Transformed - Medicaid Statistical Information System (T-MSIS)
[Medicaid] Transformed - Medicaid Statistical Information System (T-MSIS) (CMS-R-284)
T-MSIS Data Dictionary v4.0.0 508.xlsx
Transformed - Medicaid Statistical Information System (T-MSIS)
OMB: 0938-0345
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v4.0.0 DD Data Dictionary
Overview
Cover Pagev4.0.0 DD Data Dictionary
Sheet 1: Cover Page
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| Centers for Medicaid and CHIP Services (CMCS) | ||||
| Transformed Medicaid Statistical Information System (T-MSIS) | ||||
| Data Dictionary | ||||
| Version: v4.0.0 | ||||
| Last Modified: 2024-06-03 | ||||
| PRA Disclosure Statement: The Transformed Medicaid Statistical Information System (T-MSIS) is used to assist the Centers for Medicare & Medicaid Services (CMS) with monitoring and oversight of Medicaid and CHIP programs, to enable evaluation of demonstrations under section 1115 of the Social Security Act | ||||
| and to calculate quality measures and other metrics, including those reported through the new Medicaid and CHIP Scoreboard. Section 4735 of the Balanced Budget Act of 1997 included a statutory requirement for states to submit claims data, enrollee encounter data, and supporting information. Section 6504 of the Affordable Care Act strengthened | ||||
| this provision by requiring states to include data elements the Secretary determines necessary for program integrity, program oversight, and administration. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are | ||||
| required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0345 (Expires: 03/31/2026). The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, | ||||
| search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. | ||||
Sheet 2: v4.0.0 DD Data Dictionary
| V4.0.0 - Data Dictionary | Note: The new financial transactions file type and associated segments are listed under "File Segment Number" heading starting with "FTX" | |||||||||||||
| New Row Number |
Data Element Number |
System Data Element Number |
Data Element |
Data Element Name Text |
Data Element Necessity |
Definition |
Valid Value List (VVL) |
File Segment Number |
File Segment Name |
Size |
Pipe Separated Value Segment Data Element Order |
Fixed Length Field Start Position |
Fixed Length Field Stop Position |
Coding Requirements |
| 1 | CIP001 | CIP.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CIP00001 | FILE-HEADER-RECORD-IP | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CIP00001" |
| 2 | 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. | DATA-DICTIONARY-VERSION | CIP00001 | FILE-HEADER-RECORD-IP | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 3 | 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. | SUBMISSION-TRANSACTION-TYPE | CIP00001 | FILE-HEADER-RECORD-IP | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 4 | CIP004 | CIP.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | CIP00001 | FILE-HEADER-RECORD-IP | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 5 | 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. | N/A | CIP00001 | FILE-HEADER-RECORD-IP | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 6 | 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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | CIP00001 | FILE-HEADER-RECORD-IP | X(8) | 6 | 32 | 39 | 1. Value must equal "CLAIM-IP" 2. Mandatory |
| 7 | 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. | STATE | CIP00001 | FILE-HEADER-RECORD-IP | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 8 | CIP008 | CIP.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | CIP00001 | FILE-HEADER-RECORD-IP | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 9 | 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. | N/A | CIP00001 | FILE-HEADER-RECORD-IP | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 10 | 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. | N/A | CIP00001 | FILE-HEADER-RECORD-IP | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 11 | 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. | FILE-STATUS-INDICATOR | CIP00001 | FILE-HEADER-RECORD-IP | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 12 | 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 files. | SSN-INDICATOR | CIP00001 | FILE-HEADER-RECORD-IP | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 13 | 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. | N/A | CIP00001 | FILE-HEADER-RECORD-IP | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 14 | 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 original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | CIP00001 | FILE-HEADER-RECORD-IP | X(4) | 14 | 79 | 82 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 15 | CIP014 | CIP.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CIP00001 | FILE-HEADER-RECORD-IP | X(500) | 15 | 83 | 582 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 16 | CIP016 | CIP.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CIP00002" |
| 17 | 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. | STATE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CIP.001.007) |
| 18 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 19 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 20 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 21 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 6 | 122 | 133 | 1. Value must be 12 characters or less 2. Mandatory |
| 22 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(20) | 7 | 134 | 153 | 1. Value must be 20 characters or less 2. Mandatory 3. 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) |
| 23 | CIP023 | CIP.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Mandatory | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | CROSSOVER-INDICATOR | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 8 | 154 | 154 | 1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 24 | CIP024 | CIP.002.024 | TYPE-OF-HOSPITAL | Type of Hospital | Mandatory | This code denotes the type of hospital on the claim (servicing facility). | TYPE-OF-HOSPITAL | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 9 | 155 | 156 | 1. Value must be 2 characters 2. Value must be in Type of Hospital List (VVL) 3. Mandatory |
| 25 | CIP025 | CIP.002.025 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration. | 1115A-DEMONSTRATION-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 10 | 157 | 157 | 1. Value must be 1 character 2. Value must be in 1115A Demonstration Indicator List (VVL) 3. Conditional 4. When value equals "0", is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 26 | CIP026 | CIP.002.026 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 11 | 158 | 158 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" |
| 27 | 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. | ADJUSTMENT-REASON-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(3) | 12 | 159 | 161 | 1. Value must be 3 characters or less 2. Value must be in Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 28 | 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. | ADMISSION-TYPE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 13 | 162 | 162 | 1. Value must be 1 character 2. Value must be in Admission Type List (VVL) 3. Mandatory |
| 29 | CIP029 | CIP.002.029 | DRG-DESCRIPTION | DRG Description | Conditional | Description of the associated state-specific DRG code. If using standard MS-DRG classification system, leave blank. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(20) | 14 | 163 | 182 | 1. Value must be 20 characters or less 2. Conditional |
| 30 | 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 which diagnosis related groups are used to determine paid amounts. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(4) | 15 | 183 | 186 | 1. Value must be 4 characters or less 2. Conditional |
| 31 | 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. Values are generated by combining two types of information: Position 1-2, State/Group generating DRG: If state specific system, fill with two digit US postal code representation for state. If CMS Grouper, fill with 'HG'. If any other system, fill with 'XX'. Position 3-4, fill with the number that represents the DRG version used (01-98). For example, 'HG15' would represent CMS Grouper version 15. If version is unknown, fill with '99'. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(4) | 16 | 187 | 190 | 1. Value must be 4 characters or less 2. The right-most 2 positions must be found in [01-99] 3. Conditional 4. Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated |
| 32 | 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 Code1, Procedure Code Date-1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures. | PROCEDURE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 17 | 191 | 198 | 1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag 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 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 33 | 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. | PROCEDURE-CODE-FLAG | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 18 | 199 | 200 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. Conditional 4. When populated, there must be a corresponding Procedure Code 5. 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) |
| 34 | CIP073 | CIP.002.073 | PROCEDURE-CODE-DATE-1 | Procedure Code Date 1 | Conditional | The date upon which a reported medical procedure was performed. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 19 | 201 | 208 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 35 | 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 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures. | PROCEDURE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 20 | 209 | 216 | 1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag 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 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 36 | 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. | PROCEDURE-CODE-FLAG | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 21 | 217 | 218 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. Conditional 4. When populated, there must be a corresponding Procedure Code |
| 37 | CIP077 | CIP.002.077 | PROCEDURE-CODE-DATE-2 | Procedure Code Date 2 | Conditional | The date upon which a reported medical procedure was performed. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 22 | 219 | 226 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 38 | 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 Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures. | PROCEDURE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 23 | 227 | 234 | 1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag 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 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 39 | 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. | PROCEDURE-CODE-FLAG | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 24 | 235 | 236 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. Conditional 4. When populated, there must be a corresponding Procedure Code |
| 40 | CIP081 | CIP.002.081 | PROCEDURE-CODE-DATE-3 | Procedure Code Date 3 | Conditional | The date upon which a reported medical procedure was performed. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 25 | 237 | 244 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 41 | 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 Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures. | PROCEDURE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 26 | 245 | 252 | 1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag 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 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 42 | 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. | PROCEDURE-CODE-FLAG | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 27 | 253 | 254 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. Conditional 4. When populated, there must be a corresponding Procedure Code |
| 43 | CIP085 | CIP.002.085 | PROCEDURE-CODE-DATE-4 | Procedure Code Date 4 | Conditional | The date upon which a reported medical procedure was performed. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 28 | 255 | 262 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 44 | 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 Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures. | PROCEDURE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 29 | 263 | 270 | 1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag 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 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 45 | CIP088 | CIP.002.088 | PROCEDURE-CODE-FLAG-5 | Procedure Code Flag 5 | Conditional | A flag that identifies the coding system used for an associated procedure code. | PROCEDURE-CODE-FLAG | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 30 | 271 | 272 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. Conditional 4. When populated, there must be a corresponding Procedure Code |
| 46 | CIP089 | CIP.002.089 | PROCEDURE-CODE-DATE-5 | Procedure Code Date 5 | Conditional | The date upon which a reported medical procedure was performed. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 31 | 273 | 280 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 47 | 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 Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures. | PROCEDURE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(8) | 32 | 281 | 288 | 1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag 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 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 48 | 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. | PROCEDURE-CODE-FLAG | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 33 | 289 | 290 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. Conditional 4. When populated, there must be a corresponding Procedure Code |
| 49 | CIP093 | CIP.002.093 | PROCEDURE-CODE-DATE-6 | Procedure Code Date 6 | Conditional | The date upon which a reported medical procedure was performed. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 34 | 291 | 298 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 50 | CIP094 | CIP.002.094 | ADMISSION-DATE | Admission Date | Mandatory | The date on which the recipient was admitted to a hospital. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 35 | 299 | 306 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated Discharge Date value in the claim header 3. Value must be greater than or equal to associated eligible Date of Birth value 4. Value must be less than or equal to associated eligible Date of Death value 5. Mandatory 6. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) 7. Value must be before Adjudication Date (CIP.003.286) |
| 51 | CIP095 | CIP.002.095 | ADMISSION-HOUR | Admission Hour | Conditional | The hour of admission to a hospital. | HOUR | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 36 | 307 | 308 | 1. Value must be 2 characters 2. Value must be in Hour List (VVL) 3. Conditional |
| 52 | CIP096 | CIP.002.096 | DISCHARGE-DATE | Discharge Date | Conditional | The date on which the recipient was discharged from a hospital. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 37 | 309 | 316 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated Adjudication Date value. 3. Value must be greater than or equal to associated Admission Date value. 4. Value must be greater than or equal to associated eligible Date of Birth value. 5. Value must be less than or equal to associated eligible Date of Death value. 6. Conditional 7. 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. 8. When populated, Discharge Hour (CIP.002.097) must be populated |
| 53 | CIP097 | CIP.002.097 | DISCHARGE-HOUR | Discharge Hour | Conditional | The hour of discharge from a hospital. | HOUR | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 38 | 317 | 318 | 1. Value must be 2 characters 2. Value must be in Hour List (VVL) 3. Conditional 4. When populated, Discharge Date (CIP.002.096) must be populated |
| 54 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 39 | 319 | 326 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CIP.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 55 | CIP099 | CIP.002.099 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 40 | 327 | 334 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Total Medicaid Paid Amount 3. Mandatory |
| 56 | CIP100 | CIP.002.100 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. | TYPE-OF-CLAIM | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 41 | 335 | 335 | 1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 57 | 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.) | TYPE-OF-BILL | CIP00002 | CLAIM-HEADER-RECORD-IP | X(4) | 42 | 336 | 339 | 1. Value must be 4 characters 2. Value must be in Type of Bill List (VVL) 3. First character must be a "0" 4. Mandatory |
| 58 | CIP102 | CIP.002.102 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim. | CLAIM-STATUS | CIP00002 | CLAIM-HEADER-RECORD-IP | X(3) | 43 | 340 | 342 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 59 | 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. | CLAIM-STATUS-CATEGORY | CIP00002 | CLAIM-HEADER-RECORD-IP | X(3) | 44 | 343 | 345 | 1. Value must be 3 characters or less 2. Value must be in Claim Status Category List (VVL) 3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" 4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2" 5. Mandatory |
| 60 | CIP104 | CIP.002.104 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
SOURCE-LOCATION | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 45 | 346 | 347 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 61 | CIP105 | CIP.002.105 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(15) | 46 | 348 | 362 | 1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 62 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 47 | 363 | 370 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional |
| 63 | CIP108 | CIP.002.108 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(5) | 48 | 371 | 375 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique |
| 64 | CIP109 | CIP.002.109 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(5) | 49 | 376 | 380 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 1 (CIP.002.108) is not populated |
| 65 | CIP110 | CIP.002.110 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(5) | 50 | 381 | 385 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 2 (CIP.002.109) is not populated |
| 66 | CIP111 | CIP.002.111 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(5) | 51 | 386 | 390 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 3 (CIP.002.110) is not populated |
| 67 | 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 in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 52 | 391 | 403 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must equal the sum of all Billed Amount instances for the associated claim 4. Conditional 5. (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) |
| 68 | 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 determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 53 | 404 | 416 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. When populated and Payment Level Indicator equals "2", then value must equal the sum of all claim line Allowed Amount values 4. Conditional |
| 69 | 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. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 54 | 417 | 429 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 70 | 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 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 55 | 430 | 442 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated 4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value is mandatory and must be provided 5. Conditional 6. When populated, value must be less than or equal to Total Billed Amount |
| 71 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 56 | 443 | 455 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated. 4. Conditional 5. If associated Medicare Combined Deductible Indicator equals "1", then value must not be populated 6. When populated, value must be less than or equal to Total Billed Amount |
| 72 | CIP118 | CIP.002.118 | TOT-TPL-AMT | Total TPL 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 57 | 456 | 468 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) 4. Conditional |
| 73 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 58 | 469 | 481 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 74 | 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. | OTHER-INSURANCE-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 59 | 482 | 482 | 1. Value must be 1 character 2. Value must be in Other Insurance Indicator List (VVL) 3. Value must be in [0,1] or not populated 4. Conditional |
| 75 | CIP122 | CIP.002.122 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | CIP00002 | CLAIM-HEADER-RECORD-IP | X(3) | 60 | 483 | 485 | 1. Value must be in Other TPL Collection List (VVL) 2. Value must be 3 characters 3. Mandatory |
| 76 | 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 programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. | FIXED-PAYMENT-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 61 | 486 | 486 | 1. Value must be 1 character 2. Value must be in Fixed Payment Indicator List (VVL) 3. Conditional |
| 77 | CIP126 | CIP.002.126 | FUNDING-CODE | Funding Code | Conditional | A code to indicate the source of non-federal share funds. | FUNDING-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 62 | 487 | 488 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 78 | CIP127 | CIP.002.127 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Conditional | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 63 | 489 | 490 | 1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 79 | 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. | MEDICARE-COMB-DED-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 64 | 491 | 491 | 1. Value must be 1 character 2. Value must be in Medicare Combined Deductible Indicator List (VVL) 3. If value equals "1", then Total Medicare Coinsurance amount must not be populated 4. If value equals "0", then Crossover Indicator must equals "0" 5. If value equals "1", then Crossover Indicator must equals "1" 6. Conditional |
| 80 | CIP129 | CIP.002.129 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | PROGRAM-TYPE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 65 | 492 | 493 | 1. Value must be 2 characters 2. Value must be in Program Type List (VVL) 3. Mandatory 4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period 5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 81 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 66 | 494 | 505 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. When Type of Claim (CIP.002.100) in [3,C,W] 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) 7. When Type of Claim (CIP.002.100) in [3,C,W] 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) |
| 82 | 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. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
PAYMENT-LEVEL-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 67 | 506 | 506 | 1. Value must be 1 character 2. Value must be in Payment Level Indicator List (VVL) 3. Mandatory |
| 83 | CIP133 | CIP.002.133 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | MEDICARE-REIM-TYPE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 68 | 507 | 508 | 1. Value must be 2 characters 2. Value must be in Medicare Reimbursement Type List (VVL) 3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim) 4. Conditional |
| 84 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(5) | 69 | 509 | 513 | 1. Value must be 5 digits or less 2. Conditional |
| 85 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 70 | 514 | 526 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 86 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(7) | 71 | 527 | 533 | 1. Value must be a positive integer 2. Value must be between 0000000:9999999 (inclusive) 3. Conditional 4. 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 5. Value must be 7 digits or less 6. Value is required if the associated Type of Service (CIP.002.257) in [001,058,060,084,086,090,091,092,093] 7. Value is required if at least one associated Revenue Code (CIP.003.245) in [100-219] |
| 87 | CIP137 | CIP.002.137 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(4) | 72 | 534 | 537 | 1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. 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 6. Mandatory |
| 88 | 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. | FORCED-CLAIM-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 73 | 538 | 538 | 1. Value must be 1 character 2. Value must be in Forced Claim Indicator List (VVL) 3. Conditional |
| 89 | 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: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
HEALTH-CARE-ACQUIRED-CONDITION-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 74 | 539 | 539 | 1. Value must be 1 character 2. Value must be in Healthcare Acquired Condition Indicator List (VVL) 3. Conditional |
