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5424 | TPL059 | TPL.004.059 | INSURANCE-CATEGORIES-EFF-DATE | Insurance Categories Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5425 | TPL059 | TPL.004.059 | INSURANCE-CATEGORIES-EFF-DATE | Insurance Categories Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5426 | TPL060 | TPL.004.060 | INSURANCE-CATEGORIES-END-DATE | Insurance Categories End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5427 | TPL060 | TPL.004.060 | INSURANCE-CATEGORIES-END-DATE | Insurance Categories End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5428 | TPL060 | TPL.004.060 | INSURANCE-CATEGORIES-END-DATE | Insurance Categories End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5429 | TPL060 | TPL.004.060 | INSURANCE-CATEGORIES-END-DATE | Insurance Categories End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5430 | TPL060 | TPL.004.060 | INSURANCE-CATEGORIES-END-DATE | Insurance Categories End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| A2 | 5431 | TPL061 | TPL.004.061 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5432 | TPL061 | TPL.004.061 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| X1 | 5433 | TPL061 | TPL.004.061 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| D1 | 5434 | TPL062 | TPL.004.062 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 |
| C2 | 5435 | TPL063 | TPL.005.063 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5436 | TPL063 | TPL.005.063 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "TPL00005" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5437 | TPL064 | TPL.005.064 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5438 | TPL064 | TPL.005.064 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5439 | TPL064 | TPL.005.064 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5440 | TPL064 | TPL.005.064 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (TPL.001.007) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5441 | TPL065 | TPL.005.065 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5442 | TPL065 | TPL.005.065 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5443 | TPL065 | TPL.005.065 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5444 | TPL065 | TPL.005.065 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5445 | TPL066 | TPL.005.066 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier._x000D_ _x000D_ MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods._x000D_ _x000D_ See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the _x000D_ same MSIS Identification Number._x000D_ https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5446 | TPL066 | TPL.005.066 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5447 | TPL066 | TPL.005.066 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5448 | TPL066 | TPL.005.066 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Not Applicable | Not Applicable | Value must be 20 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5449 | TPL067 | TPL.005.067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Type of Other Third Party Liability | Mandatory | This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed INSURANCE-TYPE-PLAN. | If value equals "Other". then Policy Owner (TPL.003.044-047) information is not required | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5450 | TPL067 | TPL.005.067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Type of Other Third Party Liability | Not Applicable | Not Applicable | Value must be 1 character | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5451 | TPL067 | TPL.005.067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Type of Other Third Party Liability | Not Applicable | Not Applicable | Value must be in Type of Other Third Party Liability List (VVL) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C1 | 5452 | TPL067 | TPL.005.067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Type of Other Third Party Liability | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5453 | TPL068 | TPL.005.068 | OTHER-TPL-EFF-DATE | Other TPL Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5454 | TPL068 | TPL.005.068 | OTHER-TPL-EFF-DATE | Other TPL Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5455 | TPL068 | TPL.005.068 | OTHER-TPL-EFF-DATE | Other TPL Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5456 | TPL068 | TPL.005.068 | OTHER-TPL-EFF-DATE | Other TPL Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5457 | TPL068 | TPL.005.068 | OTHER-TPL-EFF-DATE | Other TPL Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5458 | TPL068 | TPL.005.068 | OTHER-TPL-EFF-DATE | Other TPL Effective Date | Not Applicable | Not Applicable | Value must occur on or before individual's Date of Death (ELG.002.025) when populated | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5459 | TPL069 | TPL.005.069 | OTHER-TPL-END-DATE | Other TPL End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5460 | TPL069 | TPL.005.069 | OTHER-TPL-END-DATE | Other TPL End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5461 | TPL069 | TPL.005.069 | OTHER-TPL-END-DATE | Other TPL End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5462 | TPL069 | TPL.005.069 | OTHER-TPL-END-DATE | Other TPL End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5463 | TPL069 | TPL.005.069 | OTHER-TPL-END-DATE | Other TPL End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| A2 | 5464 | TPL070 | TPL.005.070 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5465 | TPL070 | TPL.005.070 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| X1 | 5466 | TPL070 | TPL.005.070 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| D1 | 5467 | TPL071 | TPL.005.071 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 |
| C2 | 5468 | TPL072 | TPL.006.072 | RECORD-ID | Record ID | Mandatory | The Record Identifier element uniquely identifies each segment in a multi-segment entity record and is primarily used as a "key" to maintain referential integrity between data distributed over many segments for a particular entity. | Mandatory | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5469 | TPL072 | TPL.006.072 | RECORD-ID | Record ID | Not Applicable | Not Applicable | Value must equal "TPL00006" | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5470 | TPL073 | TPL.006.073 | SUBMITTING-STATE | Submitting State | Mandatory | A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5471 | TPL073 | TPL.006.073 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5472 | TPL073 | TPL.006.073 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5473 | TPL073 | TPL.006.073 | SUBMITTING-STATE | Submitting State | Not Applicable | Not Applicable | Value must be the same as Submitting State (TPL.001.007) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5474 | TPL074 | TPL.006.074 | RECORD-NUMBER | Record Number | Mandatory | A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. | Value must be unique within record segment over all records associated with a given Record ID | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5475 | TPL074 | TPL.006.074 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be greater than or equal to 1 | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5476 | TPL074 | TPL.006.074 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Value must be 11 digits or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5477 | TPL074 | TPL.006.074 | RECORD-NUMBER | Record Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5478 | TPL075 | TPL.006.075 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Mandatory | The state's internal identification number of the Third Party Liability Insurance carrier. | Value must be 12 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5479 | TPL075 | TPL.006.075 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5480 | TPL075 | TPL.006.075 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5481 | TPL076 | TPL.006.076 | TPL-ENTITY-ADDR-TYPE | TPL Entity Address Type | Conditional | The type of address for a TPL Entity submitted in the record segment. | Value must be in TPL Entity Address Type List (VVL) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5482 | TPL076 | TPL.006.076 | TPL-ENTITY-ADDR-TYPE | TPL Entity Address Type | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5483 | TPL076 | TPL.006.076 | TPL-ENTITY-ADDR-TYPE | TPL Entity Address Type | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5484 | TPL077 | TPL.006.077 | INSURANCE-CARRIER-ADDR-LN1 | Insurance Carrier Address Line 1 | Optional | The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5485 | TPL077 | TPL.006.077 | INSURANCE-CARRIER-ADDR-LN1 | Insurance Carrier Address Line 1 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 2 or Address Line 3 value(s) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5486 | TPL077 | TPL.006.077 | INSURANCE-CARRIER-ADDR-LN1 | Insurance Carrier Address Line 1 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5487 | TPL077 | TPL.006.077 | INSURANCE-CARRIER-ADDR-LN1 | Insurance Carrier Address Line 1 | Not Applicable | Not Applicable | When populated, the associated Address Type is required | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5488 | TPL077 | TPL.006.077 | INSURANCE-CARRIER-ADDR-LN1 | Insurance Carrier Address Line 1 | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5489 | TPL078 | TPL.006.078 | INSURANCE-CARRIER-ADDR-LN2 | Insurance Carrier Address Line 2 | Conditional | The second line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5490 | TPL078 | TPL.006.078 | INSURANCE-CARRIER-ADDR-LN2 | Insurance Carrier Address Line 2 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 3 value(s) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5491 | TPL078 | TPL.006.078 | INSURANCE-CARRIER-ADDR-LN2 | Insurance Carrier Address Line 2 | Not Applicable | Not Applicable | There must be an Address Line 1 in order to have an Address Line 2 | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5492 | TPL078 | TPL.006.078 | INSURANCE-CARRIER-ADDR-LN2 | Insurance Carrier Address Line 2 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5493 | TPL078 | TPL.006.078 | INSURANCE-CARRIER-ADDR-LN2 | Insurance Carrier Address Line 2 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5494 | TPL079 | TPL.006.079 | INSURANCE-CARRIER-ADDR-LN3 | Insurance Carrier Address Line 3 | Conditional | The third line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | Value must be 60 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5495 | TPL079 | TPL.006.079 | INSURANCE-CARRIER-ADDR-LN3 | Insurance Carrier Address Line 3 | Not Applicable | Not Applicable | Value must not be equal to associated Address Line 1 or Address Line 2 value(s) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5496 | TPL079 | TPL.006.079 | INSURANCE-CARRIER-ADDR-LN3 | Insurance Carrier Address Line 3 | Not Applicable | Not Applicable | If Address Line 2 is not populated, then value should not be populated | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5497 | TPL079 | TPL.006.079 | INSURANCE-CARRIER-ADDR-LN3 | Insurance Carrier Address Line 3 | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5498 | TPL079 | TPL.006.079 | INSURANCE-CARRIER-ADDR-LN3 | Insurance Carrier Address Line 3 | Not Applicable | Not Applicable | Conditional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5499 | TPL080 | TPL.006.080 | INSURANCE-CARRIER-CITY | Insurance Carrier City | Optional | The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). | Value must be 28 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5500 | TPL080 | TPL.006.080 | INSURANCE-CARRIER-CITY | Insurance Carrier City | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5501 | TPL080 | TPL.006.080 | INSURANCE-CARRIER-CITY | Insurance Carrier City | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5502 | TPL081 | TPL.006.081 | INSURANCE-CARRIER-STATE | Insurance Carrier State | Optional | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the TPL Insurance carrier. | Value must be in State Code List (VVL) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5503 | TPL081 | TPL.006.081 | INSURANCE-CARRIER-STATE | Insurance Carrier State | Not Applicable | Not Applicable | Value must be 2 characters | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5504 | TPL081 | TPL.006.081 | INSURANCE-CARRIER-STATE | Insurance Carrier State | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5505 | TPL082 | TPL.006.082 | INSURANCE-CARRIER-ZIP-CODE | Insurance Carrier Zip Code | Optional | The Zip Code for the location being captured on the TPL Entity Contact Information record. | Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5506 | TPL082 | TPL.006.082 | INSURANCE-CARRIER-ZIP-CODE | Insurance Carrier Zip Code | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5507 | TPL083 | TPL.006.083 | INSURANCE-CARRIER-PHONE-NUM | Insurance Carrier Phone Number | Optional | Phone number for a given entity (e.g. person, organization, agency). | Value must be 10 characters, digits (0-9) only | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5508 | TPL083 | TPL.006.083 | INSURANCE-CARRIER-PHONE-NUM | Insurance Carrier Phone Number | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5509 | TPL084 | TPL.006.084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | TPL Entity Contact Info Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5510 | TPL084 | TPL.006.084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | TPL Entity Contact Info Effective Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5511 | TPL084 | TPL.006.084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | TPL Entity Contact Info Effective Date | Not Applicable | Not Applicable | Value must be before or the same as the associated Segment End Date value | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5512 | TPL084 | TPL.006.084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | TPL Entity Contact Info Effective Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5513 | TPL084 | TPL.006.084 | TPL-ENTITY-CONTACT-INFO-EFF-DATE | TPL Entity Contact Info Effective Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20'] | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5514 | TPL085 | TPL.006.085 | TPL-ENTITY-CONTACT-INFO-END-DATE | TPL Entity Contact Info End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | Value must be 8 characters in the form "CCYYMMDD" | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5515 | TPL085 | TPL.006.085 | TPL-ENTITY-CONTACT-INFO-END-DATE | TPL Entity Contact Info End Date | Not Applicable | Not Applicable | The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5516 | TPL085 | TPL.006.085 | TPL-ENTITY-CONTACT-INFO-END-DATE | TPL Entity Contact Info End Date | Not Applicable | Not Applicable | Value must be greater than or equal to associated Segment Effective Date value | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5517 | TPL085 | TPL.006.085 | TPL-ENTITY-CONTACT-INFO-END-DATE | TPL Entity Contact Info End Date | Not Applicable | Not Applicable | Mandatory | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5518 | TPL085 | TPL.006.085 | TPL-ENTITY-CONTACT-INFO-END-DATE | TPL Entity Contact Info End Date | Not Applicable | Not Applicable | Value of the CC component must be in ['18', '19', '20', '99'] | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5519 | TPL086 | TPL.006.086 | STATE-NOTATION | State Notation | Optional | A free text field for the submitting state to enter whatever information it chooses. | Value must be 500 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5520 | TPL086 | TPL.006.086 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5521 | TPL086 | TPL.006.086 | STATE-NOTATION | State Notation | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| D1 | 5522 | TPL087 | TPL.006.087 | FILLER | Not Applicable | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5523 | TPL090 | TPL.006.090 | INSURANCE-CARRIER-NAIC-CODE | Insurance Carrier NAIC Code | Optional | The National Association of Insurance Commissioners (NAIC) code of the TPL Insurance carrier. | Value must be 10 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5524 | TPL090 | TPL.006.090 | INSURANCE-CARRIER-NAIC-CODE | Insurance Carrier NAIC Code | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5525 | TPL090 | TPL.006.090 | INSURANCE-CARRIER-NAIC-CODE | Insurance Carrier NAIC Code | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| A2 | 5526 | TPL091 | TPL.006.091 | INSURANCE-CARRIER-NAME | Insurance Carrier Name | Optional | The name of the TPL Insurance carrier. | Value must be 30 characters or less | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| C2 | 5527 | TPL091 | TPL.006.091 | INSURANCE-CARRIER-NAME | Insurance Carrier Name | Not Applicable | Not Applicable | Value must not contain a pipe or asterisk symbols | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| X1 | 5528 | TPL091 | TPL.006.091 | INSURANCE-CARRIER-NAME | Insurance Carrier Name | Not Applicable | Not Applicable | Optional | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| D1 | 5529 | TPL092 | TPL.006.092 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | National Health Care Entity ID Type | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| D1 | 5530 | TPL093 | TPL.006.093 | NATIONAL-HEALTH-CARE-ENTITY-ID | National Health Care Entity ID | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| D1 | 5531 | TPL094 | TPL.006.094 | NATIONAL-HEALTH-CARE-ENTITY-NAME | National Health Care Entity Name | Not Applicable | [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] | Not Applicable | 2/12/2021 | TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