| 90 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 75 | 540 | 541 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 91 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 76 | 542 | 543 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 92 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 77 | 544 | 545 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 93 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 78 | 546 | 547 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 94 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 79 | 548 | 549 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 95 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 80 | 550 | 551 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 96 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 81 | 552 | 553 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 97 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 82 | 554 | 555 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 98 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 83 | 556 | 557 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 99 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 84 | 558 | 559 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 100 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 85 | 560 | 567 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 101 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 86 | 568 | 575 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 102 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 87 | 576 | 583 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 103 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 88 | 584 | 591 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 104 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 89 | 592 | 599 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 105 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 90 | 600 | 607 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 106 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 91 | 608 | 615 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 107 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 92 | 616 | 623 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 108 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 93 | 624 | 631 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 109 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 94 | 632 | 639 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 110 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 95 | 640 | 647 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 111 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 96 | 648 | 655 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 112 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 97 | 656 | 663 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 113 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 98 | 664 | 671 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 114 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 99 | 672 | 679 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 115 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 100 | 680 | 687 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 116 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 101 | 688 | 695 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 117 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 102 | 696 | 703 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 118 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 103 | 704 | 711 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 119 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 104 | 712 | 719 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 120 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(6)V999 | 105 | 720 | 728 | 1. 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. Conditional |
| 121 | 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 individual financial and clinical records and posting of payment | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(20) | 106 | 729 | 748 | 1. Value must be 20 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Conditional |
| 122 | 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 with the appropriate eligibility data.) | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(30) | 107 | 749 | 778 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 123 | 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 with the appropriate eligibility data.) | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(30) | 108 | 779 | 808 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 124 | 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). | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 109 | 809 | 809 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 125 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 110 | 810 | 817 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 126 | 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 to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | HEALTH-HOME-PROV-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 111 | 818 | 818 | 1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 127 | 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. | WAIVER-TYPE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 112 | 819 | 820 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service) 4. Value must have a corresponding value in Waiver ID (CIP.002.178) 5. Conditional |
| 128 | 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(20) | 113 | 821 | 840 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (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] 6. Conditional |
| 129 | CIP179 | CIP.002.179 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or managed care 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 (billing or reporting) to the managed care plan. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(30) | 114 | 841 | 870 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 130 | CIP180 | CIP.002.180 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(10) | 115 | 871 | 880 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 131 | CIP181 | CIP.002.181 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the institution billing for the beneficiary. | PROV-TAXONOMY | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 116 | 881 | 892 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 132 | CIP182 | CIP.002.182 | BILLING-PROV-TYPE | Billing Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 117 | 893 | 894 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL) 3. Conditional |
| 133 | CIP183 | CIP.002.183 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 118 | 895 | 896 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 134 | CIP184 | CIP.002.184 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Conditional | The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(10) | 119 | 897 | 906 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 135 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(30) | 120 | 907 | 936 | 1. Value must be 30 characters or less 2. Conditional |
| 136 | CIP186 | CIP.002.186 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 121 | 937 | 938 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 137 | 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. | PROV-TAXONOMY | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 122 | 939 | 950 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 138 | CIP188 | CIP.002.188 | ADMITTING-PROV-TYPE | Admitting Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 123 | 951 | 952 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 139 | 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 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 ID for this data element. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(30) | 124 | 953 | 982 | 1. Value must be 30 characters or less 2. Conditional |
| 140 | CIP190 | CIP.002.190 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(10) | 125 | 983 | 992 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 141 | 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. 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 126 | 993 | 1005 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be populated when Outlier Code (CIP.002.197) is in [01,02,10] 4. Conditional |
| 142 | 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 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. This data element in T-MSIS is expected to capture the relative weight of the DRG in the state's system regardless of which DRG system the state uses. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(3)V99999 | 127 | 1006 | 1013 | 1. Value may include up to 3 digits to the left of the decimal point, and 5 digits to the right e.g. 123.45678 2. Conditional 3. When populated value must be zero or greater |
| 143 | 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 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 and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based). | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 128 | 1014 | 1025 | 1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CIP.002.023) equals "1" and Medicare Beneficiary Identifier (CIP.002.222) is not populated |
| 144 | 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), denotes the source for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code |
OUTLIER-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 129 | 1026 | 1027 | 1. Value must be 2 characters 2. Value must be in Outlier Code List (VVL) 3. Value is mandatory if either DRG Outlier Amount (CIP.002.194) or Outlier Days (CIP.002.198) are populated 4. Conditional |
| 145 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(5) | 130 | 1028 | 1032 | 1. Value must be 5 digits or less 2. Value must be numeric 3. Value must be populated, if Outlier Code (CIP.002.197) equals "01" 4. Conditional |
| 146 | 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 |
PATIENT-STATUS | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 131 | 1033 | 1034 | 1. Value must be 2 characters 2. Value must be in Patient Status List (VVL) 3. Mandatory 4. 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) |
| 147 | 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 RA is the detailed explanation of the reason for the payment amount. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(30) | 132 | 1035 | 1064 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 148 | 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. | SPLIT-CLAIM-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 133 | 1065 | 1065 | 1. Value must be 1 character 2. Value must be in Split Claim Indicator List (VVL) 3. Conditional |
| 149 | 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.) | BORDER-STATE-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 134 | 1066 | 1066 | 1. Value must be 1 character 2. Value must be in Border State Indicator List (VVL) 3. Conditional |
| 150 | CIP206 | CIP.002.206 | TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Beneficiary Coinsurance Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 135 | 1067 | 1079 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 151 | CIP207 | CIP.002.207 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 136 | 1080 | 1087 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Coinsurance Amount 3. Conditional |
| 152 | CIP208 | CIP.002.208 | TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Total Beneficiary Copayment Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 137 | 1088 | 1100 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 153 | CIP209 | CIP.002.209 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 138 | 1101 | 1108 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Copayment Amount 3. Conditional |
| 154 | CIP210 | CIP.002.210 | TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Total Beneficiary Deductible Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 139 | 1109 | 1121 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 155 | CIP211 | CIP.002.211 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 140 | 1122 | 1129 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Deductible Amount 3. Conditional |
| 156 | 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. | CLAIM-DENIED-INDICATOR | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 141 | 1130 | 1130 | 1. Value must be 1 character 2. Value must be in Claim Denied Indicator List (VVL) 3. If value equals "0", then Claim Status Category must equal "F2" 4. Mandatory |
| 157 | CIP213 | CIP.002.213 | COPAY-WAIVED-IND | Copayment Waived Indicator | Situational | An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. | COPAY-WAIVED-IND | CIP00002 | CLAIM-HEADER-RECORD-IP | X(1) | 142 | 1131 | 1131 | 1. Value must be 1 character 2. Value must be in Copay Waived Indicator List (VVL) 3. Situational |
| 158 | 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 or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(50) | 143 | 1132 | 1181 | 1. Value must not contain a pipe or asterisk symbols 2. Value must 50 characters or less 3. Conditional |
| 159 | CIP216 | CIP.002.216 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 144 | 1182 | 1194 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 160 | CIP217 | CIP.002.217 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date the third party paid the coinsurance amount | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 145 | 1195 | 1202 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Coinsurance Amount 3. Conditional |
| 161 | CIP218 | CIP.002.218 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards copayment. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 146 | 1203 | 1215 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 162 | CIP219 | CIP.002.219 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Situational | The date the third party paid the copayment amount. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 147 | 1216 | 1223 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Copayment Amount 3. Situational |
| 163 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 148 | 1224 | 1236 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 164 | CIP221 | CIP.002.221 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | The National Provider ID (NPI) of the health home provider. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(10) | 149 | 1237 | 1246 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 165 | 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 over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 150 | 1247 | 1258 | 1. Conditional 2. Value must be an 11-character string 3. Character 1 must be numeric values 1 thru 9 4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 6. Character 4 must be numeric values 0 thru 9 7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 9. Character 7 must be numeric values 0 thru 9 10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 12. Character 10 must be numeric values 0 thru 9 13. Character 11 must be numeric values 0 thru 9 14. Value must not contain a pipe or asterisk symbols |
| 166 | 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. | PROV-TAXONOMY | CIP00002 | CLAIM-HEADER-RECORD-IP | X(12) | 151 | 1259 | 1270 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 167 | CIP228 | CIP.002.228 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 152 | 1271 | 1283 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0", then the value must not be populated 4. Conditional 5. If value is populated, Crossover Indicator must be equal to "1" |
| 168 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(5) | 153 | 1284 | 1288 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 169 | CIP290 | CIP.002.290 | 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 covered by this claim began. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 154 | 1289 | 1296 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be less than or equal to associated Ending Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values 7. Mandatory |
| 170 | CIP291 | CIP.002.291 | 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 claim ended. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | 9(8) | 155 | 1297 | 1304 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be greater than or equal to associated Beginning Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value 7. Mandatory |
| 171 | CIP292 | CIP.002.292 | TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Total Beneficiary Copayment Liable Amount | Conditional | The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 156 | 1305 | 1317 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 172 | CIP293 | CIP.002.293 | TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Total Beneficiary Coinsurance Liable Amount | Conditional | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 157 | 1318 | 1330 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 173 | CIP294 | CIP.002.294 | TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Total Beneficiary Deductible Liable Amount | Conditional | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 158 | 1331 | 1343 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 174 | CIP295 | CIP.002.295 | COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Combined Beneficiary Cost Sharing Paid Amount | Conditional | The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 159 | 1344 | 1356 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 175 | CIP297 | CIP.002.297 | 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. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 160 | 1357 | 1369 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 176 | CIP298 | CIP.002.298 | BILLING-PROV-ADDR-LN-1 | Billing Provider Address Line 1 | Mandatory | Billing provider address line 1 from X12 837I loop 2010AA. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(60) | 161 | 1370 | 1429 | 1. Value must not be more than 60 characters long 2. Mandatory 3. Value must not contain a pipe or asterisk symbols |
| 177 | CIP299 | CIP.002.299 | BILLING-PROV-ADDR-LN-2 | Billing Provider Address Line 2 | Conditional | Billing provider address line 2 from X12 837I loop 2010AA. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(60) | 162 | 1430 | 1489 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. Value must not contain a pipe or asterisk symbols 5. There must be an Address Line 1 in order to have an Address Line 2 |
| 178 | CIP300 | CIP.002.300 | BILLING-PROV-CITY | Billing Provider City | Mandatory | Billing provider address city name from X12 837I loop 2010AA. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(28) | 163 | 1490 | 1517 | 1. Value must not be more than 28 characters long 2. Mandatory |
| 179 | CIP301 | CIP.002.301 | BILLING-PROV-STATE | Billing Provider State Code | Mandatory | Billing provider address state code from X12 837I loop 2010AA. | STATE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 164 | 1518 | 1519 | 1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 180 | CIP302 | CIP.002.302 | BILLING-PROV-ZIP-CODE | Billing Provider ZIP Code | Mandatory | Billing provider address ZIP code from X12 837I loop 2010AA. | ZIP-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(9) | 165 | 1520 | 1528 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 181 | CIP303 | CIP.002.303 | SERVICE-FACILITY-LOCATION-ORG-NPI | Service Facility Location Organization NPI | Conditional | Service facility location organization NPI from X12 837I loop 2310E. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(10) | 166 | 1529 | 1538 | 1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 182 | CIP304 | CIP.002.304 | SERVICE-FACILITY-LOCATION-ADDR-LN-1 | Service Facility Location Address Line 1 | Conditional | Service facility location address line 1 from X12 837I loop 2310E. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(60) | 167 | 1539 | 1598 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 183 | CIP305 | CIP.002.305 | SERVICE-FACILITY-LOCATION-ADDR-LN-2 | Service Facility Location Address Line 2 | Conditional | Service facility location address line 2 from X12 837I loop 2310E. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(60) | 168 | 1599 | 1658 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 184 | CIP306 | CIP.002.306 | SERVICE-FACILITY-LOCATION-CITY | Service Facility Location City | Conditional | Service facility location address city name from X12 837I loop 2310E. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(28) | 169 | 1659 | 1686 | 1. Value must not be more than 28 characters long 2. Conditional |
| 185 | CIP307 | CIP.002.307 | SERVICE-FACILITY-LOCATION-STATE | Service Facility Location State | Conditional | Service facility location address state code from X12 837I loop 2310E. | STATE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 170 | 1687 | 1688 | 1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Conditional |
| 186 | CIP308 | CIP.002.308 | SERVICE-FACILITY-LOCATION-ZIP-CODE | Service Facility Location ZIP Code | Conditional | Service facility location address ZIP code from X12 837I loop 2310E. | ZIP-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(9) | 171 | 1689 | 1697 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 187 | CIP309 | CIP.002.309 | PROVIDER-CLAIM-FORM-CODE | Provider Claim Form Code | Mandatory | A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". | PROVIDER-CLAIM-FORM-CODE | CIP00002 | CLAIM-HEADER-RECORD-IP | X(2) | 172 | 1698 | 1699 | 1. Value must not be more than 2 characters 2. Value must be in Provider Claim Form Code List (VVL) 3. Mandatory |
| 188 | CIP310 | CIP.002.310 | PROVIDER-CLAIM-FORM-OTHER-TEXT | Provider Claim Form Other Text | Conditional | A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(50) | 173 | 1700 | 1749 | 1. Value must not be more than 50 characters long 2. Conditional 3. Value must be provided when corresponding Provider Claim Form Code is "Other" |
| 189 | CIP311 | CIP.002.311 | TOT-GME-AMOUNT-PAID | Total GME Amount Paid | Conditional | The amount included in the Total Medicaid Amount (CIP.002.114) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 174 | 1750 | 1762 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 190 | CIP338 | CIP.002.338 | TOT-SDP-ALLOWED-AMT | Total State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 175 | 1763 | 1775 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 191 | CIP339 | CIP.002.339 | TOT-SDP-PAID-AMT | Total State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | S9(11)V99 | 176 | 1776 | 1788 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 192 | CIP229 | CIP.002.229 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CIP00002 | CLAIM-HEADER-RECORD-IP | X(500) | 177 | 1789 | 2288 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 193 | CIP231 | CIP.003.231 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CIP00003 | CLAIM-LINE-RECORD-IP | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CIP00003" |
| 194 | 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. | STATE | CIP00003 | CLAIM-LINE-RECORD-IP | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CIP.001.007) |
| 195 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 196 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 197 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(50) | 5 | 42 | 91 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 198 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(50) | 6 | 92 | 141 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 199 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 7 | 142 | 144 | 1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 200 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 8 | 145 | 147 | 1. Value must be 3 characters or less 2. If associated Line Adjustment Indicator value equals "0", then value must not be populated 3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided 4. Conditional 5. When populated, value must be one or greater |
| 201 | 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. | LINE-ADJUSTMENT-IND | CIP00003 | CLAIM-LINE-RECORD-IP | X(1) | 9 | 148 | 148 | 1. Value must be 1 character 2. Value must be in Line Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Conditional 5. If associated Line Adjustment Number is populated, then value must be populated |
| 202 | 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. | LINE-ADJUSTMENT-REASON-CODE | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 10 | 149 | 151 | 1. Value must be 3 characters or less 2. Value must be in Line Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 203 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(12) | 11 | 152 | 163 | 1. Value must be 12 characters or less 2. Mandatory |
| 204 | CIP242 | CIP.003.242 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. | CLAIM-STATUS | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 12 | 164 | 166 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2" |
| 205 | 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 covered by this claim began. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | 9(8) | 13 | 167 | 174 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be less than or equal to associated Ending Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values 7. Mandatory |
| 206 | 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 claim ended. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | 9(8) | 14 | 175 | 182 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be greater than or equal to associated Beginning Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value 7. Mandatory |
| 207 | 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 Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims. | REVENUE-CODE | CIP00003 | CLAIM-LINE-RECORD-IP | X(4) | 15 | 183 | 186 | 1. Value must be 4 characters or less 2. Value must be in Revenue Code List (VVL) 3. A Revenue Code value requires an associated Revenue Charge 4. Mandatory |
| 208 | CIP249 | CIP.003.249 | REVENUE-CENTER-QUANTITY-ACTUAL | Revenue Center Quantity Actual | Mandatory | On facility claims/encounters, 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. For CLAIMOT claims/encounters use Service Quantity Actual and CLAIMRX claims/encounters use the Prescription Quantity Actual field | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(6)V999 | 16 | 187 | 195 | 1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 3. Mandatory |
| 209 | CIP250 | CIP.003.250 | REVENUE-CENTER-QUANTITY-ALLOWED | Revenue Center Quantity Allowed | Conditional | On facility claims/encounters, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was allowed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounters use Service Quantity Allowed and CLAIMRX claims/encounters use the Prescription Quantity Allowed field. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(6)V999 | 17 | 196 | 204 | 1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 3. Conditional |
| 210 | 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 managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 18 | 205 | 217 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be less than or equal to associated Total Billed Amount value. 4. When populated, associated claim line Revenue Charge must be populated 5. Conditional |
| 211 | 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 care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 19 | 218 | 230 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 212 | 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 sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 20 | 231 | 243 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 213 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 21 | 244 | 256 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Type of Claim value in [3,C,W], then value is mandatory and must be provided 4. Conditional |
| 214 | CIP256 | CIP.003.256 | BILLING-UNIT | Billing Unit | Conditional | Unit of billing that is used for billing services by the facility. | BILLING-UNIT | CIP00003 | CLAIM-LINE-RECORD-IP | X(2) | 22 | 257 | 258 | 1. Value must be 2 characters 2. Value must be in Billing Unit List (VVL) 3. Conditional |
| 215 | CIP257 | CIP.003.257 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | TYPE-OF-SERVICE-IP | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 23 | 259 | 261 | 1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service IP List (VVL) 4. If Sex (ELG.002.023) equals "M", then value must not equal "086" |
| 216 | 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 value is conditional as its usage varies by state. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(30) | 24 | 262 | 291 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W], then value may match (PRV.005.081) Provider Identifier or 4. When Type of Claim not in [3,C,W], then value may match (PRV.002.019) Submitting State Provider ID |
| 217 | 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 procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(10) | 25 | 292 | 301 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 218 | CIP263 | CIP.003.263 | SERVICING-PROV-TYPE | Servicing Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | CIP00003 | CLAIM-LINE-RECORD-IP | X(2) | 26 | 302 | 303 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL) 3. Conditional |
| 219 | CIP264 | CIP.003.264 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CIP00003 | CLAIM-LINE-RECORD-IP | X(2) | 27 | 304 | 305 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 220 | CIP265 | CIP.003.265 | OPERATING-PROV-NPI-NUM | Operating Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(10) | 28 | 306 | 315 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Conditional 4. Value must exist in the NPPES NPI data file |
| 221 | CIP266 | CIP.003.266 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 29 | 316 | 318 | 1. Value must be 3 characters 2. Value must be in Other TPL Collection List (VVL) 3. Mandatory |
| 222 | 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. | PROV-FACILITY-TYPE | CIP00003 | CLAIM-LINE-RECORD-IP | X(9) | 30 | 319 | 327 | 1. Value must be 9 characters or less 2. Value must be in Provider Facility Type List (VVL) 3. Mandatory |
| 223 | CIP269 | CIP.003.269 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CIP00003 | CLAIM-LINE-RECORD-IP | X(2) | 31 | 328 | 329 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 224 | CIP272 | CIP.003.272 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 32 | 330 | 342 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 225 | 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/encounter. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(9)V(9) | 33 | 343 | 360 | 1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 226 | 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. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(12) | 34 | 361 | 372 | 1. Value must be 12 digits or less 2. Value must be a valid National Drug Code 3. Conditional |
| 227 | 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. | NDC-UNIT-OF-MEASURE | CIP00003 | CLAIM-LINE-RECORD-IP | X(2) | 35 | 373 | 374 | 1. Value must be 2 characters 2. Value must be in NDC Unit of Measure List (VVL) 3. Conditional |
| 228 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | 9(8) | 36 | 375 | 382 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CRX.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 229 | CIP287 | CIP.003.287 | SELF-DIRECTION-TYPE | Self Direction Type | Mandatory | This data element is not applicable to this file type. | SELF-DIRECTION-TYPE | CIP00003 | CLAIM-LINE-RECORD-IP | X(3) | 37 | 383 | 385 | 1. Value must be 3 characters 2. Value must be in Self Direction Type List (VVL) 3. Mandatory |
| 230 | 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). | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(18) | 38 | 386 | 403 | 1. Value must be 18 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 231 | CIP296 | CIP.003.296 | IHS-SERVICE-IND | IHS Service Indicator | Mandatory | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | IHS-SERVICE-IND | CIP00003 | CLAIM-LINE-RECORD-IP | X(1) | 39 | 404 | 404 | 1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 232 | CIP314 | CIP.003.314 | UNIQUE-DEVICE-IDENTIFIER | Unique Device Identifier | Conditional | An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(76) | 40 | 405 | 480 | 1. Value must not be more than 76 characters long 2. Conditional |
| 233 | CIP340 | CIP.003.340 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Conditional | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | CIP00003 | CLAIM-LINE-RECORD-IP | X(1) | 41 | 481 | 481 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 234 | CIP316 | CIP.003.316 | MBESCBES-FORM | MBESCBES Form | Conditional | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | CIP00003 | CLAIM-LINE-RECORD-IP | X(50) | 42 | 482 | 531 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 235 | CIP315 | CIP.003.315 | MBESCBES-CATEGORY-OF-SERVICE | 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 MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
CIP00003 | CLAIM-LINE-RECORD-IP | X(5) | 43 | 532 | 536 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 236 | CIP317 | CIP.003.317 | GME-AMOUNT-PAID | GME Amount Paid | Conditional | The amount included in the Medicaid Amount (CIP.003.254) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 44 | 537 | 549 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 237 | CIP318 | CIP.003.318 | 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 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 ID for this data element. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(30) | 45 | 550 | 579 | 1. Value must be 30 characters or less 2. Conditional |
| 238 | CIP319 | CIP.003.319 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(10) | 46 | 580 | 589 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 239 | CIP336 | CIP.003.336 | SDP-ALLOWED-AMT | State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 47 | 590 | 602 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 240 | CIP337 | CIP.003.337 | SDP-PAID-AMT | State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | S9(11)V99 | 48 | 603 | 615 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 241 | CIP273 | CIP.003.273 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CIP00003 | CLAIM-LINE-RECORD-IP | X(500) | 49 | 616 | 1115 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 242 | CIP322 | CIP.004.322 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CIP00004 | CLAIM-DX-IP | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CIP00004" |
| 243 | CIP323 | CIP.004.323 | 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. | STATE | CIP00004 | CLAIM-DX-IP | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CIP.001.007) |
| 244 | CIP324 | CIP.004.324 | 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. | N/A | CIP00004 | CLAIM-DX-IP | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 245 | CIP325 | CIP.004.325 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | N/A | CIP00004 | CLAIM-DX-IP | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 246 | CIP326 | CIP.004.326 | 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. | N/A | CIP00004 | CLAIM-DX-IP | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 247 | CIP327 | CIP.004.327 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | CIP00004 | CLAIM-DX-IP | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (CIP.002.026) |
| 248 | CIP328 | CIP.004.328 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CIP00004 | CLAIM-DX-IP | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CIP.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 249 | CIP329 | CIP.004.329 | DIAGNOSIS-TYPE | Diagnosis Type | Mandatory | Indicates the context of the diagnosis code from the provider's claim (i.e., an 837I claim can have one principal diagnosis code, one admitting diagnosis code, up to 12 external cause of injury diagnosis codes, and up to 24 other diagnosis codes; a UB-04 claim can have one principal diagnosis code, one admitting diagnosis code, and up to 17 other diagnosis codes). The type of diagnosis code (e.g., principal, admitting, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number. | DIAGNOSIS-TYPE | CIP00004 | CLAIM-DX-IP | X(1) | 8 | 131 | 131 | 1. Value must be 1 character 2. Value must be in Diagnosis Type Code List (VVL) 3. Value must be in [P,A,E,O] 4. Mandatory |
| 250 | CIP330 | CIP.004.330 | DIAGNOSIS-SEQUENCE-NUMBER | Diagnosis Sequence Number | Mandatory | The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837I claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes). | N/A | CIP00004 | CLAIM-DX-IP | 9(2) | 9 | 132 | 133 | 1. Value must be in [01-24] 2. Mandatory |
| 251 | CIP331 | CIP.004.331 | DIAGNOSIS-CODE-FLAG | Diagnosis Code Flag | Mandatory | Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. | DIAGNOSIS-CODE-FLAG | CIP00004 | CLAIM-DX-IP | X(1) | 10 | 134 | 134 | 1. Value must be 1 character 2. Value must be in Diagnosis Code Flag List (VVL) 3. Mandatory |
| 252 | CIP332 | CIP.004.332 | DIAGNOSIS-CODE | Diagnosis Code | Mandatory | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '21051'. | DIAGNOSIS-CODE | CIP00004 | CLAIM-DX-IP | X(7) | 11 | 135 | 141 | 1. Value must be a minimum of 3 characters 2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must not contain a decimal point 5. Mandatory |
| 253 | CIP333 | CIP.004.333 | DIAGNOSIS-POA-FLAG | Diagnosis POA Flag | 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. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. | DIAGNOSIS-POA-FLAG | CIP00004 | CLAIM-DX-IP | X(1) | 12 | 142 | 142 | 1. Value must be 1 character 2. Value must be in Diagnosis POA Flag List (VVL) 3. Conditional |
| 254 | CIP334 | CIP.004.334 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CIP00004 | CLAIM-DX-IP | X(500) | 13 | 143 | 642 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 255 | CLT001 | CLT.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CLT00001 | FILE-HEADER-RECORD-LT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CLT00001" |
| 256 | 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. | DATA-DICTIONARY-VERSION | CLT00001 | FILE-HEADER-RECORD-LT | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 257 | 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. | SUBMISSION-TRANSACTION-TYPE | CLT00001 | FILE-HEADER-RECORD-LT | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 258 | CLT004 | CLT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | CLT00001 | FILE-HEADER-RECORD-LT | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 259 | 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. | N/A | CLT00001 | FILE-HEADER-RECORD-LT | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 260 | CLT006 | CLT.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | CLT00001 | FILE-HEADER-RECORD-LT | X(8) | 6 | 32 | 39 | 1. Value must equal "CLAIM-LT" 2. Mandatory |
| 261 | 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. | STATE | CLT00001 | FILE-HEADER-RECORD-LT | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 262 | CLT008 | CLT.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | CLT00001 | FILE-HEADER-RECORD-LT | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 263 | 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. | N/A | CLT00001 | FILE-HEADER-RECORD-LT | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 264 | 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. | N/A | CLT00001 | FILE-HEADER-RECORD-LT | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 265 | 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. | FILE-STATUS-INDICATOR | CLT00001 | FILE-HEADER-RECORD-LT | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 266 | 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 files. | SSN-INDICATOR | CLT00001 | FILE-HEADER-RECORD-LT | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 267 | 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. | N/A | CLT00001 | FILE-HEADER-RECORD-LT | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 268 | 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 original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | CLT00001 | FILE-HEADER-RECORD-LT | X(4) | 14 | 79 | 82 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 269 | CLT014 | CLT.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CLT00001 | FILE-HEADER-RECORD-LT | X(500) | 15 | 83 | 582 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 270 | CLT016 | CLT.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CLT00002 | CLAIM-HEADER-RECORD-LT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CLT00002" |
| 271 | 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. | STATE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CLT.001.007) |
| 272 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 273 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 274 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 275 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 6 | 122 | 133 | 1. Value must be 12 characters or less 2. Mandatory |
| 276 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(20) | 7 | 134 | 153 | 1. Mandatory 2. Value must be 20 characters or less. 3. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 277 | CLT023 | CLT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Mandatory | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | CROSSOVER-INDICATOR | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 8 | 154 | 154 | 1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 278 | CLT024 | CLT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration. | 1115A-DEMONSTRATION-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 9 | 155 | 155 | 1. Value must be 1 character 2. Value must be in 1115A Demonstration Indicator List (VVL) 3. Conditional 4. When value equals "0", is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 279 | CLT025 | CLT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 10 | 156 | 156 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (CIP.002.026) |
| 280 | 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. | ADJUSTMENT-REASON-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(3) | 11 | 157 | 159 | 1. Value must be 3 characters or less 2. Value must be in Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 281 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 12 | 160 | 167 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated Discharge Date value in the claim header 3. Value must be greater than or equal to associated eligible Date of Birth value 4. Value must be less than or equal to associated eligible Date of Death value 5. Mandatory 6. Value must be before Adjudication Date (CLT.002.050) |
| 282 | CLT045 | CLT.002.045 | ADMISSION-HOUR | Admission Hour | Conditional | The time of admission to a psychiatric or long-term care facility. | HOUR | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 13 | 168 | 169 | 1. Value must be 2 characters 2. Value must be in Hour List (VVL) 3. Conditional |
| 283 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 14 | 170 | 177 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated Adjudication Date value. 3. Value must be greater than or equal to associated Admission Date value. 4. Value must be greater than or equal to associated eligible Date of Birth value. 5. Value must be less than or equal to associated eligible Date of Death value. 6. Conditional 7. When populated, Discharge Hour (CLT.002.047) must be populated |
| 284 | CLT047 | CLT.002.047 | DISCHARGE-HOUR | Discharge Hour | Conditional | The time of discharge from a psychiatric or long-term care facility. | HOUR | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 15 | 178 | 179 | 1. Value must be 2 characters 2. Value must be in Hour List (VVL) 3. Conditional 4. When populated, Discharge Date (CLT.002.046) must be populated |
| 285 | 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 covered by this claim began. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 16 | 180 | 187 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be less than or equal to associated Ending Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values 7. Mandatory |
| 286 | 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 claim ended. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 17 | 188 | 195 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be greater than or equal to associated Beginning Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value 7. Mandatory |
| 287 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 18 | 196 | 203 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CIP.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 288 | CLT051 | CLT.002.051 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 19 | 204 | 211 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Total Medicaid Paid Amount 3. Mandatory |
| 289 | CLT052 | CLT.002.052 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. | TYPE-OF-CLAIM | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 20 | 212 | 212 | 1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 290 | 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.) | TYPE-OF-BILL | CLT00002 | CLAIM-HEADER-RECORD-LT | X(4) | 21 | 213 | 216 | 1. Value must be 4 characters 2. Value must be in Type of Bill List (VVL) 3. First character must be a "0" 4. Mandatory |
| 291 | CLT054 | CLT.002.054 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim. | CLAIM-STATUS | CLT00002 | CLAIM-HEADER-RECORD-LT | X(3) | 22 | 217 | 219 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 292 | CLT055 | CLT.002.055 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status. | CLAIM-STATUS-CATEGORY | CLT00002 | CLAIM-HEADER-RECORD-LT | X(3) | 23 | 220 | 222 | 1. Value must be 3 characters or less 2. Value must be in Claim Status Category List (VVL) 3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" 4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2" 5. Mandatory |
| 293 | CLT056 | CLT.002.056 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
SOURCE-LOCATION | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 24 | 223 | 224 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 294 | CLT057 | CLT.002.057 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(15) | 25 | 225 | 239 | 1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 295 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 26 | 240 | 247 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional |
| 296 | CLT059 | CLT.002.059 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(5) | 27 | 248 | 252 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique |
| 297 | CLT060 | CLT.002.060 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(5) | 28 | 253 | 257 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 1 (CLT.002.059) is not populated |
| 298 | CLT061 | CLT.002.061 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(5) | 29 | 258 | 262 | 1. Value must be in Claim Payment Remittance Code List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 2 (CLT.002.060) is not populated |
| 299 | CLT062 | CLT.002.062 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(5) | 30 | 263 | 267 | 1. Value must be in Claim Payment Remittance Code List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 3 (CLT.002.061) is not populated |
| 300 | 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 in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 31 | 268 | 280 | 1. Value must be between -99999999999.99 and 99999999999.99. 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ). 3. Value must equal the sum of all Billed Amount instances for the associated claim. 4. Conditional 5. (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). |
| 301 | 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 determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 32 | 281 | 293 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. When populated and Payment Level Indicator equals "2", then value must equal the sum of all claim line Allowed Amount values 4. Conditional |
| 302 | 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. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 33 | 294 | 306 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (CLT.002.064) |
| 303 | 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 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 34 | 307 | 319 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated 4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value is mandatory and must be provided 5. Conditional 6. When populated, value must be less than or equal to Total Billed Amount |
| 304 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 35 | 320 | 332 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated. 4. Conditional 5. If associated Medicare Combined Deductible Indicator equals "1", then value must not be populated 6. When populated, value must be less than or equal to Total Billed Amount |
| 305 | CLT069 | CLT.002.069 | TOT-TPL-AMT | Total TPL 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 36 | 333 | 345 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) 4. Conditional |
| 306 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 37 | 346 | 358 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 307 | 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. | OTHER-INSURANCE-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 38 | 359 | 359 | 1. Value must be 1 character 2. Value must be in Other Insurance Indicator List (VVL) 3. Conditional |
| 308 | CLT072 | CLT.002.072 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | CLT00002 | CLAIM-HEADER-RECORD-LT | X(3) | 39 | 360 | 362 | 1. Value must be in Other TPL Collection List (VVL) 2. Value must be 3 characters 3. Mandatory |
| 309 | 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 programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. | FIXED-PAYMENT-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 40 | 363 | 363 | 1. Value must be 1 character 2. Value must be in Fixed Payment Indicator List (VVL) 3. Conditional |
| 310 | CLT076 | CLT.002.076 | FUNDING-CODE | Funding Code | Conditional | A code to indicate the source of non-federal share funds. | FUNDING-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 41 | 364 | 365 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 311 | CLT077 | CLT.002.077 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Conditional | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 42 | 366 | 367 | 1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 312 | 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. | MEDICARE-COMB-DED-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 43 | 368 | 368 | 1. Value must be 1 character 2. Value must be in Medicare Combined Deductible Indicator List (VVL) 3. If value equals "1", then Total Medicare Coinsurance amount must not be populated 4. If value equals "0", then Crossover Indicator must equals "0" 5. If value equals "1", then Crossover Indicator must equals "1" 6. Conditional |
| 313 | CLT079 | CLT.002.079 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | PROGRAM-TYPE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 44 | 369 | 370 | 1. Value must be 2 characters 2. Value must be in Program Type List (VVL) 3. Mandatory 4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period 5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 314 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 45 | 371 | 382 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192). 5. Value must match State Plan ID Number (MCR.002.019). 6. Value should not be populated when Type of Claim is not in [3,C,W] 7. When Type of Claim in [3,C,W] 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) 8. When Type of Claim in [3,C,W] 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) |
| 315 | 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. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
PAYMENT-LEVEL-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 46 | 383 | 383 | 1. Value must be 1 character 2. Value must be in Payment Level Indicator List (VVL) 3. Mandatory |
| 316 | CLT083 | CLT.002.083 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | MEDICARE-REIM-TYPE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 47 | 384 | 385 | 1. Value must be 2 characters 2. Value must be in Medicare Reimbursement Type List (VVL) 3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim) 4. Conditional |
| 317 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(5) | 48 | 386 | 390 | 1. Value must be 5 digits or less 2. Conditional |
| 318 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 49 | 391 | 403 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 319 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(5) | 50 | 404 | 408 | 1. Value must be a positive integer 2. Value must be between 00000:99999 (inclusive) 3. Conditional 4. 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 5. Value must be 5 digits or less 6. (inpatient mental health/psychiatric services) when associated Type of Service (CLT.003.211) in [044,048,050], this field must be populated |
| 320 | CLT087 | CLT.002.087 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(4) | 51 | 409 | 412 | 1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. 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 6. Mandatory |
| 321 | 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. | FORCED-CLAIM-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 52 | 413 | 413 | 1. Value must be 1 character 2. Value must be in Forced Claim Indicator List (VVL) 3. Conditional |