| End of Sheet |
Sheet 3: Summ - Req Action Code Metrics
| Requirement Action Code Summary (Disclaimer: Each requirement during this specific data dictionary release is assigned an action code; metrics below summarize this action code.) | |
| Summary | Count |
| Total Requirement Count | 5,522 |
| A1: Add, new requirement from guidance | 42 |
| A2: Add, new testable requirement | 1,704 |
| Total Added | 1,746 |
| Total Added Percentage | 32% |
| C1: Change, material requirement impact | 180 |
| C2: Change, non-material requirement impact | 1,532 |
| Total Change | 1,712 |
| Total Changed Percentage | 31% |
| X1: No change from previous requirements | 1,933 |
| No change percentage | 35% |
| D1: No longer essential - Data element and/or associated requirement(s); preserved for file submission integrity. | 131 |
| No longer essential percentage | 2% |
| End of Sheet |
Sheet 4: RecSegment Keys & Constraints
| Record Segment Keys and Constraints (a) = Data element is part of the record segment key, but is not considered when evaluating the date constraints | |||||
| File Name | File Segment (with Record-ID) | Key Field Identifier | Data Element Name | Intra-Record Segment Constraints | Inter-Record Segment Constraints |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | 3 | 1115A-DEMONSTRATION-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | (a) | 1115A-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and 1115A-DEMONSTRATION-IND | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | 1115A-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and 1115A-DEMONSTRATION-IND | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | 1115A-DEMONSTRATION-INFORMATION-ELG00018 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | 3 | DISABILITY-TYPE-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | (a) | DISABILITY-TYPE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and DISABILITY-TYPE-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | DISABILITY-TYPE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and DISABILITY-TYPE-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | DISABILITY-INFORMATION-ELG00017 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 3 | MSIS-CASE-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | MEDICAID-BASIS-OF-ELIGIBILITY | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | DUAL-ELIGIBLE-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 4 | PRIMARY-ELIGIBILITY-GROUP-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | ELIGIBILITY-GROUP | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | LEVEL-OF-CARE-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSDI-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSI-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSI-STATE-SUPPLEMENT-STATUS-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | SSI-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | STATE-SPEC-ELIG-GROUP | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | CONCEPTION-TO-BIRTH-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | ELIGIBILITY-CHANGE-REASON | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | MAINTENANCE-ASSISTANCE-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | TPL-HEALTH-INSURANCE-COVERAGE-IND | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | TPL-OTHER-COVERAGE-IND | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIGIBLE-FIRST-NAME | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIGIBLE-LAST-NAME | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | (a) | ELIG-PRSN-MAIN-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | ELIG-PRSN-MAIN-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 3 | INSURANCE-CARRIER-ID-NUM | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 4 | INSURANCE-PLAN-ID | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 5 | GROUP-NUM | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | 6 | MEMBER-ID | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | INSURANCE-PLAN-TYPE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | COVERAGE-TYPE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | ANNUAL-DEDUCTIBLE-AMT | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-FIRST-NAME | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-LAST-NAME | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-SSN | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | POLICY-OWNER-CODE | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | (a) | INSURANCE-COVERAGE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, GROUP-NUM, MEMBER-ID, and COVERAGE-TYPE | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | INSURANCE-COVERAGE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, GROUP-NUM, MEMBER-ID, and COVERAGE-TYPE | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003 | Not Applicable | FILLER | Not Applicable | There must be both an active TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002 record segment and a TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 record in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | RECORD-ID | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 2 | INSURANCE-CARRIER-ID-NUM | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 3 | INSURANCE-PLAN-ID | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | INSURANCE-PLAN-TYPE | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | 4 | COVERAGE-TYPE | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | (a) | INSURANCE-CATEGORIES-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, and COVERAGE-TYPE | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | INSURANCE-CATEGORIES-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, INSURANCE-PLAN-ID, and COVERAGE-TYPE | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004 | Not Applicable | FILLER | Not Applicable | There must be an active TPL-ENTITY-CONTACT-INFORMATION-TPL00006 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | RECORD-ID | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | 3 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | (a) | OTHER-TPL-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | OTHER-TPL-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005 | Not Applicable | FILLER | Not Applicable | There must be an active TPL-ELIGIBLE-PERSON-MAIN-TPL00002 record segment in the current TPL file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | 2 | INSURANCE-CARRIER-ID-NUM | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | 3 | TPL-ENTITY-ADDR-TYPE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ADDR-LN1 | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ADDR-LN2 | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ADDR-LN3 | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-CITY | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-STATE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-ZIP-CODE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-PHONE-NUM | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | (a) | TPL-ENTITY-CONTACT-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, and TPL-ENTITY-ADDR-TYPE | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | TPL-ENTITY-CONTACT-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, INSURANCE-CARRIER-ID-NUM, and TPL-ENTITY-ADDR-TYPE | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-NAIC-CODE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | INSURANCE-CARRIER-NAME | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | Not Applicable |