| 322 | 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: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
HEALTH-CARE-ACQUIRED-CONDITION-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 53 | 414 | 414 | 1. Value must be 1 character 2. Value must be in Healthcare Acquired Condition Indicator List (VVL) 3. Conditional |
| 323 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 54 | 415 | 416 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 324 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 55 | 417 | 418 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 325 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 56 | 419 | 420 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 326 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 57 | 421 | 422 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 327 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 58 | 423 | 424 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 328 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 59 | 425 | 426 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 329 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 60 | 427 | 428 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 330 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 61 | 429 | 430 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 331 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 62 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 332 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 63 | 433 | 434 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 333 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 64 | 435 | 442 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 334 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 65 | 443 | 450 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 335 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 66 | 451 | 458 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 336 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 67 | 459 | 466 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 337 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 68 | 467 | 474 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 338 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 69 | 475 | 482 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 339 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 70 | 483 | 490 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 340 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 71 | 491 | 498 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 341 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 72 | 499 | 506 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 342 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 73 | 507 | 514 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 343 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 74 | 515 | 522 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 344 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 75 | 523 | 530 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 345 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 76 | 531 | 538 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 346 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 77 | 539 | 546 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 347 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 78 | 547 | 554 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 348 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 79 | 555 | 562 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 349 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 80 | 563 | 570 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 350 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 81 | 571 | 578 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 351 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 82 | 579 | 586 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 352 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 83 | 587 | 594 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 353 | 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 | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(20) | 84 | 595 | 614 | 1. Value must be 20 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Conditional |
| 354 | 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 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 with the appropriate eligibility data.) | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(30) | 85 | 615 | 644 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 355 | 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 with the appropriate eligibility data.) | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(30) | 86 | 645 | 674 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 356 | 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). | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 87 | 675 | 675 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 357 | CLT126 | CLT.002.126 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 88 | 676 | 683 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 358 | 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 to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | HEALTH-HOME-PROV-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 89 | 684 | 684 | 1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 359 | 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. | WAIVER-TYPE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 90 | 685 | 686 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service) 4. Value must have a corresponding value in Waiver ID (CLT.002.129) 5. Conditional |
| 360 | 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(20) | 91 | 687 | 706 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (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] 6. Conditional |
| 361 | CLT130 | CLT.002.130 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or managed care 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 (billing or reporting) to the managed care plan. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(30) | 92 | 707 | 736 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 362 | CLT131 | CLT.002.131 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(10) | 93 | 737 | 746 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 363 | CLT132 | CLT.002.132 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the institution billing for the beneficiary. | PROV-TAXONOMY | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 94 | 747 | 758 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 364 | CLT133 | CLT.002.133 | BILLING-PROV-TYPE | Billing Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 95 | 759 | 760 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL) 3. Conditional |
| 365 | CLT134 | CLT.002.134 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 96 | 761 | 762 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 366 | 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 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 ID for this data element. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(30) | 97 | 763 | 792 | 1. Value must be 30 characters or less 2. Conditional |
| 367 | CLT136 | CLT.002.136 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(10) | 98 | 793 | 802 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 368 | 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 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 and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based). | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 99 | 803 | 814 | 1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CLT.002.023) equals "1" and Medicare Beneficiary Identifier (CLT.002.168) is not populated |
| 369 | 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 |
PATIENT-STATUS | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 100 | 815 | 816 | 1. Value must be 2 characters 2. Value must be in Patient Status List (VVL) 3. Mandatory |
| 370 | 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 RA is the detailed explanation of the reason for the payment amount. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(30) | 101 | 817 | 846 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 371 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 102 | 847 | 859 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 372 | 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). | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(5) | 103 | 860 | 864 | 1. Value must be 5 digits or less 2. Conditional 3. Value is mandatory when associated Type of Service (CLT.003.211) equals "046" 4. 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 5. 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 |
| 373 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(5) | 104 | 865 | 869 | 1. Value must be numeric 2. Value must be 5 digits or less 3. Conditional 4. (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009,045,046,047,059] |
| 374 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(5) | 105 | 870 | 874 | 1. Value must be 5 digits or less 2. Value must be numeric 3. Conditional 4. 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 5. (nursing facility) value is required when the Type of Service in [009,045,047,059] 6. 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 beginning and ending date of service |
| 375 | 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. | SPLIT-CLAIM-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 106 | 875 | 875 | 1. Value must be 1 character 2. Value must be in Split Claim Indicator List (VVL) 3. Conditional |
| 376 | 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.) | BORDER-STATE-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 107 | 876 | 876 | 1. Value must be 1 character 2. Value must be in Border State Indicator List (VVL) 3. Conditional |
| 377 | CLT153 | CLT.002.153 | TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Total Beneficiary Coinsurance Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 108 | 877 | 889 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 378 | CLT154 | CLT.002.154 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 109 | 890 | 897 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Coinsurance Amount 3. Conditional |
| 379 | CLT155 | CLT.002.155 | TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Total Beneficiary Copayment Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary.. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 110 | 898 | 910 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 380 | CLT156 | CLT.002.156 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 111 | 911 | 918 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Copayment Amount 3. Conditional |
| 381 | CLT157 | CLT.002.157 | TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Total Beneficiary Deductible Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 112 | 919 | 931 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 382 | CLT158 | CLT.002.158 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 113 | 932 | 939 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Deductible Amount 3. Conditional |
| 383 | 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. | CLAIM-DENIED-INDICATOR | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 114 | 940 | 940 | 1. Value must be 1 character 2. Value must be in Claim Denied Indicator List (VVL) 3. If value equals "0", then Claim Status Category must equal "F2" 4. Mandatory |
| 384 | CLT160 | CLT.002.160 | COPAY-WAIVED-IND | Copayment Waived Indicator | Situational | An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. | COPAY-WAIVED-IND | CLT00002 | CLAIM-HEADER-RECORD-LT | X(1) | 115 | 941 | 941 | 1. Value must be 1 character 2. Value must be in Copay Waived Indicator List (VVL) 3. Situational |
| 385 | 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 or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(50) | 116 | 942 | 991 | 1. Value must not contain a pipe or asterisk symbols 2. Value must 50 characters or less 3. Conditional |
| 386 | CLT163 | CLT.002.163 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 117 | 992 | 1004 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 387 | CLT164 | CLT.002.164 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date the third party paid the coinsurance amount | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 118 | 1005 | 1012 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Coinsurance Amount 3. Conditional |
| 388 | CLT165 | CLT.002.165 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards copayment. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 119 | 1013 | 1025 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 389 | CLT166 | CLT.002.166 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Situational | The date the third party paid the copayment amount. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | 9(8) | 120 | 1026 | 1033 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Copayment Amount 3. Situational |
| 390 | CLT167 | CLT.002.167 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | The National Provider ID (NPI) of the health home provider. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 121 | 1034 | 1045 | 1. Value must be 12 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 391 | 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 over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 122 | 1046 | 1057 | 1. Conditional 2. Value must be an 11-character string 3. Character 1 must be numeric values 1 thru 9 4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 6. Character 4 must be numeric values 0 thru 9 7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 9. Character 7 must be numeric values 0 thru 9 10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 12. Character 10 must be numeric values 0 thru 9 13. Character 11 must be numeric values 0 thru 9 14. Value must not contain a pipe or asterisk symbols |
| 392 | CLT174 | CLT.002.174 | ADMITTING-PROV-NPI-NUM | Admitting Provider NPI Number | Conditional | The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(10) | 123 | 1058 | 1067 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 393 | 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. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(30) | 124 | 1068 | 1097 | 1. Value must be 30 characters or less 2. Conditional |
| 394 | CLT176 | CLT.002.176 | ADMITTING-PROV-SPECIALTY | Admitting Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 125 | 1098 | 1099 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 395 | 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. | PROV-TAXONOMY | CLT00002 | CLAIM-HEADER-RECORD-LT | X(12) | 126 | 1100 | 1111 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 396 | CLT178 | CLT.002.178 | ADMITTING-PROV-TYPE | Admitting Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 127 | 1112 | 1113 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 397 | CLT179 | CLT.002.179 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 128 | 1114 | 1126 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0", then the value must not be populated 4. Conditional 5. If value is populated, Crossover Indicator must be equal to "1" |
| 398 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(5) | 129 | 1127 | 1131 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 399 | CLT239 | CLT.002.239 | TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Total Beneficiary Copayment Liable Amount | Conditional | The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 130 | 1132 | 1144 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 400 | CLT240 | CLT.002.240 | TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Total Beneficiary Coinsurance Liable Amount | Conditional | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 131 | 1145 | 1157 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 401 | CLT241 | CLT.002.241 | TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Total Beneficiary Deductible Liable Amount | Conditional | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 132 | 1158 | 1170 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 402 | CLT242 | CLT.002.242 | COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Combined Beneficiary Cost Sharing Paid Amount | Conditional | The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 133 | 1171 | 1183 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 403 | CLT244 | CLT.002.244 | BILLING-PROV-ADDR-LN-1 | Billing Provider Address Line 1 | Mandatory | Billing provider address line 1 from X12 837I loop 2010AA. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(60) | 134 | 1184 | 1243 | 1. Value must not be more than 60 characters long 2. Mandatory 3. Value must not contain a pipe or asterisk symbols |
| 404 | CLT245 | CLT.002.245 | BILLING-PROV-ADDR-LN-2 | Billing Provider Address Line 2 | Conditional | Billing provider address line 2 from X12 837I loop 2010AA. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(60) | 135 | 1244 | 1303 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. Value must not contain a pipe or asterisk symbols 5. There must be an Address Line 1 in order to have an Address Line 2 |
| 405 | CLT246 | CLT.002.246 | BILLING-PROV-CITY | Billing Provider City | Mandatory | Billing provider address city name from X12 837I loop 2010AA. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(28) | 136 | 1304 | 1331 | 1. Value must not be more than 28 characters long 2. Mandatory |
| 406 | CLT247 | CLT.002.247 | BILLING-PROV-STATE | Billing Provider State Code | Mandatory | Billing provider address state code from X12 837I loop 2010AA. | STATE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 137 | 1332 | 1333 | 1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 407 | CLT248 | CLT.002.248 | BILLING-PROV-ZIP-CODE | Billing Provider ZIP Code | Mandatory | Billing provider address ZIP code from X12 837I loop 2010AA. | ZIP-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(9) | 138 | 1334 | 1342 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 408 | CLT249 | CLT.002.249 | SERVICE-FACILITY-LOCATION-ORG-NPI | Service Facility Location Organization NPI | Conditional | Service facility location organization NPI from X12 837I loop 2310E. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(10) | 139 | 1343 | 1352 | 1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 409 | CLT250 | CLT.002.250 | SERVICE-FACILITY-LOCATION-ADDR-LN-1 | Service Facility Location Address Line 1 | Conditional | Service facility location address line 1 from X12 837I loop 2310E. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(60) | 140 | 1353 | 1412 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 410 | CLT251 | CLT.002.251 | SERVICE-FACILITY-LOCATION-ADDR-LN-2 | Service Facility Location Address Line 2 | Conditional | Service facility location address line 2 from X12 837I loop 2310E. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(60) | 141 | 1413 | 1472 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 411 | CLT252 | CLT.002.252 | SERVICE-FACILITY-LOCATION-CITY | Service Facility Location City | Conditional | Service facility location address city name from X12 837I loop 2310E. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(28) | 142 | 1473 | 1500 | 1. Value must not be more than 28 characters long 2. Conditional |
| 412 | CLT253 | CLT.002.253 | SERVICE-FACILITY-LOCATION-STATE | Service Facility Location State | Conditional | Service facility location address state code from X12 837I loop 2310E. | STATE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 143 | 1501 | 1502 | 1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 413 | CLT254 | CLT.002.254 | SERVICE-FACILITY-LOCATION-ZIP-CODE | Service Facility Location ZIP Code | Conditional | Service facility location address ZIP code from X12 837I loop 2310E. | ZIP-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(9) | 144 | 1503 | 1511 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 414 | CLT255 | CLT.002.255 | PROVIDER-CLAIM-FORM-CODE | Provider Claim Form Code | Mandatory | A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". | PROVIDER-CLAIM-FORM-CODE | CLT00002 | CLAIM-HEADER-RECORD-LT | X(2) | 145 | 1512 | 1513 | 1. Value must not be more than 2 characters 2. Value must be in Provider Claim Form Code List (VVL) 3. Mandatory |
| 415 | CLT256 | CLT.002.256 | PROVIDER-CLAIM-FORM-OTHER-TEXT | Provider Claim Form Other Text | Conditional | A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(50) | 146 | 1514 | 1563 | 1. Value must not be more than 50 characters long 2. Conditional 3. Value must be provided when corresponding Provider Claim Form Code is "Other" |
| 416 | CLT257 | CLT.002.257 | TOT-GME-AMOUNT-PAID | Total GME Amount Paid | Conditional | The amount included in the Total Medicaid Amount (CLT.002.065) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 147 | 1564 | 1576 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 417 | CLT258 | CLT.002.258 | TOT-SDP-ALLOWED-AMT | Total State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 148 | 1577 | 1589 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 418 | CLT259 | CLT.002.259 | TOT-SDP-PAID-AMT | Total State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | S9(11)V99 | 149 | 1590 | 1602 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 419 | CLT173 | CLT.002.173 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CLT00002 | CLAIM-HEADER-RECORD-LT | X(500) | 150 | 1603 | 2102 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 420 | CLT184 | CLT.003.184 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CLT00003 | CLAIM-LINE-RECORD-LT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CLT00003" |
| 421 | 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. | STATE | CLT00003 | CLAIM-LINE-RECORD-LT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CLT.001.007) |
| 422 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 423 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 424 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(50) | 5 | 42 | 91 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 425 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(50) | 6 | 92 | 141 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 426 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 7 | 142 | 144 | 1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 427 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 8 | 145 | 147 | 1. Value must be 3 characters or less 2. If associated Line Adjustment Indicator value equals "0", then value must not be populated 3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided 4. Conditional 5. When populated, value must be one or greater |
| 428 | 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. | LINE-ADJUSTMENT-IND | CLT00003 | CLAIM-LINE-RECORD-LT | X(1) | 9 | 148 | 148 | 1. Value must be 1 character 2. Value must be in Line Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Conditional 5. If associated Line Adjustment Number is populated, then value must be populated |
| 429 | 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. | LINE-ADJUSTMENT-REASON-CODE | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 10 | 149 | 151 | 1. Value must be 3 characters or less 2. Value must be in Line Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 430 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(12) | 11 | 152 | 163 | 1. Value must be 12 characters or less 2. Mandatory |
| 431 | CLT195 | CLT.003.195 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. | CLAIM-STATUS | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 12 | 164 | 166 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2" |
| 432 | 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 covered by this claim began. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | 9(8) | 13 | 167 | 174 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be less than or equal to associated Ending Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values 7. Mandatory |
| 433 | 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 claim ended. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | 9(8) | 14 | 175 | 182 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be greater than or equal to associated Beginning Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value 7. Mandatory |
| 434 | 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 Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims. | REVENUE-CODE | CLT00003 | CLAIM-LINE-RECORD-LT | X(4) | 15 | 183 | 186 | 1. Value must be 4 characters or less 2. Value must be in Revenue Code List (VVL) 3. A Revenue Code value requires an associated Revenue Charge 4. Mandatory |
| 435 | CLT202 | CLT.003.202 | REVENUE-CENTER-QUANTITY-ACTUAL | Revenue Center Quantity Actual | Mandatory | On facility claims/encounters, 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. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(6)V999 | 16 | 187 | 195 | 1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 3. Mandatory |
| 436 | CLT203 | CLT.003.203 | REVENUE-CENTER-QUANTITY-ALLOWED | Revenue Center Quantity Allowed | Conditional | On facility claims/encounters, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was allowed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounters use Service Quantity Allowed and CLAIMRX claims/encounters use the Prescription Quantity Allowed field. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(6)V999 | 17 | 196 | 204 | 1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 3. Conditional |
| 437 | 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 managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 18 | 205 | 217 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be less than or equal to associated Total Billed Amount value. 4. When populated, associated claim line Revenue Charge must be populated 5. Conditional |
| 438 | 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 care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 19 | 218 | 230 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 439 | CLT206 | CLT.003.206 | TPL-AMT | TPL 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 20 | 231 | 243 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 440 | CLT207 | CLT.003.207 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 21 | 244 | 256 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 441 | 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 sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 22 | 257 | 269 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 442 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 23 | 270 | 282 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Type of Claim value in [3,C,W], then value is mandatory and must be provided 4. Conditional |
| 443 | CLT210 | CLT.003.210 | BILLING-UNIT | Billing Unit | Conditional | Unit of billing that is used for billing services by the facility. | BILLING-UNIT | CLT00003 | CLAIM-LINE-RECORD-LT | X(2) | 24 | 283 | 284 | 1. Value must be 2 characters 2. Value must be in Billing Unit List (VVL) 3. Conditional |
| 444 | CLT211 | CLT.003.211 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | TYPE-OF-SERVICE-LT | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 25 | 285 | 287 | 1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service LT List (VVL) |
| 445 | 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 value is conditional as its usage varies by state. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(30) | 26 | 288 | 317 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W], then value may match (PRV.005.081) Provider Identifier or 4. When Type of Claim not in [3,C,W], then value may match (PRV.002.019) Submitting State Provider ID |
| 446 | CLT213 | CLT.003.213 | 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 procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(10) | 27 | 318 | 327 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Conditional 4. If Type of Claim (CLT.002.052) not in [3,C,W], then value must match Provider Identifier (PRV.005.081) 5. Value must exist in the NPPES NPI data file |
| 447 | CLT215 | CLT.003.215 | SERVICING-PROV-TYPE | Servicing Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | CLT00003 | CLAIM-LINE-RECORD-LT | X(2) | 28 | 328 | 329 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL). 3. Conditional |
| 448 | CLT216 | CLT.003.216 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CLT00003 | CLAIM-LINE-RECORD-LT | X(2) | 29 | 330 | 331 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 449 | CLT217 | CLT.003.217 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 30 | 332 | 334 | 1. Value must be 3 characters 2. Value must be in Other TPL Collection List (VVL) 3. Mandatory |
| 450 | CLT219 | CLT.003.219 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CLT00003 | CLAIM-LINE-RECORD-LT | X(2) | 31 | 335 | 336 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 451 | 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. | PROV-FACILITY-TYPE | CLT00003 | CLAIM-LINE-RECORD-LT | X(9) | 32 | 337 | 345 | 1. Value must be 9 characters or less 2. Value must be in Provider Facility Type List (VVL) 3. Mandatory |
| 452 | 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. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(12) | 33 | 346 | 357 | 1. Value must be 12 digits or less 2. Value must be a valid National Drug Code 3. Conditional |
| 453 | 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. | NDC-UNIT-OF-MEASURE | CLT00003 | CLAIM-LINE-RECORD-LT | X(2) | 34 | 358 | 359 | 1. Value must be 2 characters 2. Value must be in NDC Unit of Measure List (VVL) 3. Conditional |
| 454 | 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/encounters. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(9)V(9) | 35 | 360 | 377 | 1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 455 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | 9(8) | 36 | 378 | 385 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CLT.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 456 | CLT234 | CLT.003.234 | SELF-DIRECTION-TYPE | Self Direction Type | Mandatory | This data element is not applicable to this file type. | SELF-DIRECTION-TYPE | CLT00003 | CLAIM-LINE-RECORD-LT | X(3) | 37 | 386 | 388 | 1. Value must be 3 characters 2. Value must be in Self Direction Type List (VVL) 3. Mandatory |
| 457 | 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). | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(18) | 38 | 389 | 406 | 1. Value must be 18 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 458 | CLT243 | CLT.003.243 | IHS-SERVICE-IND | IHS Service Indicator | Mandatory | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | IHS-SERVICE-IND | CLT00003 | CLAIM-LINE-RECORD-LT | X(1) | 39 | 407 | 407 | 1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 459 | CLT260 | CLT.003.260 | UNIQUE-DEVICE-IDENTIFIER | Unique Device Identifier | Conditional | An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(76) | 40 | 408 | 483 | 1. Value must not be more than 76 characters long 2. Conditional |
| 460 | CLT282 | CLT.003.282 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Conditional | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | CLT00003 | CLAIM-LINE-RECORD-LT | X(1) | 41 | 484 | 484 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 461 | CLT262 | CLT.003.262 | MBESCBES-FORM | MBESCBES Form | Conditional | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | CLT00003 | CLAIM-LINE-RECORD-LT | X(50) | 42 | 485 | 534 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 462 | CLT261 | CLT.003.261 | MBESCBES-CATEGORY-OF-SERVICE | 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 MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
CLT00003 | CLAIM-LINE-RECORD-LT | X(5) | 43 | 535 | 539 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 463 | CLT263 | CLT.003.263 | GME-AMOUNT-PAID | GME Amount Paid | Conditional | The amount included in the Medicaid Amount (CLT.003.208) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 44 | 540 | 552 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 464 | CLT264 | CLT.003.264 | 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 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 ID for this data element. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(30) | 45 | 553 | 582 | 1. Value must be 30 characters or less 2. Conditional |
| 465 | CLT265 | CLT.003.265 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(10) | 46 | 583 | 592 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 466 | CLT266 | CLT.003.266 | SDP-ALLOWED-AMT | State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 47 | 593 | 605 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 467 | CLT267 | CLT.003.267 | SDP-PAID-AMT | State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | S9(11)V99 | 48 | 606 | 618 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 468 | CLT226 | CLT.003.226 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CLT00003 | CLAIM-LINE-RECORD-LT | X(500) | 49 | 619 | 1118 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 469 | CLT268 | CLT.004.268 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CLT00004 | CLAIM-DX-LT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CLT00004" |
| 470 | CLT269 | CLT.004.269 | 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. | STATE | CLT00004 | CLAIM-DX-LT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CLT.001.007) |
| 471 | CLT270 | CLT.004.270 | 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. | N/A | CLT00004 | CLAIM-DX-LT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 472 | CLT271 | CLT.004.271 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | N/A | CLT00004 | CLAIM-DX-LT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 473 | CLT272 | CLT.004.272 | 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. | N/A | CLT00004 | CLAIM-DX-LT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 474 | CLT273 | CLT.004.273 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | CLT00004 | CLAIM-DX-LT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (CLT.002.025) |
| 475 | CLT274 | CLT.004.274 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CLT00004 | CLAIM-DX-LT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CLT.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 476 | CLT275 | CLT.004.275 | DIAGNOSIS-TYPE | Diagnosis Type | Mandatory | Indicates the context of the diagnosis code from the provider's claim (i.e., an 837I claim can have one principal diagnosis code, one admitting diagnosis code, up to 12 external cause of injury diagnosis codes, and up to 24 other diagnosis codes; a UB-04 claim can have one principal diagnosis code, one admitting diagnosis code, and up to 17 other diagnosis codes). The type of diagnosis code (e.g., principal, admitting, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number. | DIAGNOSIS-TYPE | CLT00004 | CLAIM-DX-LT | X(1) | 8 | 131 | 131 | 1. Value must be 1 character 2. Value must be in Diagnosis Type Code List (VVL) 3. Value must be in [P,A,E,O] 4. Mandatory |
| 477 | CLT276 | CLT.004.276 | DIAGNOSIS-SEQUENCE-NUMBER | Diagnosis Sequence Number | Mandatory | The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837I claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes). | N/A | CLT00004 | CLAIM-DX-LT | 9(2) | 9 | 132 | 133 | 1. Value must be in [01-24] 2. Mandatory |
| 478 | CLT277 | CLT.004.277 | DIAGNOSIS-CODE-FLAG | Diagnosis Code Flag | Mandatory | Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. | DIAGNOSIS-CODE-FLAG | CLT00004 | CLAIM-DX-LT | X(1) | 10 | 134 | 134 | 1. Value must be 1 character 2. Value must be in Diagnosis Code Flag List (VVL) 3. Mandatory |
| 479 | CLT278 | CLT.004.278 | DIAGNOSIS-CODE | Diagnosis Code | Mandatory | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'. | DIAGNOSIS-CODE | CLT00004 | CLAIM-DX-LT | X(7) | 11 | 135 | 141 | 1. Value must be a minimum of 3 characters 2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must not contain a decimal point 5. Mandatory |
| 480 | CLT279 | CLT.004.279 | DIAGNOSIS-POA-FLAG | Diagnosis POA Flag | 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. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. | DIAGNOSIS-POA-FLAG | CLT00004 | CLAIM-DX-LT | X(1) | 12 | 142 | 142 | 1. Value must be 1 character 2. Value must be in Diagnosis POA Flag List (VVL) 3. Conditional |
| 481 | CLT280 | CLT.004.280 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CLT00004 | CLAIM-DX-LT | X(500) | 13 | 143 | 642 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 482 | COT001 | COT.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | COT00001 | FILE-HEADER-RECORD-OT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "COT00001" |
| 483 | 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. | DATA-DICTIONARY-VERSION | COT00001 | FILE-HEADER-RECORD-OT | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 484 | 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. | SUBMISSION-TRANSACTION-TYPE | COT00001 | FILE-HEADER-RECORD-OT | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 485 | COT004 | COT.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | COT00001 | FILE-HEADER-RECORD-OT | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 486 | 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. | N/A | COT00001 | FILE-HEADER-RECORD-OT | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 487 | COT006 | COT.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | COT00001 | FILE-HEADER-RECORD-OT | X(8) | 6 | 32 | 39 | 1. Value must equal "CLAIM-OT" 2. Mandatory |
| 488 | 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. | STATE | COT00001 | FILE-HEADER-RECORD-OT | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 489 | COT008 | COT.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | COT00001 | FILE-HEADER-RECORD-OT | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 490 | 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. | N/A | COT00001 | FILE-HEADER-RECORD-OT | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 491 | 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. | N/A | COT00001 | FILE-HEADER-RECORD-OT | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 492 | 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. | FILE-STATUS-INDICATOR | COT00001 | FILE-HEADER-RECORD-OT | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 493 | 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 files. | SSN-INDICATOR | COT00001 | FILE-HEADER-RECORD-OT | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 494 | 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. | N/A | COT00001 | FILE-HEADER-RECORD-OT | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 495 | 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 original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | COT00001 | FILE-HEADER-RECORD-OT | X(4) | 14 | 79 | 82 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 496 | COT014 | COT.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | COT00001 | FILE-HEADER-RECORD-OT | X(500) | 15 | 83 | 582 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 497 | COT016 | COT.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | COT00002 | CLAIM-HEADER-RECORD-OT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "COT00002" |
| 498 | 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. | STATE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (COT.001.007) |
| 499 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 500 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 501 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 502 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(12) | 6 | 122 | 133 | 1. Value must be 12 characters or less 2. Mandatory |
| 503 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(20) | 7 | 134 | 153 | 1. Value must be 20 characters or less 2. Mandatory 3. 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) |
| 504 | COT023 | COT.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Mandatory | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | CROSSOVER-INDICATOR | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 8 | 154 | 154 | 1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 505 | COT024 | COT.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration. | 1115A-DEMONSTRATION-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 9 | 155 | 155 | 1. Value must be 1 character 2. Value must be in 1115A Demonstration Indicator List (VVL) 3. Conditional 4. When value equals "0", is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 506 | COT025 | COT.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 10 | 156 | 156 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" |
| 507 | 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. | ADJUSTMENT-REASON-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(3) | 11 | 157 | 159 | 1. Value must be 3 characters or less 2. Value must be in Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 508 | 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 covered by this claim began. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 12 | 160 | 167 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be less than or equal to associated Ending Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values 7. Mandatory |
| 509 | 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 claim ended. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 13 | 168 | 175 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be greater than or equal to associated Beginning Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value 7. Mandatory |
| 510 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 14 | 176 | 183 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CIP.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 511 | COT036 | COT.002.036 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 15 | 184 | 191 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Total Medicaid Paid Amount 3. Mandatory |
| 512 | COT037 | COT.002.037 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record | TYPE-OF-CLAIM | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 16 | 192 | 192 | 1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 513 | 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.) | TYPE-OF-BILL | COT00002 | CLAIM-HEADER-RECORD-OT | X(4) | 17 | 193 | 196 | 1. Value must be 4 characters 2. Value must be in Type of Bill List (VVL) 3. First character must be a "0" 4. Conditional |
| 514 | COT039 | COT.002.039 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim. | CLAIM-STATUS | COT00002 | CLAIM-HEADER-RECORD-OT | X(3) | 18 | 197 | 199 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 515 | COT040 | COT.002.040 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status. | CLAIM-STATUS-CATEGORY | COT00002 | CLAIM-HEADER-RECORD-OT | X(3) | 19 | 200 | 202 | 1. Value must be 3 characters or less 2. Value must be in Claim Status Category List (VVL) 3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" 4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2" 5. Mandatory |
| 516 | COT041 | COT.002.041 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
SOURCE-LOCATION | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 20 | 203 | 204 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 517 | COT042 | COT.002.042 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(15) | 21 | 205 | 219 | 1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 518 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 22 | 220 | 227 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional |
| 519 | COT044 | COT.002.044 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(5) | 23 | 228 | 232 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique |
| 520 | COT045 | COT.002.045 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(5) | 24 | 233 | 237 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 1 (COT.002.044) is not populated |
| 521 | COT046 | COT.002.046 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(5) | 25 | 238 | 242 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 2 (CLT.002.045) is not populated |
| 522 | COT047 | COT.002.047 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(5) | 26 | 243 | 247 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 3 (COT.002.046) is not populated |
| 523 | 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 in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 27 | 248 | 260 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must equal the sum of all Billed Amount instances for the associated claim 4. Conditional 5. (individual line item payments) when populated and Payment Level Indicator (COT.002.068) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (COT.003.168) |
| 524 | 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 determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 28 | 261 | 273 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. When populated and Payment Level Indicator equals "2", then value must equal the sum of all claim line Allowed Amount values 4. Conditional |
| 525 | 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. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 29 | 274 | 286 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (COT.002.049) |
| 526 | 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 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 30 | 287 | 299 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated 4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value is mandatory and must be provided 5. Conditional 6. When populated, value must be less than or equal to Total Billed Amount |
| 527 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 31 | 300 | 312 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated. 4. Conditional 5. If associated Medicare Combined Deductible Indicator equals "1", then value must not be populated 6. When populated, value must be less than or equal to Total Billed Amount |
| 528 | COT054 | COT.002.054 | TOT-TPL-AMT | Total TPL 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 32 | 313 | 325 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) 4. Conditional |
| 529 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 33 | 326 | 338 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 530 | 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. | OTHER-INSURANCE-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 34 | 339 | 339 | 1. Value must be 1 character 2. Value must be in Other Insurance Indicator List (VVL) 3. Conditional |
| 531 | COT058 | COT.002.058 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | COT00002 | CLAIM-HEADER-RECORD-OT | X(3) | 35 | 340 | 342 | 1. Value must be in Other TPL Collection List (VVL) 2. Value must be 3 characters 3. Mandatory |
| 532 | 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 programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. | FIXED-PAYMENT-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 36 | 343 | 343 | 1. Value must be 1 character 2. Value must be in Fixed Payment Indicator List (VVL) 3. Conditional |
| 533 | COT062 | COT.002.062 | FUNDING-CODE | Funding Code | Conditional | A code to indicate the source of non-federal share funds. | FUNDING-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 37 | 344 | 345 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 534 | COT063 | COT.002.063 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Conditional | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 38 | 346 | 347 | 1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 535 | 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. | MEDICARE-COMB-DED-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 39 | 348 | 348 | 1. Value must be 1 character 2. Value must be in Medicare Combined Deductible Indicator List (VVL) 3. If value equals "1", then Total Medicare Coinsurance amount must not be populated 4. If value equals "0", then Crossover Indicator must equals "0" 5. If value equals "1", then Crossover Indicator must equals "1" 6. Conditional |
| 536 | COT065 | COT.002.065 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | PROGRAM-TYPE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 40 | 349 | 350 | 1. Value must be 2 characters 2. Value must be in Program Type List (VVL) 3. Mandatory 4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period 5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 537 | 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. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(12) | 41 | 351 | 362 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. When Type of Claim (COT.002.037) in [3,C,W] 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) 7. When Type of Claim (COT.002.037) in [3,C,W] value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.037) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 538 | 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. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
PAYMENT-LEVEL-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 42 | 363 | 363 | 1. Value must be 1 character 2. Value must be in Payment Level Indicator List (VVL) 3. Mandatory |
| 539 | COT069 | COT.002.069 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | MEDICARE-REIM-TYPE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 43 | 364 | 365 | 1. Value must be 2 characters 2. Value must be in Medicare Reimbursement Type List (VVL) 3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim) 4. Conditional |
| 540 | COT070 | COT.002.070 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(4) | 44 | 366 | 369 | 1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. 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 6. Mandatory |
| 541 | COT072 | COT.002.072 | FORCED-CLAIM-IND | Forced Claim Indicator | Conditional | Indicates if the claim was processed by forcing it through a manual override process. | FORCED-CLAIM-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 45 | 370 | 370 | 1. Value must be 1 character 2. Value must be in Forced Claim Indicator List (VVL) 3. Conditional |
| 542 | 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: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
HEALTH-CARE-ACQUIRED-CONDITION-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 46 | 371 | 371 | 1. Value must be 1 character 2. Value must be in Healthcare Acquired Condition Indicator List (VVL) 3. Conditional |
| 543 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 47 | 372 | 373 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 544 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 48 | 374 | 375 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 545 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 49 | 376 | 377 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 546 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 50 | 378 | 379 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 547 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 51 | 380 | 381 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 548 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 52 | 382 | 383 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 549 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 53 | 384 | 385 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 550 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 54 | 386 | 387 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 551 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 55 | 388 | 389 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 552 | 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 From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. | OCCURRENCE-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 56 | 390 | 391 | 1. Value must be 2 characters 2. Value must be in Occurrence Code List (VVL) 3. Conditional |