| TPL | TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | RESTRICTED-BENEFITS-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | TANF-CASH-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | 5 | ELIGIBILITY-DETERMINANT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, and MSIS-CASE-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | ELIGIBILITY-DETERMINANT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM, and MSIS-CASE-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBILITY-DETERMINANTS-ELG00005 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | 3 | ADDR-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-LN1 | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-LN2 | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-LN3 | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-CITY | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ZIP-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-COUNTY-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-PHONE-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | TYPE-OF-LIVING-ARRANGEMENT | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 3 | PROV-CLASSIFICATION-TYPE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | 4 | PROV-CLASSIFICATION-CODE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | (a) | PROV-TAXONOMY-CLASSIFICATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-CLASSIFICATION-TYPE, PROV-CLASSIFICATION-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | PROV-TAXONOMY-CLASSIFICATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-CLASSIFICATION-TYPE, PROV-CLASSIFICATION-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-TAXONOMY-CLASSIFICATION-PRV00006 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | (a) | PROV-MEDICAID-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-MEDICAID-ENROLLMENT-STATUS-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | PROV-MEDICAID-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, and PROV-MEDICAID-ENROLLMENT-STATUS-CODE | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | 3 | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | STATE-PLAN-ENROLLMENT | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | PROV-ENROLLMENT-METHOD | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | APPL-DATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-MEDICAID-ENROLLMENT-PRV00007 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 3 | PROV-LOCATION-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | (a) | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | 4 | ADDR-TYPE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-LN1 | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-LN2 | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-LN3 | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-CITY | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-ZIP-CODE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-TELEPHONE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-EMAIL | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-FAX-NUM | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-BORDER-STATE-IND | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | ADDR-COUNTY | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LOCATION-AND-CONTACT-INFO-PRV00003 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current Provider file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 3 | PROV-LOCATION-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | (a) | PROV-LICENSE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | PROV-LICENSE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, LICENSE-TYPE, and LICENSE-ISSUING-ENTITY-ID | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 4 | LICENSE-TYPE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 5 | LICENSE-ISSUING-ENTITY-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | 6 | LICENSE-OR-ACCREDITATION-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-LICENSING-INFO-PRV00004 | Not Applicable | FILLER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current Provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 3 | PROV-LOCATION-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 4 | PROV-IDENTIFIER-TYPE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 5 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | (a) | PROV-IDENTIFIER-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, PROV-IDENTIFIER-TYPE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, and PROV-IDENTIFIER | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | PROV-IDENTIFIER-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, PROV-IDENTIFIER-TYPE, PROV-IDENTIFIER-ISSUING-ENTITY-ID, and PROV-IDENTIFIER | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | 6 | PROV-IDENTIFIER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-IDENTIFIERS-PRV00005 | Not Applicable | FILLER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | RECORD-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 1 | SUBMITTING-STATE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 3 | PROV-LOCATION-ID | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | (a) | BED-TYPE-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, and BED-TYPE-CODE | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | BED-TYPE-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, PROV-LOCATION-ID, and BED-TYPE-CODE | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | 4 | BED-TYPE-CODE | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | BED-COUNT | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | STATE-NOTATION | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-BED-TYPE-INFO-PRV00010 | Not Applicable | FILLER | Not Applicable | There must be both an active PROV-ATTRIBUTES-MAIN-PRV00002 record segment and a PROV-LOCATION-AND-CONTACT-INFO-PRV00003 record in the current provider file submission. In addition, the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | (a) | PROV-ATTRIBUTES-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-ATTRIBUTES-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-DOING-BUSINESS-AS-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-LEGAL-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-ORGANIZATION-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-TAX-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | FACILITY-GROUP-INDIVIDUAL-CODE | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | TEACHING-IND | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-FIRST-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-MIDDLE-INITIAL | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-LAST-NAME | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | SEX | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | OWNERSHIP-CODE | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | PROV-PROFIT-STATUS | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | DATE-OF-BIRTH | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | DATE-OF-DEATH | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | ACCEPTING-NEW-PATIENTS-IND | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| PROVIDER | PROV-ATTRIBUTES-MAIN-PRV00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 3 | AFFILIATED-PROGRAM-TYPE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | 4 | AFFILIATED-PROGRAM-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | (a) | PROV-AFFILIATED-PROGRAM-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, AFFILIATED-PROGRAM-TYPE, and AFFILIATED-PROGRAM-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | PROV-AFFILIATED-PROGRAM-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, SUBMITTING-STATE-PROV-ID, AFFILIATED-PROGRAM-TYPE, and AFFILIATED-PROGRAM-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-PROGRAMS-PRV00009 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for the SUBMITTING-STATE-PROV-ID and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | 2 | SUBMITTING-STATE-PROV-ID | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | 3 | SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | (a) | PROV-AFFILIATED-GROUP-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | PROV-AFFILIATED-GROUP-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and SUBMITTING-STATE-PROV-ID | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| PROVIDER | PROV-AFFILIATED-GROUPS-PRV00008 | Not Applicable | FILLER | Not Applicable | There must be an active PROV-ATTRIBUTES-MAIN-PRV00002 record in the current provider file submission for both the SUBMITTING-STATE-PROV-ID and the SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY, and the effective date span of the child record segment must be fully contained within the set of effective date spans of all active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | (a) | ELIGIBLE-ADDR-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE MSIS-IDENTIFICATION-NUM, and ADDR-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | ELIGIBLE-ADDR-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE MSIS-IDENTIFICATION-NUM, and ADDR-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELIGIBLE-CONTACT-INFORMATION-ELG00004 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | 3 | ENROLLMENT-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | (a) | ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ENROLLMENT-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ENROLLMENT-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ENROLLMENT-TIME-SPAN-SEGMENT-ELG00021 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 3 | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | 4 | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-NAME | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | (a) | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, NATIONAL-HEALTH-CARE-ENTITY-ID, and NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, NATIONAL-HEALTH-CARE-ENTITY-ID, and NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | 3 | ETHNICITY-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | (a) | ETHNICITY-DECLARATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ETHNICITY-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | ETHNICITY-DECLARATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and ETHNICITY-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ETHNICITY-INFORMATION-ELG00015 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | 3 | MANAGED-CARE-SERVICE-AREA-NAME | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | (a) | MANAGED-CARE-SERVICE-AREA-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-SERVICE-AREA-NAME | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | MANAGED-CARE-SERVICE-AREA-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-SERVICE-AREA-NAME | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-SERVICE-AREA-MCR00004 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | 3 | MANAGED-CARE-PLAN-POP | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | (a) | MANAGED-CARE-PLAN-POP-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-PLAN-POP | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | MANAGED-CARE-PLAN-POP-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, and MANAGED-CARE-PLAN-POP | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| ELIGIBLE | FILE-HEADER-RECORD-ELIGIBILITY-ELG00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 3 | OPERATING-AUTHORITY | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | 4 | WAIVER-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | (a) | MANAGED-CARE-OP-AUTHORITY-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, OPERATING-AUTHORITY, and WAIVER-ID | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | MANAGED-CARE-OP-AUTHORITY-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, OPERATING-AUTHORITY, and WAIVER-ID | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-OPERATING-AUTHORITY-MCR00005 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | 2 | STATE-PLAN-ID-NUM | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-CONTRACT-EFF-DATE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-CONTRACT-END-DATE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-NAME | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-PROGRAM | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | 3 | MANAGED-CARE-PLAN-TYPE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | REIMBURSEMENT-ARRANGEMENT | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-PROFIT-STATUS | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | CORE-BASED-STATISTICAL-AREA-CODE | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | PERCENT-BUSINESS | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-SERVICE-AREA | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | (a) | MANAGED-CARE-MAIN-REC-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and STATE-PLAN-ID-NUM | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | MANAGED-CARE-MAIN-REC-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and STATE-PLAN-ID-NUM | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-MAIN-MCR00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 3 | MANAGED-CARE-LOCATION-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | (a) | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, MANAGED-CARE-LOCATION-ID, and MANAGED-CARE-ADDR-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, MANAGED-CARE-LOCATION-ID, and MANAGED-CARE-ADDR-TYPE | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | 4 | MANAGED-CARE-ADDR-TYPE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ADDR-LN1 | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ADDR-LN2 | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ADDR-LN3 | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-CITY | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-ZIP-CODE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-COUNTY | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-TELEPHONE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-EMAIL | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | MANAGED-CARE-FAX-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | RECORD-ID | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | 3 | ACCREDITATION-ORGANIZATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | (a) | DATE-ACCREDITATION-ACHIEVED | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, ACCREDITATION-ORGANIZATION | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | DATE-ACCREDITATION-END | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, ACCREDITATION-ORGANIZATION | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | MANAGED- CARE-ACCREDITATION-ORGANIZATION-MCR00007 | Not Applicable | FILLER | Not Applicable | There must be an active MANAGED-CARE-MAIN-MCR00002 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | 3 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | (a) | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 3 | HEALTH-HOME-CHRONIC-CONDITION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | 4 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | (a) | HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-CHRONIC-CONDITION, and HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | HEALTH-HOME-CHRONIC-CONDITION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-CHRONIC-CONDITION, and HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 3 | HEALTH-HOME-SPA-NAME | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | 4 | HEALTH-HOME-ENTITY-NAME | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | (a) | HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, and HEALTH-HOME-ENTITY-NAME | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | HEALTH-HOME-SPA-PARTICIPATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, and HEALTH-HOME-ENTITY-NAME | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | RECORD-ID | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 3 | HEALTH-HOME-SPA-NAME | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 4 | HEALTH-HOME-ENTITY-NAME | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | 5 | HEALTH-HOME-PROV-NUM | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | (a) | HEALTH-HOME-SPA-PROVIDER-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, HEALTH-HOME-ENTITY-NAME, and HEALTH-HOME-PROV-NUM | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | HEALTH-HOME-SPA-PROVIDER-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, HEALTH-HOME-SPA-NAME, HEALTH-HOME-ENTITY-NAME, and HEALTH-HOME-PROV-NUM | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | HEALTH-HOME-ENTITY-EFF-DATE | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | HEALTH-HOME-SPA-PROVIDERS-ELG00007 | Not Applicable | FILLER | Not Applicable | There must be an active HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 3 | LOCKIN-PROV-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | 4 | LOCKIN-PROV-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | (a) | LOCKIN-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LOCKIN-PROV-NUM, and LOCKIN-PROV-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | LOCKIN-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LOCKIN-PROV-NUM, and LOCKIN-PROV-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LOCK-IN-INFORMATION-ELG00009 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 3 | LTSS-LEVEL-CARE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | 4 | LTSS-PROV-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | (a) | LTSS-ELIGIBILITY-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LTSS-LEVEL-CARE, and LTSS-PROV-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | LTSS-ELIGIBILITY-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, LTSS-LEVEL-CARE, and LTSS-PROV-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | LTSS-PARTICIPATION-ELG00013 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| TPL | FILE-HEADER-RECORD-TPL-TPL00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMRX | FILE-HEADER-RECORD-RX-CRX00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| PROVIDER | FILE-HEADER-RECORD-PROVIDER-PRV00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMOT | FILE-HEADER-RECORD-OT-COT00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| MNGDCARE | FILE-HEADER-RECORD-MANAGED-CARE-MCR00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMLT | FILE-HEADER-RECORD-LT-CLT00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | DATA-DICTIONARY-VERSION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SUBMISSION-TRANSACTION-TYPE | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILE-ENCODING-SPECIFICATION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | DATA-MAPPING-DOCUMENT-VERSION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILE-NAME | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SUBMITTING-STATE | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | DATE-FILE-CREATED | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | START-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | END-OF-TIME-PERIOD | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILE-STATUS-INDICATOR | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SSN-INDICATOR | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | TOT-REC-CNT | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | SEQUENCE-NUMBER | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| CLAIMIP | FILE-HEADER-RECORD-IP-CIP00001 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 3 | MANAGED-CARE-PLAN-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | 4 | MANAGED-CARE-PLAN-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | (a) | MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and MANAGED-CARE-PLAN-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and MANAGED-CARE-PLAN-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MANAGED-CARE-PARTICIPATION-ELG00014 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-LIVES-WITH-FAMILY | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-QUALIFIED-INSTITUTION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-QUALIFIED-RESIDENCE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-REASON-PARTICIPATION-ENDED | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-REINSTITUTIONALIZED-REASON | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | (a) | MFP-ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | MFP-ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | MFP-INFORMATION-ELG00010 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | RECORD-ID | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | 1 | SUBMITTING-STATE | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | RECORD-NUMBER | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | ELIGIBLE-FIRST-NAME | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | ELIGIBLE-LAST-NAME | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | SEX | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | DATE-OF-BIRTH | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | DATE-OF-DEATH | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | (a) | PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | STATE-NOTATION | Not Applicable | Not Applicable |
| ELIGIBLE | PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 | Not Applicable | FILLER | Not Applicable | Not Applicable |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 3 | RACE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | 4 | RACE-OTHER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | AMERICAN-INDIAN/ALASKAN-NATIVE-INDICATOR | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | (a) | RACE-DECLARATION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, RACE, and RACE-OTHER | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | RACE-DECLARATION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, RACE, and RACE-OTHER | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | RACE-INFORMATION-ELG00016 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | 3 | STATE-PLAN-OPTION-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | (a) | STATE-PLAN-OPTION-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and STATE-PLAN-OPTION-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | STATE-PLAN-OPTION-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and STATE-PLAN-OPTION-TYPE | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | STATE-PLAN-OPTION-PARTICIPATION-ELG00011 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MARITAL-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MARITAL-STATUS-OTHER-EXPLANATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | SSN | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | SSN-VERIFICATION-FLAG | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | INCOME-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | VETERAN-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | CITIZENSHIP-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | CITIZENSHIP-VERIFICATION-FLAG | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | IMMIGRATION-STATUS | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | IMMIGRATION-VERIFICATION-FLAG | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | PRIMARY-LANGUAGE-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | HOUSEHOLD-SIZE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | PREGNANCY-IND | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MEDICARE-HIC-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | CHIP-CODE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | (a) | VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE and MSIS-IDENTIFICATION-NUM | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | RECORD-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. --ADJUSTMENT-IND (LINE-ADJUSTMENT-IND) |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | HCBS-SERVICE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | HCBS-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DAYS-SUPPLY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | NEW-REFILL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | BRAND-GENERIC-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DISPENSE-FEE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | PRESCRIPTION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DRUG-UTILIZATION-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | DTL-METRIC-DEC-QTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | COMPOUND-DOSAGE-FORM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | REBATE-ELIGIBLE-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-LINE-RECORD-RX-CRX00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-RX-COT00002 record in the current RX claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | REVENUE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-FLAG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OT-RX-CLAIM-QUANTITY-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | HCBS-SERVICE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | HCBS-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SERVICING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-DESIGNATION-SYSTEM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-QUAD-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | TOOTH-SURFACE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-ADDR-LN1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-ADDR-LN2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-CITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | ORIGINATION-ZIP-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-ADDR-LN1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-ADDR-LN2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-CITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | DESTINATION-ZIP-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PROCEDURE-CODE-MOD-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | HCPCS-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | NDC-UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | NDC-QUANTITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMOT | CLAIM-LINE-RECORD-OT-COT00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-OT-COT00002 record in the current OT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE. -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | REVENUE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | REVENUE-CHARGE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | BILLING-UNIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SERVICING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | PROV-FACILITY-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | NDC-UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | NDC-QUANTITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | HCPCS-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMLT | CLAIM-LINE-RECORD-LT-CLT00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-LT-CLT00002 record in the current LT claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 4 | LINE-NUM-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 5 | LINE-NUM-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 6 | LINE-ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | LINE-ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | CLAIM-LINE-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | REVENUE-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | IMMUNIZATION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ACTUAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | REVENUE-CHARGE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | MEDICAID-FFS-EQUIVALENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | BILLING-UNIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | TYPE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SERVICING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | OPERATING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | PROV-FACILITY-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | BENEFIT-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | XIX-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | XXI-MBESCBES-CATEGORY-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | HCPCS-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | NATIONAL-DRUG-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | NDC-UNIT-OF-MEASURE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | NDC-QUANTITY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | 7 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | SELF-DIRECTION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | PRE-AUTHORIZATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMIP | CLAIM-LINE-RECORD-IP-CIP00003 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | There must be an active CLAIM-HEADER-RECORD-IP-CIP00002 record in the current IP claim file submission that matches on: -- SUBMITTING-STATE -- ICN-ORIG -- ICN-ADJ -- ADJUDICATION-DATE -- ADJUSTMENT-IND (LINE-ADJUSTMENT-IND). |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIBING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DATE-PRESCRIBED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PRESCRIPTION-FILL-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | COMPOUND-DRUG-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMRX | CLAIM-HEADER-RECORD-RX-CRX00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TYPE-OF-BILL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-CARE-ACQUIRED-CONDITION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REFERRING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PLACE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BMI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DAILY-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | DATE-CAPITATED-AMOUNT-REQUESTED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | CAPITATED-PAYMENT-AMT-REQUESTED | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMOT | CLAIM-HEADER-RECORD-OT-COT00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE-FLAG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DIAGNOSIS-POA-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMISSION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMISSION-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DISCHARGE-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DISCHARGE-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BEGINNING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ENDING-DATE-OF-SERVICE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TYPE-OF-BILL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NON-COV-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NON-COV-CHARGES | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICAID-COV-INPATIENT-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-CARE-ACQUIRED-CONDITION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REFERRING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PATIENT-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BMI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | LTC-RCP-LIAB-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | DAILY-RATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ICF-IID-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | LEAVE-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | NURSING-FACILITY-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | SPLIT-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | ADMITTING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMLT | CLAIM-HEADER-RECORD-LT-CLT00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | RECORD-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 1 | SUBMITTING-STATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | RECORD-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 2 | ICN-ORIG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 3 | ICN-ADJ | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SUBMITTER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MSIS-IDENTIFICATION-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CROSSOVER-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TYPE-OF-HOSPITAL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | 1115A-DEMONSTRATION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 4 | ADJUSTMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADJUSTMENT-REASON-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMISSION-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DRG-DESCRIPTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-DIAGNOSIS-CODE-FLAG | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-7 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-7 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-7 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-8 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-8 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-8 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-9 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-9 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-9 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-11 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-11 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-11 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-12 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-CODE-FLAG-12 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-POA-FLAG-12 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-RELATED-GROUP | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DIAGNOSIS-RELATED-GROUP-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-5 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-MOD-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-FLAG-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROCEDURE-CODE-DATE-6 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMISSION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMISSION-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DISCHARGE-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DISCHARGE-HOUR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | 5 | ADJUDICATION-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICAID-PAID-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TYPE-OF-CLAIM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TYPE-OF-BILL | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-STATUS-CATEGORY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SOURCE-LOCATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CHECK-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CHECK-EFF-DATE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ALLOWED-CHARGE-SRC | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-1 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-2 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-3 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-PYMT-REM-CODE-4 