| 553 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 57 | 392 | 399 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 554 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 58 | 400 | 407 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 555 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 59 | 408 | 415 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 556 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 60 | 416 | 423 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 557 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 61 | 424 | 431 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 558 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 62 | 432 | 439 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 559 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 63 | 440 | 447 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 560 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 64 | 448 | 455 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 561 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 65 | 456 | 463 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 562 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 66 | 464 | 471 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated populated Occurrence Code 3. Conditional 4. Value must be less than or equal to Occurrence Code End Date |
| 563 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 67 | 472 | 479 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 564 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 68 | 480 | 487 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 565 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 69 | 488 | 495 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 566 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 70 | 496 | 503 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 567 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 71 | 504 | 511 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 568 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 72 | 512 | 519 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 569 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 73 | 520 | 527 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 570 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 74 | 528 | 535 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 571 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 75 | 536 | 543 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 572 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 76 | 544 | 551 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Occurrence Code 3. Must be greater than or equal to Occurrence Code Effective Date 4. Conditional |
| 573 | 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 | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(20) | 77 | 552 | 571 | 1. Value must be 20 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Conditional |
| 574 | 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 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 with the appropriate eligibility data.) | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(30) | 78 | 572 | 601 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 575 | 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 with the appropriate eligibility data.) | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(30) | 79 | 602 | 631 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 576 | 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). | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 80 | 632 | 632 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 577 | COT108 | COT.002.108 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 81 | 633 | 640 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 578 | 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 to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | HEALTH-HOME-PROV-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 82 | 641 | 641 | 1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 579 | 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. | WAIVER-TYPE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 83 | 642 | 643 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service) 4. When populated, Waiver ID (COT.002.111) must be populated 5. Conditional 6. 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" |
| 580 | 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(20) | 84 | 644 | 663 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (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] 6. Conditional |
| 581 | COT112 | COT.002.112 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or managed care 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 (billing or reporting) to the managed care plan. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(30) | 85 | 664 | 693 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. 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 6. 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). 7. Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'. |
| 582 | COT113 | COT.002.113 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(10) | 86 | 694 | 703 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 583 | COT114 | COT.002.114 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the provider billing for the service. | PROV-TAXONOMY | COT00002 | CLAIM-HEADER-RECORD-OT | X(12) | 87 | 704 | 715 | 1. Value must be in Provider Taxonomy List (VVL) 2. Value must be 12 characters or less 3. Conditional |
| 584 | COT115 | COT.002.115 | BILLING-PROV-TYPE | Billing Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 88 | 716 | 717 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL) 3. Conditional |
| 585 | COT116 | COT.002.116 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 89 | 718 | 719 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 586 | 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 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 ID for this data element. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(30) | 90 | 720 | 749 | 1. Value must be 30 characters or less 2. Conditional |
| 587 | COT118 | COT.002.118 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(10) | 91 | 750 | 759 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 588 | 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 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 and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based). | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(12) | 92 | 760 | 771 | 1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (COT.002.023) equals "1" and Medicare Beneficiary Identifier (COT.002.147) is not populated |
| 589 | 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. | PLACE-OF-SERVICE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 93 | 772 | 773 | 1. Value must be 2 characters 2. Value must be in Place of Service Code List (VVL) 3. Conditional 4. If value is populated, then Type of Bill must not be populated |
| 590 | 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 RA is the detailed explanation of the reason for the payment amount. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(30) | 94 | 774 | 803 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 591 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(5)V99 | 95 | 804 | 810 | 1. Value must be between 0.00 and 99999.99 2. Conditional 3. Value must be expressed as a number with 2-digit precision (e.g. 100.50) |
| 592 | 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.) | BORDER-STATE-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 96 | 811 | 811 | 1. Value must be 1 character 2. Value must be in Border State Indicator List (VVL) 3. Conditional |
| 593 | COT130 | COT.002.130 | TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Total Beneficiary Coinsurance Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 97 | 812 | 824 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 594 | COT131 | COT.002.131 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 98 | 825 | 832 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Coinsurance Amount 3. Conditional |
| 595 | COT132 | COT.002.132 | TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Total Beneficiary Copayment Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 99 | 833 | 845 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 596 | COT133 | COT.002.133 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 100 | 846 | 853 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Copayment Amount 3. Conditional |
| 597 | COT134 | COT.002.134 | TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Total Beneficiary Deductible Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 101 | 854 | 866 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 598 | COT135 | COT.002.135 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 102 | 867 | 874 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Deductible Amount 3. Conditional |
| 599 | 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. | CLAIM-DENIED-INDICATOR | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 103 | 875 | 875 | 1. Value must be 1 character 2. Value must be in Claim Denied Indicator List (VVL) 3. If value equals "0", then Claim Status Category must equal "F2" 4. Mandatory |
| 600 | COT137 | COT.002.137 | COPAY-WAIVED-IND | Copayment Waived Indicator | Situational | An indicator signifying that the copay was waived by the provider | COPAY-WAIVED-IND | COT00002 | CLAIM-HEADER-RECORD-OT | X(1) | 104 | 876 | 876 | 1. Value must be 1 character 2. Value must be in Copay Waived Indicator List (VVL) 3. Situational |
| 601 | 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 or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(50) | 105 | 877 | 926 | 1. Value must not contain a pipe or asterisk symbols 2. Value must 50 characters or less 3. Conditional |
| 602 | COT140 | COT.002.140 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 106 | 927 | 939 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 603 | COT141 | COT.002.141 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date the third party paid the coinsurance amount | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 107 | 940 | 947 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Coinsurance Amount 3. Conditional |
| 604 | COT142 | COT.002.142 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards copayment. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 108 | 948 | 960 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 605 | COT143 | COT.002.143 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Situational | The date the third party paid the copayment amount. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | 9(8) | 109 | 961 | 968 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Copayment Amount 3. Situational |
| 606 | COT146 | COT.002.146 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | The National Provider ID (NPI) of the health home provider. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(10) | 110 | 969 | 978 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 607 | 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 over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(12) | 111 | 979 | 990 | 1. Conditional 2. Value must be an 11-character string 3. Character 1 must be numeric values 1 thru 9 4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 6. Character 4 must be numeric values 0 thru 9 7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 9. Character 7 must be numeric values 0 thru 9 10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 12. Character 10 must be numeric values 0 thru 9 13. Character 11 must be numeric values 0 thru 9 14. Value must not contain a pipe or asterisk symbols |
| 608 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(5) | 112 | 991 | 995 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 609 | COT230 | COT.002.230 | TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Total Beneficiary Copayment Liable Amount | Conditional | The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 113 | 996 | 1008 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 610 | COT231 | COT.002.231 | TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Total Beneficiary Coinsurance Liable Amount | Conditional | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 114 | 1009 | 1021 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 611 | COT232 | COT.002.232 | TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Total Beneficiary Deductible Liable Amount | Conditional | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 115 | 1022 | 1034 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 612 | COT233 | COT.002.233 | COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Combined Beneficiary Cost Sharing Paid Amount | Conditional | The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 116 | 1035 | 1047 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 613 | COT235 | COT.002.235 | 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. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 117 | 1048 | 1060 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 614 | COT236 | COT.002.236 | BILLING-PROV-ADDR-LN-1 | Billing Provider Address Line 1 | Mandatory | Billing provider address line 1 from X12 837I, 837P, and 837D loop 2010AA. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(60) | 118 | 1061 | 1120 | 1. Value must not be more than 60 characters long 2. Mandatory 3. Value must not contain a pipe or asterisk symbols |
| 615 | COT237 | COT.002.237 | BILLING-PROV-ADDR-LN-2 | Billing Provider Address Line 2 | Conditional | Billing provider address line 2 from X12 837I, 837P, and 837D loop 2010AA. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(60) | 119 | 1121 | 1180 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. Value must not contain a pipe or asterisk symbols 5. There must be an Address Line 1 in order to have an Address Line 2 |
| 616 | COT238 | COT.002.238 | BILLING-PROV-CITY | Billing Provider City | Mandatory | Billing provider address city name from X12 837I, 837P, and 837D loop 2010AA. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(28) | 120 | 1181 | 1208 | 1. Value must not be more than 28 characters long 2. Mandatory |
| 617 | COT239 | COT.002.239 | BILLING-PROV-STATE | Billing Provider State Code | Mandatory | Billing provider address state code from X12 837I, 837P, and 837D loop 2010AA. | STATE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 121 | 1209 | 1210 | 1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 618 | COT240 | COT.002.240 | BILLING-PROV-ZIP-CODE | Billing Provider ZIP Code | Mandatory | Billing provider address ZIP code from X12 837I, 837P, and 837D loop 2010AA. | ZIP-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(9) | 122 | 1211 | 1219 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 619 | COT241 | COT.002.241 | SERVICE-FACILITY-LOCATION-ORG-NPI | Service Facility Location Organization NPI | Conditional | Service facility location organization NPI from X12 837I loop 2310E or 837P and 837D loop 2310C. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(10) | 123 | 1220 | 1229 | 1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 620 | COT242 | COT.002.242 | SERVICE-FACILITY-LOCATION-ADDR-LN-1 | Service Facility Location Address Line 1 | Conditional | Service facility location address line 1 from X12 837I loop 2310E or 837P and 837D loop 2310C. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(60) | 124 | 1230 | 1289 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 621 | COT243 | COT.002.243 | SERVICE-FACILITY-LOCATION-ADDR-LN-2 | Service Facility Location Address Line 2 | Conditional | Service facility location address line 2 from X12 837I loop 2310E or 837P and 837D loop 2310C. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(60) | 125 | 1290 | 1349 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 622 | COT244 | COT.002.244 | SERVICE-FACILITY-LOCATION-CITY | Service Facility Location City | Conditional | Service facility location address city name from X12 837I loop 2310E or 837P and 837D loop 2310C. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(28) | 126 | 1350 | 1377 | 1. Value must not be more than 28 characters long 2. Conditional |
| 623 | COT245 | COT.002.245 | SERVICE-FACILITY-LOCATION-STATE | Service Facility Location State | Conditional | Service facility location address state code from X12 837I loop 2310E or 837P and 837D loop 2310C. | STATE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 127 | 1378 | 1379 | 1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 624 | COT246 | COT.002.246 | SERVICE-FACILITY-LOCATION-ZIP-CODE | Service Facility Location ZIP Code | Conditional | Service facility location address ZIP code from X12 837I loop 2310E or 837P and 837D loop 2310C. | ZIP-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(9) | 128 | 1380 | 1388 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 625 | COT247 | COT.002.247 | PROVIDER-CLAIM-FORM-CODE | Provider Claim Form Code | Mandatory | A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". | PROVIDER-CLAIM-FORM-CODE | COT00002 | CLAIM-HEADER-RECORD-OT | X(2) | 129 | 1389 | 1390 | 1. Value must not be more than 2 characters 2. Value must be in Provider Claim Form Code List (VVL) 3. Mandatory |
| 626 | COT248 | COT.002.248 | PROVIDER-CLAIM-FORM-OTHER-TEXT | Provider Claim Form Other Text | Conditional | A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(50) | 130 | 1391 | 1440 | 1. Value must not be more than 50 characters long 2. Conditional 3. Value must be provided when corresponding Provider Claim Form Code is "Other" |
| 627 | COT249 | COT.002.249 | TOT-GME-AMOUNT-PAID | Total GME Amount Paid | Conditional | The amount included in the Total Medicaid Amount (COT.002.050) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 131 | 1441 | 1453 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 628 | COT250 | COT.002.250 | REFERRING-PROV-NUM-2 | Referring Provider Number 2 | 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 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 ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(30) | 132 | 1454 | 1483 | 1. Value must be 30 characters or less 2. Conditional 3. Value must not be populated when Referring Provider Number is not populated. 4. Value must not equal Referring Provider Number |
| 629 | COT251 | COT.002.251 | REFERRING-PROV-NPI-NUM-2 | Referring Provider NPI Number 2 | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the header of their claim. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(10) | 133 | 1484 | 1493 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File 5. Value must not be populated when Referring Provider NPI Number is not populated 6. Value must not equal Referring Provider NPI Number |
| 630 | COT252 | COT.002.252 | TOT-SDP-ALLOWED-AMT | Total State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 134 | 1494 | 1506 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 631 | COT253 | COT.002.253 | TOT-SDP-PAID-AMT | Total State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | S9(11)V99 | 135 | 1507 | 1519 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 632 | COT152 | COT.002.152 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | COT00002 | CLAIM-HEADER-RECORD-OT | X(500) | 136 | 1520 | 2019 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 633 | COT154 | COT.003.154 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | COT00003 | CLAIM-LINE-RECORD-OT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "COT00003" |
| 634 | 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. | STATE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (COT.001.007) |
| 635 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 636 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 637 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(50) | 5 | 42 | 91 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 638 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(50) | 6 | 92 | 141 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 639 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 7 | 142 | 144 | 1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 640 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 8 | 145 | 147 | 1. Value must be 3 characters or less 2. If associated Line Adjustment Indicator value equals "0", then value must not be populated 3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided 4. Conditional 5. When populated, value must be one or greater |
| 641 | 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. | LINE-ADJUSTMENT-IND | COT00003 | CLAIM-LINE-RECORD-OT | X(1) | 9 | 148 | 148 | 1. Value must be 1 character 2. Value must be in Line Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Conditional 5. If associated Line Adjustment Number is populated, then value must be populated |
| 642 | 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. | LINE-ADJUSTMENT-REASON-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 10 | 149 | 151 | 1. Value must be 3 characters or less 2. Value must be in Line Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 643 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(12) | 11 | 152 | 163 | 1. Value must be 12 characters or less 2. Mandatory |
| 644 | COT165 | COT.003.165 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. | CLAIM-STATUS | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 12 | 164 | 166 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2" |
| 645 | 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 covered by this claim began. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(8) | 13 | 167 | 174 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be less than or equal to associated Ending Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values 7. Mandatory |
| 646 | 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 claim ended. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(8) | 14 | 175 | 182 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period value 3. Value must be greater than or equal to associated Beginning Date of Service value 4. Value must be less than or equal to associated Adjudication Date value 5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated 6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value 7. Mandatory |
| 647 | 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 Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims. | REVENUE-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(4) | 15 | 183 | 186 | 1. Value must be 4 characters or less 2. Value must be in Revenue Code List (VVL) 3. A Revenue Code value requires an associated Revenue Charge 4. Conditional |
| 648 | 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. | PROCEDURE-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(8) | 16 | 187 | 194 | 1. Value must be 8 characters or less 2. Value must be in Procedure Code List (VVL) 3. When populated, there must be a corresponding Procedure Code Flag 4. If associated Procedure Code Flag value indicates an CPT-4 encoding "01", then value must be a valid CPT-4 procedure code 5. If associated Procedure Code Flag 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 6. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding "06", then value must be a valid HCPCS code 7. Conditional |
| 649 | COT170 | COT.003.170 | PROCEDURE-CODE-DATE | Procedure Code Date | Conditional | The date upon which a reported medical procedure was performed. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(8) | 17 | 195 | 202 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated Discharge Date value 3. Value must be provided with an associated Procedure Code value 4. Value must be on or after associated Beginning Date of Service value 5. Value must be on or before associated Eligible Date of Death value 6. Value must be not be populated when associated Procedure Code is not populated 7. Conditional |
| 650 | COT171 | COT.003.171 | PROCEDURE-CODE-FLAG | Procedure Code Flag | Conditional | A flag that identifies the coding system used for an associated procedure code. | PROCEDURE-CODE-FLAG | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 18 | 203 | 204 | 1. Value must be 2 characters 2. Value must be in Procedure Code Flag List (VVL) 3. When populated, there must be a corresponding Procedure Code 4. Conditional |
| 651 | 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. | PROCEDURE-CODE-MOD | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 19 | 205 | 206 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 652 | 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. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 20 | 207 | 219 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 653 | 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 care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 21 | 220 | 232 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 654 | COT176 | COT.003.176 | BENEFICIARY-COPAYMENT-PAID-AMOUNT | Beneficiary Copayment Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 22 | 233 | 245 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 655 | COT177 | COT.003.177 | TPL-AMT | TPL 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 23 | 246 | 258 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 656 | 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 sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 24 | 259 | 271 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654]\ |
| 657 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 25 | 272 | 284 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Type of Claim value in [3,C,W], then value is mandatory and must be provided 4. Conditional |
| 658 | COT182 | COT.003.182 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 26 | 285 | 297 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0", then the value must not be populated 4. Conditional 5. If value is populated, Crossover Indicator must be equal to "1" |
| 659 | COT183 | COT.003.183 | SERVICE-QUANTITY-ACTUAL | Service Quantity Actual | Mandatory | The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim/encounter line. For use with CLAIMOT claims. For CLAIMRX claims/encounters, use the Prescription Quantity Actual field. For CLAIMIP and CLAIMLT claims/encounters, use the Revenue Center Quantity Actual field. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(8)V999 | 27 | 298 | 308 | 1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Mandatory |
| 660 | COT184 | COT.003.184 | SERVICE-QUANTITY-ALLOWED | Service Quantity Allowed | Conditional | The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT claims/encounters. For CLAIMIP and CLAIMLT claims/encounters, use the Revenue Center Quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Service Quantity Allowed = 100. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(8)V999 | 28 | 309 | 319 | 1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Conditional |
| 661 | COT186 | COT.003.186 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | TYPE-OF-SERVICE-OT | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 29 | 320 | 322 | 1. Value must be 3 characters. 2. Mandatory 3. Value must be in Type of Service OT List (VVL) 4. When value is not in [025,085], Sex (ELG.002.023) equals "M" |
| 662 | 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. 1915(c), 1915(i), 1915(j), and 1915(k) services). | HCBS-SERVICE-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(1) | 30 | 323 | 323 | 1. Value must be 1 character 2. Value must be in HCBS Service Code List (VVL) 3. If value is in [1-7], then HCBS Taxonomy must be populated 4. Conditional |
| 663 | 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. The HCBS Taxonomic classification system was adopted by CMS in August 2012. To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting. Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as “extended state plan” services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment. The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state’s service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc. Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf. |
HCBS-TAXONOMY | COT00003 | CLAIM-LINE-RECORD-OT | X(5) | 31 | 324 | 328 | 1. Value must be 5 characters or less 2. Value must be in HCBS Taxonomy Code List (VVL) 3. Conditional |
| 664 | 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 value is conditional as its usage varies by state. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(30) | 32 | 329 | 358 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W], then value may match (PRV.005.081) Provider Identifier or 4. When Type of Claim not in [3,C,W], then value may match (PRV.002.019) Submitting State Provider ID |
| 665 | COT190 | COT.003.190 | 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 procedure. The SERVICING-PROV-NPI-NUM is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(10) | 33 | 359 | 368 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Conditional 4. If Type of Claim (COT.002.037) not in [3,C,W], then value must match Provider Identifier (PRV.005.081) 5. Value must exist in the NPPES NPI data file |
| 666 | COT191 | COT.003.191 | SERVICING-PROV-TAXONOMY | Servicing Provider Taxonomy | Conditional | The taxonomy code for the provider who treated the recipient. | PROV-TAXONOMY | COT00003 | CLAIM-LINE-RECORD-OT | X(12) | 34 | 369 | 380 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 667 | COT192 | COT.003.192 | SERVICING-PROV-TYPE | Servicing Provider Type | Conditional | A code to describe the type of provider being reported. | PROV-TYPE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 35 | 381 | 382 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL). 3. Conditional |
| 668 | COT193 | COT.003.193 | SERVICING-PROV-SPECIALTY | Servicing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 36 | 383 | 384 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 669 | COT194 | COT.003.194 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 37 | 385 | 387 | 1. Value must be 3 characters 2. Value must be in Other TPL Collection List (VVL) 3. Mandatory |
| 670 | COT195 | COT.003.195 | TOOTH-DESIGNATION-SYSTEM | Tooth Designation System | Conditional | A code to identify the tooth numbering system being used. | TOOTH-DESIGNATION-SYSTEM | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 38 | 388 | 389 | 1. Value must be 2 characters 2. Value must be in Tooth Designation System List (VVL) 3. Value must not contain a pipe symbol 4. Conditional |
| 671 | 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. | TOOTH-NUM | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 39 | 390 | 391 | 1. Value must be 2 characters or less 2. Value must be in Tooth Number List (VVL) 3. If Tooth Designation System (COT.003.195) is "JP" value must be found in [1..32][51-82][A..T]or [AS..KS] 4. If Tooth Designation System (COT.003.195) is "JO" value must have 1 digit before and after the decimal (N.N) 5. 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 6. Conditional 7. 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 |
| 672 | COT197 | COT.003.197 | TOOTH-QUAD-CODE | Tooth Quad Code | Conditional | The area of the oral cavity is designated by a two-digit code. | TOOTH-QUAD-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 40 | 392 | 393 | 1. Value must be 2 characters 2. Value must be in Tooth Quad Code List (VVL) 3. Conditional 4. When populated, associated type of service value must be in [013,029,035] |
| 673 | 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. | TOOTH-SURFACE-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(1) | 41 | 394 | 394 | 1. Value must be 1 character 2. Value must be in Tooth Surface Code List (VVL) 3. Conditional 4. When populated, associated type of service value must be in [013,029,035] |
| 674 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(60) | 42 | 395 | 454 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 675 | COT200 | COT.003.200 | ORIGINATION-ADDR-LN2 | Origination Address Line 2 | Conditional | The second line of 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. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(60) | 43 | 455 | 514 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s) 3. There must be an Address Line 1 in order to have an Address Line 2 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 676 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(28) | 44 | 515 | 542 | 1. Value must be 28 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 677 | 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. | STATE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 45 | 543 | 544 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Conditional |
| 678 | COT203 | COT.003.203 | ORIGINATION-ZIP-CODE | Origination ZIP Code | Conditional | The zip code of the origination city 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. | ZIP-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(9) | 46 | 545 | 553 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 679 | 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. For transportation claims only. Required if state has captured this information, otherwise it is conditional. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(60) | 47 | 554 | 613 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 680 | 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. For transportation claims only. Required if state has captured this information, otherwise it is conditional. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(60) | 48 | 614 | 673 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s) 3. There must be an Address Line 1 in order to have an Address Line 2 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 681 | 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. For transportation claims only. Required if state has captured this information, otherwise it is conditional. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(28) | 49 | 674 | 701 | 1. Value must be 28 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 682 | 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. For transportation claims only. Required if state has captured this information, otherwise it is conditional. | STATE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 50 | 702 | 703 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Conditional |
| 683 | COT208 | COT.003.208 | DESTINATION-ZIP-CODE | Destination ZIP Code | Conditional | The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. | ZIP-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(9) | 51 | 704 | 712 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 684 | COT210 | COT.003.210 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 52 | 713 | 714 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 685 | COT213 | COT.003.213 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 53 | 715 | 727 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 686 | 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. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(12) | 54 | 728 | 739 | 1. Value must be 12 digits or less 2. Value must be a valid National Drug Code 3. Conditional |
| 687 | 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. | PROCEDURE-CODE-MOD | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 55 | 740 | 741 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 688 | 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. | PROCEDURE-CODE-MOD | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 56 | 742 | 743 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 689 | 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. | PROCEDURE-CODE-MOD | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 57 | 744 | 745 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 690 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(8) | 58 | 746 | 753 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (COT.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 691 | COT222 | COT.003.222 | SELF-DIRECTION-TYPE | Self Direction Type | Mandatory | A data element to identify how the beneficiary self-directed the service, i.e. hiring authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services), budget authority (The beneficiary has decision-making authority over how the Medicaid funds in a budget are spent), or both hiring and budget authority. | SELF-DIRECTION-TYPE | COT00003 | CLAIM-LINE-RECORD-OT | X(3) | 59 | 754 | 756 | 1. Value must be 3 characters 2. Value must be in Self Direction Type List (VVL) 3. Mandatory |
| 692 | 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). | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(18) | 60 | 757 | 774 | 1. Value must be 18 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 693 | 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. | NDC-UNIT-OF-MEASURE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 61 | 775 | 776 | 1. Value must be 2 characters 2. Value must be in NDC Unit of Measure List (VVL) 3. Conditional |
| 694 | 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/encounters. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(9)V(9) | 62 | 777 | 794 | 1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 695 | COT234 | COT.003.234 | IHS-SERVICE-IND | IHS Service Indicator | Mandatory | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | IHS-SERVICE-IND | COT00003 | CLAIM-LINE-RECORD-OT | X(1) | 63 | 795 | 795 | 1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 696 | COT254 | COT.003.254 | DIAGNOSIS-CODE-POINTER-1 | Diagnosis Code Pointer 1 | Mandatory | A pointer to the diagnosis code in the order of importance to this service. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(2) | 64 | 796 | 797 | 1. Value must be numeric 2. Value must be 2 digits or less 3. Value must be between 1 and 12 4. Mandatory |
| 697 | COT287 | COT.003.287 | DIAGNOSIS-CODE-POINTER-2 | Diagnosis Code Pointer 2 | Conditional | A pointer to the diagnosis code in the order of importance to this service. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(2) | 65 | 798 | 799 | 1. Value must be numeric 2. Value must not be more than 2 digits long 3. Value must be between 1 and 12 4. Conditional |
| 698 | COT288 | COT.003.288 | DIAGNOSIS-CODE-POINTER-3 | Diagnosis Code Pointer 3 | Conditional | A pointer to the diagnosis code in the order of importance to this service. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(2) | 66 | 800 | 801 | 1. Value must be numeric 2. Value must not be more than 2 digits long 3. Value must be between 1 and 12 4. Conditional |
| 699 | COT289 | COT.003.289 | DIAGNOSIS-CODE-POINTER-4 | Diagnosis Code Pointer 4 | Conditional | A pointer to the diagnosis code in the order of importance to this service. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | 9(2) | 67 | 802 | 803 | 1. Value must be numeric 2. Value must not be more than 2 digits long 3. Value must be between 1 and 12 4. Conditional |
| 700 | COT255 | COT.003.255 | UNIQUE-DEVICE-IDENTIFIER | Unique Device Identifier | Conditional | An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(76) | 68 | 804 | 879 | 1. Value must not be more than 76 characters long 2. Conditional |
| 701 | COT290 | COT.003.290 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Conditional | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | COT00003 | CLAIM-LINE-RECORD-OT | X(1) | 69 | 880 | 880 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 702 | COT257 | COT.003.257 | MBESCBES-FORM | MBESCBES Form | Conditional | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | COT00003 | CLAIM-LINE-RECORD-OT | X(50) | 70 | 881 | 930 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 703 | COT256 | COT.003.256 | MBESCBES-CATEGORY-OF-SERVICE | 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 MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
COT00003 | CLAIM-LINE-RECORD-OT | X(5) | 71 | 931 | 935 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 704 | COT258 | COT.003.258 | SERVICE-FACILITY-LOCATION-ORG-NPI | Service Facility Location Organization NPI | Conditional | Service facility location organization NPI from X12 837P loop 2420C and 837D loop 2420D. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(10) | 72 | 936 | 945 | 1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 705 | COT259 | COT.003.259 | SERVICE-FACILITY-LOCATION-ADDR-LN-1 | Service Facility Location Address Line 1 | Conditional | Service facility location address line 1 from X12 837P loop 2420C and 837D loop 2420D. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(60) | 73 | 946 | 1005 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 706 | COT260 | COT.003.260 | SERVICE-FACILITY-LOCATION-ADDR-LN-2 | Service Facility Location Address Line 2 | Conditional | Service facility location address line 2 from X12 837P loop 2420C and 837D loop 2420D. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(60) | 74 | 1006 | 1065 | 1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 707 | COT261 | COT.003.261 | SERVICE-FACILITY-LOCATION-CITY | Service Facility Location City | Conditional | Service facility location address city name from X12 837P loop 2420C and 837D loop 2420D. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(28) | 75 | 1066 | 1093 | 1. Value must not be more than 28 characters long 2. Conditional |
| 708 | COT262 | COT.003.262 | SERVICE-FACILITY-LOCATION-STATE | Service Facility Location State | Conditional | Service facility location address state code from X12 837P loop 2420C and 837D loop 2420D. | STATE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 76 | 1094 | 1095 | 1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 709 | COT263 | COT.003.263 | SERVICE-FACILITY-LOCATION-ZIP-CODE | Service Facility Location ZIP Code | Conditional | Service facility location address ZIP code from X12 837P loop 2420C and 837D loop 2420D. | ZIP-CODE | COT00003 | CLAIM-LINE-RECORD-OT | X(9) | 77 | 1096 | 1104 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 710 | COT264 | COT.003.264 | PLACE-OF-SERVICE | Place of Service | Conditional | PLACE-OF-SERVICE is a pass-through data element meaning that the state should report the field in T-MSIS as reported by the provider on the claims form (i.e., 837P, CMS-1500, or 837D). If the claim is submitted on the 837p electronic claims form and the Facility Code Qualifier is reported with any value other than “B”, then the PLACE-OF-SERVICE value should be blank or space-filled. If the claim is submitted on the CMS 1450 (UB04) institutional claims form, the PLACE-OF-SERVICE field should be blank or space-filled. Otherwise, if the claim is submitted with the place of service populated with any value other than the valid values listed in T-MSIS Data Guide for PLACE-OF-SERVICE values, that value should still be reported in the PLACE-OF-SERVICE data element. If the claim is submitted by a provider with the place of service fields blank, then the PLACE-OF-SERVICE on the T-MSIS OT claims file should be blank or space-filled. | PLACE-OF-SERVICE | COT00003 | CLAIM-LINE-RECORD-OT | X(2) | 78 | 1105 | 1106 | 1. Value must not be more than 2 characters 2. Value must be in Place of Service Code List (VVL) 3. Conditional 4. if value is populated, then Revenue Code must be null |
| 711 | COT265 | COT.003.265 | GME-AMOUNT-PAID | GME Amount Paid | Conditional | The amount included in the Medicaid Amount (COT.003.178) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 79 | 1107 | 1119 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 712 | COT266 | COT.003.266 | 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 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 ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(30) | 80 | 1120 | 1149 | 1. Value must be 30 characters or less 2. Conditional |
| 713 | COT267 | COT.003.267 | REFERRING-PROV-NPI-NUM | Referring Provider NPI Number | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(10) | 81 | 1150 | 1159 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 714 | COT268 | COT.003.268 | REFERRING-PROV-NUM-2 | Referring Provider Number 2 | 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 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 ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(30) | 82 | 1160 | 1189 | 1. Value must be 30 characters or less 2. Conditional |
| 715 | COT269 | COT.003.269 | REFERRING-PROV-NPI-NUM-2 | Referring Provider NPI Number 2 | Conditional | The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the line/detail of their claim. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(10) | 83 | 1190 | 1199 | 1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File 5. Value must not be populated when Referring Provider NPI Number is not populated. 6. Value must not equal Referring Provider NPI Number |
| 716 | COT270 | COT.003.270 | ORDERING-PROV-NUM | Ordering Provider Number | Conditional | The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(30) | 84 | 1200 | 1229 | 1. Value must be 30 characters or less 2. Conditional |
| 717 | COT271 | COT.003.271 | ORDERING-PROV-NPI-NUM | order Provider NPI Number | Conditional | The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(10) | 85 | 1230 | 1239 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 718 | COT272 | COT.003.272 | SDP-ALLOWED-AMT | State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 86 | 1240 | 1252 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 719 | COT273 | COT.003.273 | SDP-PAID-AMT | State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | COT00003 | CLAIM-LINE-RECORD-OT | S9(11)V99 | 87 | 1253 | 1265 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 720 | COT214 | COT.003.214 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | COT00003 | CLAIM-LINE-RECORD-OT | X(500) | 88 | 1266 | 1765 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 721 | COT274 | COT.004.274 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | COT00004 | CLAIM-DX-OT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "COT00004" |
| 722 | COT275 | COT.004.275 | 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. | STATE | COT00004 | CLAIM-DX-OT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (COT.001.007) |
| 723 | COT276 | COT.004.276 | 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. | N/A | COT00004 | CLAIM-DX-OT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 724 | COT277 | COT.004.277 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | N/A | COT00004 | CLAIM-DX-OT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 725 | COT278 | COT.004.278 | 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. | N/A | COT00004 | CLAIM-DX-OT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 726 | COT279 | COT.004.279 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | COT00004 | CLAIM-DX-OT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (COT.002.025) |
| 727 | COT280 | COT.004.280 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | COT00004 | CLAIM-DX-OT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (COT.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 728 | COT281 | COT.004.281 | DIAGNOSIS-TYPE | Diagnosis Type | Mandatory | Indicates the context of the diagnosis code from the provider's claim (i.e., an 837I claim can have one principal diagnosis code, up to 12 external cause of injury diagnosis codes, and up to 24 other diagnosis codes; a UB-04 claim can have one principal diagnosis code, one admitting diagnosis code, and up to 17 other diagnosis codes; an 837P or CMS-1500 claim can have up to 12 diagnosis codes; an 837D or ADA claim can have up to 4 diagnosis codes). The type of diagnosis code (e.g., principal, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number. | DIAGNOSIS-TYPE | COT00004 | CLAIM-DX-OT | X(1) | 8 | 131 | 131 | 1. Value must be 1 character 2. Value must be in Diagnosis Type Code List (VVL) 3. Value must be in [P,A,E,O] 4. Mandatory |
| 729 | COT282 | COT.004.282 | DIAGNOSIS-SEQUENCE-NUMBER | Diagnosis Sequence Number | Mandatory | The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837P claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes). | N/A | COT00004 | CLAIM-DX-OT | 9(2) | 9 | 132 | 133 | 1. Value must be in [01-24] 2. Mandatory |
| 730 | COT283 | COT.004.283 | DIAGNOSIS-CODE-FLAG | Diagnosis Code Flag | Mandatory | Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. | DIAGNOSIS-CODE-FLAG | COT00004 | CLAIM-DX-OT | X(1) | 10 | 134 | 134 | 1. Value must be 1 character 2. Value must be in Diagnosis Code Flag List (VVL) 3. Mandatory |
| 731 | COT284 | COT.004.284 | DIAGNOSIS-CODE | Diagnosis Code | Mandatory | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'. | DIAGNOSIS-CODE | COT00004 | CLAIM-DX-OT | X(7) | 11 | 135 | 141 | 1. Value must be a minimum of 3 characters 2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must not contain a decimal point 5. Mandatory |
| 732 | COT285 | COT.004.285 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | COT00004 | CLAIM-DX-OT | X(500) | 12 | 142 | 641 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 733 | CRX001 | CRX.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CRX00001 | FILE-HEADER-RECORD-RX | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CRX00001" |
| 734 | 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. | DATA-DICTIONARY-VERSION | CRX00001 | FILE-HEADER-RECORD-RX | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 735 | 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. | SUBMISSION-TRANSACTION-TYPE | CRX00001 | FILE-HEADER-RECORD-RX | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 736 | CRX004 | CRX.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | CRX00001 | FILE-HEADER-RECORD-RX | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 737 | 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. | N/A | CRX00001 | FILE-HEADER-RECORD-RX | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 738 | CRX006 | CRX.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | CRX00001 | FILE-HEADER-RECORD-RX | X(8) | 6 | 32 | 39 | 1. Value must equal "CLAIM-RX" 2. Mandatory |
| 739 | 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. | STATE | CRX00001 | FILE-HEADER-RECORD-RX | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 740 | CRX008 | CRX.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | CRX00001 | FILE-HEADER-RECORD-RX | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 741 | 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. | N/A | CRX00001 | FILE-HEADER-RECORD-RX | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 742 | 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. | N/A | CRX00001 | FILE-HEADER-RECORD-RX | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 743 | 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. | FILE-STATUS-INDICATOR | CRX00001 | FILE-HEADER-RECORD-RX | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 744 | 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 files. | SSN-INDICATOR | CRX00001 | FILE-HEADER-RECORD-RX | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 745 | 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. | N/A | CRX00001 | FILE-HEADER-RECORD-RX | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 746 | 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 original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | CRX00001 | FILE-HEADER-RECORD-RX | X(4) | 14 | 79 | 82 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 747 | CRX014 | CRX.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CRX00001 | FILE-HEADER-RECORD-RX | X(500) | 15 | 83 | 582 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 748 | CRX016 | CRX.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CRX00002 | CLAIM-HEADER-RECORD-RX | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CRX00002" |
| 749 | 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. | STATE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CRX.001.007) |
| 750 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 751 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 752 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 753 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(12) | 6 | 122 | 133 | 1. Value must be 12 characters or less 2. Mandatory |
| 754 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(20) | 7 | 134 | 153 | 1. Value must be 20 characters or less 2. Mandatory 3. 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) |
| 755 | CRX023 | CRX.002.023 | CROSSOVER-INDICATOR | Crossover Indicator | Mandatory | An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. | CROSSOVER-INDICATOR | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 8 | 154 | 154 | 1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 756 | CRX024 | CRX.002.024 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration. | 1115A-DEMONSTRATION-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 9 | 155 | 155 | 1. Value must be 1 character 2. Value must be in 1115A Demonstration Indicator List (VVL) 3. Conditional 4. When value equals "0", is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 757 | CRX025 | CRX.002.025 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 10 | 156 | 156 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" |