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-BILLED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-ALLOWED-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-MEDICAID-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-COPAY-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-MEDICARE-DEDUCTIBLE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-MEDICARE-COINS-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-TPL-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | TOT-OTHER-INSURANCE-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OTHER-INSURANCE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OTHER-TPL-COLLECTION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SERVICE-TRACKING-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SERVICE-TRACKING-PAYMENT-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FIXED-PAYMENT-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FUNDING-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FUNDING-SOURCE-NONFEDERAL-SHARE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-COMB-DED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROGRAM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PLAN-ID-NUMBER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | NATIONAL-HEALTH-CARE-ENTITY-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PAYMENT-LEVEL-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-REIM-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | NON-COV-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | NON-COV-CHARGES | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICAID-COV-INPATIENT-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-LINE-COUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FORCED-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-CARE-ACQUIRED-CONDITION-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-EFF-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-01 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-02 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-03 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-04 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-05 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-06 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-07 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-08 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-09 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OCCURRENCE-CODE-END-DATE-10 | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BIRTH-WEIGHT-GRAMS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PATIENT-CONTROL-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ELIGIBLE-LAST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ELIGIBLE-FIRST-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ELIGIBLE-MIDDLE-INIT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DATE-OF-BIRTH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-HOME-PROV-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | WAIVER-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | WAIVER-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BILLING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | ADMITTING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-NPI-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-TYPE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REFERRING-PROV-SPECIALTY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DRG-OUTLIER-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | DRG-REL-WEIGHT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-HIC-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OUTLIER-CODE | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OUTLIER-DAYS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PATIENT-STATUS | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BMI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | REMITTANCE-NUM | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | SPLIT-CLAIM-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BORDER-STATE-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COINSURANCE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COPAYMENT-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-AMOUNT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | BENEFICIARY-DEDUCTIBLE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | CLAIM-DENIED-INDICATOR | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | COPAY-WAIVED-IND | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-HOME-ENTITY-NAME | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COINSURANCE-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | THIRD-PARTY-COPAYMENT-DATE-PAID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICAID-AMOUNT-PAID-DSH | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | HEALTH-HOME-PROVIDER-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-BENEFICIARY-IDENTIFIER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | OPERATING-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-DIRECTION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-NPI | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | UNDER-SUPERVISION-OF-PROV-TAXONOMY | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | MEDICARE-PAID-AMT | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | STATE-NOTATION | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | PROV-LOCATION-ID | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| CLAIMIP | CLAIM-HEADER-RECORD-IP-CIP00002 | Not Applicable | FILLER | None. The claim (or encounter record) should be submitted as it was adjudicated (or received) | Not Applicable |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | RECORD-ID | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 2 | STATE-PLAN-ID-NUM | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 3 | CHPID | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | 4 | SHPID | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | (a) | CHPID-SHPID-RELATIONSHIP-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, CHPID, and SHPID | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | CHPID-SHPID-RELATIONSHIP-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, STATE-PLAN-ID-NUM, CHPID, and SHPID | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| MNGDCARE | CHPID-SHPID-RELATIONSHIPS-MCR00009 | Not Applicable | FILLER | Not Applicable | There must be an active NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 record in the current Managed Care file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | 1 | SUBMITTING-STATE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | RECORD-NUMBER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | 3 | WAIVER-ID | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | WAIVER-TYPE | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | (a) | WAIVER-ENROLLMENT-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and WAIVER-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | WAIVER-ENROLLMENT-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM, and WAIVER-ID | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | STATE-NOTATION | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | WAIVER-PARTICIPATION-ELG00012 | Not Applicable | FILLER | Not Applicable | There must be an active PRIMARY DEMOGRAPHICS - ELIGIBILITY-ELG00002 record in the current Eligibility file submission, and the effective date span of the child record segment must be fully contained within the set of effective date spans of the associated active parent records. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | RECORD-ID | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | 1 | SUBMITTING-STATE | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | RECORD-NUMBER | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | 2 | MSIS-IDENTIFICATION-NUM | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | 3 | ELG-IDENTIFIER-TYPE | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | 4 | ELG-IDENTIFIER | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | ELG-IDENTIFIER-ISSUING-ENTITY-ID | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | (a) | ELG-IDENTIFIER-EFF-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION NUM, and ELG-IDENTIFIER-TYPE | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | ELG-IDENTIFIER-END-DATE | No overlapping date spans for a given combination of SUBMITTING-STATE, MSIS-IDENTIFICATION NUM, and ELG-IDENTIFIER-TYPE | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | REASON-FOR-CHANGE | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | STATE-NOTATION | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| ELIGIBLE | ELG-IDENTIFIERS-ELG00022 | Not Applicable | FILLER | Not Applicable | Both ELG-IDENTIFIER-EFF-DATE and ELG-IDENTIFIER-END-DATE must be valid dates and fall within a corresponding time span for the same SUBMITTING-STATE, MSIS-IDENTIFICATION-NUM combination in the PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002 segment. |
| End of Sheet |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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