| 758 | 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. | ADJUSTMENT-REASON-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(3) | 11 | 157 | 159 | 1. Value must be 3 characters or less 2. Value must be in Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 759 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 12 | 160 | 167 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CIP.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 760 | CRX028 | CRX.002.028 | MEDICAID-PAID-DATE | Medicaid Paid Date | Mandatory | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 13 | 168 | 175 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Total Medicaid Paid Amount 3. Mandatory |
| 761 | CRX029 | CRX.002.029 | TYPE-OF-CLAIM | Type of Claim | Mandatory | A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. | TYPE-OF-CLAIM | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 14 | 176 | 176 | 1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 762 | CRX030 | CRX.002.030 | CLAIM-STATUS | Claim Status | Conditional | The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim. | CLAIM-STATUS | CRX00002 | CLAIM-HEADER-RECORD-RX | X(3) | 15 | 177 | 179 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 763 | CRX031 | CRX.002.031 | CLAIM-STATUS-CATEGORY | Claim Status Category | Mandatory | The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status. | CLAIM-STATUS-CATEGORY | CRX00002 | CLAIM-HEADER-RECORD-RX | X(3) | 16 | 180 | 182 | 1. Value must be 3 characters or less 2. Value must be in Claim Status Category List (VVL) 3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2" 4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2" 5. Mandatory |
| 764 | CRX032 | CRX.002.032 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
SOURCE-LOCATION | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 17 | 183 | 184 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 765 | CRX033 | CRX.002.033 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(15) | 18 | 185 | 199 | 1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 766 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 19 | 200 | 207 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional |
| 767 | CRX035 | CRX.002.035 | CLAIM-PYMT-REM-CODE-1 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(5) | 20 | 208 | 212 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique |
| 768 | CRX036 | CRX.002.036 | CLAIM-PYMT-REM-CODE-2 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(5) | 21 | 213 | 217 | 1. Value must be 5 characters or less 2. Value must be in Claim Payment Remittance Code List (VVL) 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 1 (CRX.002.035) is not populated |
| 769 | CRX037 | CRX.002.037 | CLAIM-PYMT-REM-CODE-3 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(5) | 22 | 218 | 222 | 1. Value must be in Claim Payment Remittance Code List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 2 (CRX.002.036) is not populated |
| 770 | CRX038 | CRX.002.038 | CLAIM-PYMT-REM-CODE-4 | Remittance Advice 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 shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). | CLAIM-PYMT-REM-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(5) | 23 | 223 | 227 | 1. Value must be in Claim Payment Remittance Code List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique 5. Value must not be populated when Remittance Advice Remark Code 3 (CIP.002.110) is not populated |
| 771 | 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 in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 24 | 228 | 240 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must equal the sum of all Billed Amount instances for the associated claim 4. Conditional |
| 772 | 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 determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 25 | 241 | 253 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. When populated and Payment Level Indicator equals "2", then value must equal the sum of all claim line Allowed Amount values 4. Conditional |
| 773 | 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. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 26 | 254 | 266 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must be populated, when Type of Claim is in [1,A] 8. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 9. Value must not be greater than Total Allowed Amount (CRX.002.040) |
| 774 | 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 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 27 | 267 | 279 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated 4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value is mandatory and must be provided 5. Conditional 6. When populated, value must be less than or equal to Total Billed Amount |
| 775 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 28 | 280 | 292 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0" (not a crossover claim), then value should not be populated. 4. Conditional 5. If associated Medicare Combined Deductible Indicator equals "1", then value must not be populated 6. When populated, value must be less than or equal to Total Billed Amount |
| 776 | CRX045 | CRX.002.045 | TOT-TPL-AMT | Total TPL 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 29 | 293 | 305 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount) 4. Conditional |
| 777 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 30 | 306 | 318 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 778 | 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. | OTHER-INSURANCE-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 31 | 319 | 319 | 1. Value must be 1 character 2. Value must be in Other Insurance Indicator List (VVL) 3. Conditional |
| 779 | CRX049 | CRX.002.049 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | CRX00002 | CLAIM-HEADER-RECORD-RX | X(3) | 32 | 320 | 322 | 1. Value must be in Other TPL Collection List (VVL) 2. Value must be 3 characters 3. Mandatory |
| 780 | 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 programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. | FIXED-PAYMENT-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 33 | 323 | 323 | 1. Value must be 1 character 2. Value must be in Fixed Payment Indicator List (VVL) 3. Conditional |
| 781 | CRX053 | CRX.002.053 | FUNDING-CODE | Funding Code | Conditional | A code to indicate the source of non-federal share funds. | FUNDING-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 34 | 324 | 325 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 782 | CRX054 | CRX.002.054 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Non-Federal Share | Conditional | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 35 | 326 | 327 | 1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 783 | CRX055 | CRX.002.055 | PROGRAM-TYPE | Program Type | Mandatory | A code to indicate special Medicaid program under which the service was provided. | PROGRAM-TYPE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 36 | 328 | 329 | 1. Value must be 2 characters 2. Value must be in Program Type List (VVL) 3. Mandatory 4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period 5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 784 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(12) | 37 | 330 | 341 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. Value should be populated when Type of Claim (CRX.002.029) is in [3,C,W] 7. When Type of Claim (CRX.002.029) in [3,C,W] 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) 8. When Type of Claim (CRX.002.029) in [3,C,W] 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) |
| 785 | 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. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
PAYMENT-LEVEL-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 38 | 342 | 342 | 1. Value must be 1 character 2. Value must be in Payment Level Indicator List (VVL) 3. Mandatory |
| 786 | CRX059 | CRX.002.059 | MEDICARE-REIM-TYPE | Medicare Reimbursement Type | Conditional | A code to indicate the type of Medicare reimbursement. | MEDICARE-REIM-TYPE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 39 | 343 | 344 | 1. Value must be 2 characters 2. Value must be in Medicare Reimbursement Type List (VVL) 3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim) 4. Conditional |
| 787 | CRX060 | CRX.002.060 | CLAIM-LINE-COUNT | Claim Line Count | Mandatory | The total number of lines on the claim. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(4) | 40 | 345 | 348 | 1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. 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 6. Mandatory |
| 788 | 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. | FORCED-CLAIM-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 41 | 349 | 349 | 1. Value must be 1 character 2. Value must be in Forced Claim Indicator List (VVL) 3. Conditional |
| 789 | 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 | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(20) | 42 | 350 | 369 | 1. Value must be 20 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Conditional |
| 790 | 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 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 with the appropriate eligibility data.) | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(30) | 43 | 370 | 399 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 791 | 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 with the appropriate eligibility data.) | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(30) | 44 | 400 | 429 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 792 | 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). | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 45 | 430 | 430 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 793 | CRX066 | CRX.002.066 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 46 | 431 | 438 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 794 | 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 to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. | HEALTH-HOME-PROV-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 47 | 439 | 439 | 1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 795 | 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. | WAIVER-TYPE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 48 | 440 | 441 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service) 4. Value must have a corresponding value in Waiver ID (CRX.002.069) 5. Conditional 6. 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" |
| 796 | 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(20) | 49 | 442 | 461 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (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] 6. Conditional |
| 797 | CRX070 | CRX.002.070 | BILLING-PROV-NUM | Billing Provider Number | Conditional | A unique identification number assigned by the state to a provider or managed care 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 (billing or reporting) to the managed care plan. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(30) | 50 | 462 | 491 | 1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 798 | CRX071 | CRX.002.071 | BILLING-PROV-NPI-NUM | Billing Provider NPI Number | Conditional | The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(10) | 51 | 492 | 501 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 799 | CRX072 | CRX.002.072 | BILLING-PROV-TAXONOMY | Billing Provider Taxonomy | Conditional | The taxonomy code for the provider billing for the service. | PROV-TAXONOMY | CRX00002 | CLAIM-HEADER-RECORD-RX | X(12) | 52 | 502 | 513 | 1. Value must be 12 characters or less 2. Value must be in Provider Taxonomy List (VVL) 3. Conditional |
| 800 | CRX073 | CRX.002.073 | BILLING-PROV-SPECIALTY | Billing Provider Specialty | Conditional | This code describes the area of specialty for the provider being reported. | PROV-SPECIALTY | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 53 | 514 | 515 | 1. Value must be 2 characters 2. Value must be in Provider Specialty List (VVL) 3. Conditional |
| 801 | 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) ID is on the state file, then the State should use the DEA ID for this data element | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(30) | 54 | 516 | 545 | 1. Value must be 30 characters or less 2. Mandatory |
| 802 | CRX075 | CRX.002.075 | PRESCRIBING-PROV-NPI-NUM | Prescribing Provider NPI Number | Mandatory | The National Provider ID (NPI) of the provider who prescribed a medication to a patient. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(10) | 55 | 546 | 555 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Mandatory 4. Value must exist in the NPPES NPI data file 5. NPPES Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 803 | 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 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 and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based). | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(12) | 56 | 556 | 567 | 1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CRX.002.023) equals "1" and Medicare Beneficiary Identifier (CRX.002.105) is not populated |
| 804 | 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 RA is the detailed explanation of the reason for the payment amount. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(30) | 57 | 568 | 597 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 805 | 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.) | BORDER-STATE-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 58 | 598 | 598 | 1. Value must be 1 character 2. Value must be in Border State Indicator List (VVL) 3. Conditional |
| 806 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 59 | 599 | 606 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or after associated eligible party's Date of Birth (ELG.002.024) 3. Value must be on or before associated Prescription Fill Date (CRX.002.085) 4. Value must be on or before associated Adjudication Date (CRX.002.027) 5. Value must be on or before associated eligible party's Date of Death (ELG.002.025) 6. Mandatory 7. Value should be on or before End of Time Period (CRX.001.010) |
| 807 | CRX085 | CRX.002.085 | PRESCRIPTION-FILL-DATE | Prescription Fill Date | Mandatory | Date the drug, device, or supply was dispensed by the provider. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 60 | 607 | 614 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be on or before associated End of Time Period (CRX.001.010) 3. Value must be on or after associated Start of Time Period (CRX.001.009) 4. Value must be on or after associated Date Prescribed (CRX.002.084) 5. Value must be on or after associated eligible party's Date of Birth (ELG.002.024) 6. Value must be on or before associated eligible party's Date of Death (ELG.002.025) 7. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal "1" 8. Mandatory |
| 808 | CRX086 | CRX.002.086 | COMPOUND-DRUG-IND | Compound Drug Indicator | Conditional | Indicator to specify if the drug is compound or not. | COMPOUND-DRUG-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 61 | 615 | 615 | 1. Value must be 1 character 2. Value must be in Compound Drug Indicator List (VVL) 3. Conditional |
| 809 | CRX087 | CRX.002.087 | TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Total Beneficiary Coinsurance Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 62 | 616 | 628 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 810 | CRX088 | CRX.002.088 | BENEFICIARY-COINSURANCE-DATE-PAID | Beneficiary Coinsurance Date Paid | Conditional | The date the beneficiary paid the coinsurance amount. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 63 | 629 | 636 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Coinsurance Amount 3. Conditional |
| 811 | CRX089 | CRX.002.089 | TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Total Beneficiary Copayment Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 64 | 637 | 649 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 812 | CRX090 | CRX.002.090 | BENEFICIARY-COPAYMENT-DATE-PAID | Beneficiary Copayment Date Paid | Conditional | The date the beneficiary paid the copayment amount. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 65 | 650 | 657 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Copayment Amount 3. Conditional |
| 813 | CRX092 | CRX.002.092 | TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Total Beneficiary Deductible Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 66 | 658 | 670 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 814 | CRX093 | CRX.002.093 | BENEFICIARY-DEDUCTIBLE-DATE-PAID | Beneficiary Deductible Date Paid | Conditional | The date the beneficiary paid the deductible amount. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 67 | 671 | 678 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Beneficiary Deductible Amount 3. Conditional |
| 815 | 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. | CLAIM-DENIED-INDICATOR | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 68 | 679 | 679 | 1. Value must be 1 character 2. Value must be in Claim Denied Indicator List (VVL) 3. If value equals "0", then Claim Status Category must equal "F2" 4. Mandatory |
| 816 | CRX095 | CRX.002.095 | COPAY-WAIVED-IND | Copayment Waived Indicator | Situational | An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. | COPAY-WAIVED-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 69 | 680 | 680 | 1. Value must be 1 character 2. Value must be in Copay Waived Indicator List (VVL) 3. Situational |
| 817 | 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 or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(50) | 70 | 681 | 730 | 1. Value must not contain a pipe or asterisk symbols 2. Value must 50 characters or less 3. Conditional |
| 818 | CRX098 | CRX.002.098 | THIRD-PARTY-COINSURANCE-AMOUNT-PAID | Third Party Coinsurance Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 71 | 731 | 743 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 819 | CRX099 | CRX.002.099 | THIRD-PARTY-COINSURANCE-DATE-PAID | Third Party Coinsurance Date Paid | Conditional | The date the third party paid the coinsurance amount | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 72 | 744 | 751 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Coinsurance Amount 3. Conditional |
| 820 | CRX100 | CRX.002.100 | THIRD-PARTY-COPAYMENT-AMOUNT-PAID | Third Party Copayment Amount Paid | Situational | The amount of money paid by a third party on behalf of the beneficiary towards copayment. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 73 | 752 | 764 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Situational |
| 821 | CRX101 | CRX.002.101 | THIRD-PARTY-COPAYMENT-DATE-PAID | Third Party Copayment Date Paid | Situational | The date the third party paid the copayment amount. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | 9(8) | 74 | 765 | 772 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. When populated, value must have an associated Third Party Copayment Amount 3. Situational |
| 822 | CRX102 | CRX.002.102 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Dispensing Prescription Drug Provider NPI Number | Mandatory | The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(10) | 75 | 773 | 782 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. When Type of Claim not in [3,C,W], then value must match Provider Identifier (PRV.005.081) 4. Mandatory 5. Value must exist in the NPPES NPI data file 6. NPPES Entity Type Code associate with this NPI must equal "1" (Individual) |
| 823 | CRX104 | CRX.002.104 | HEALTH-HOME-PROVIDER-NPI | Health Home Provider NPI Number | Conditional | The National Provider ID (NPI) of the health home provider. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(10) | 76 | 783 | 792 | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 824 | 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 over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(12) | 77 | 793 | 804 | 1. Conditional 2. Value must be an 11-character string 3. Character 1 must be numeric values 1 thru 9 4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 6. Character 4 must be numeric values 0 thru 9 7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 9. Character 7 must be numeric values 0 thru 9 10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 12. Character 10 must be numeric values 0 thru 9 13. Character 11 must be numeric values 0 thru 9 14. Value must not contain a pipe or asterisk symbols |
| 825 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(30) | 78 | 805 | 834 | 1. Value must be 30 characters or less 2. When Type of Claim not in [3,C,W] then value may match Submitting State Provider ID (PRV.002.019) or 3. When Type of Claim not in[3,C,W] then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) equals "1" 4. Mandatory |
| 826 | 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. | MEDICARE-COMB-DED-IND | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 79 | 835 | 835 | 1. Value must be 1 character 2. Value must be in Medicare Combined Deductible Indicator List (VVL) 3. If value equals "1", then Total Medicare Coinsurance amount must not be populated 4. If value equals "0", then Crossover Indicator must equals "0" 5. If value equals "1", then Crossover Indicator must equals "1" 6. Conditional |
| 827 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(5) | 80 | 836 | 840 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 828 | CRX162 | CRX.002.162 | PRESCRIPTION-ORIGIN-CODE | Prescription Origin Code | Conditional | How the prescription was sent to the pharmacy. | PRESCRIPTION-ORIGIN-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(1) | 81 | 841 | 841 | 1. Value must be one digit 2. Value must be in Prescription Origin Code List (VVL) 3. Conditional |
| 829 | CRX163 | CRX.002.163 | TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Total Beneficiary Copayment Liable Amount | Conditional | The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 82 | 842 | 854 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 830 | CRX164 | CRX.002.164 | TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Total Beneficiary Coinsurance Liable Amount | Conditional | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 83 | 855 | 867 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 831 | CRX165 | CRX.002.165 | TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Total Beneficiary Deductible Liable Amount | Conditional | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 84 | 868 | 880 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 832 | CRX166 | CRX.002.166 | COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Combined Beneficiary Cost Sharing Paid Amount | Conditional | The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 85 | 881 | 893 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 833 | CRX173 | CRX.002.173 | 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. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 86 | 894 | 906 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 834 | CRX174 | CRX.002.174 | PROVIDER-CLAIM-FORM-CODE | Provider Claim Form Code | Mandatory | A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". | PROVIDER-CLAIM-FORM-CODE | CRX00002 | CLAIM-HEADER-RECORD-RX | X(2) | 87 | 907 | 908 | 1. Value must not be more than 2 characters 2. Value must be in Provider Claim Form Code List (VVL) 3. Mandatory |
| 835 | CRX175 | CRX.002.175 | PROVIDER-CLAIM-FORM-OTHER-TEXT | Provider Claim Form Other Text | Conditional | A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(50) | 88 | 909 | 958 | 1. Value must not be more than 50 characters long 2. Conditional 3. Value must be provided when corresponding Provider Claim Form Code is "Other" |
| 836 | CRX176 | CRX.002.176 | TOT-GME-AMOUNT-PAID | Total GME Amount Paid | Conditional | The amount included in the Total Medicaid Amount (CRX.002.041) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 89 | 959 | 971 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 837 | CRX177 | CRX.002.177 | TOT-SDP-ALLOWED-AMT | Total State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 90 | 972 | 984 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 838 | CRX178 | CRX.002.178 | TOT-SDP-PAID-AMT | Total State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | S9(11)V99 | 91 | 985 | 997 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 839 | CRX106 | CRX.002.106 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CRX00002 | CLAIM-HEADER-RECORD-RX | X(500) | 92 | 998 | 1497 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 840 | CRX108 | CRX.003.108 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CRX00003 | CLAIM-LINE-RECORD-RX | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CRX00003" |
| 841 | 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. | STATE | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CRX.001.007) |
| 842 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 843 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 844 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(50) | 5 | 42 | 91 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 845 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(50) | 6 | 92 | 141 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 846 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 7 | 142 | 144 | 1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 847 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 8 | 145 | 147 | 1. Value must be 3 characters or less 2. If associated Line Adjustment Indicator value equals "0", then value must not be populated 3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided 4. Conditional 5. When populated, value must be one or greater |
| 848 | 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. | LINE-ADJUSTMENT-IND | CRX00003 | CLAIM-LINE-RECORD-RX | X(1) | 9 | 148 | 148 | 1. Value must be 1 character 2. Value must be in Line Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Conditional 5. If associated Line Adjustment Number is populated, then value must be populated |
| 849 | 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. | LINE-ADJUSTMENT-REASON-CODE | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 10 | 149 | 151 | 1. Value must be 3 characters or less 2. Value must be in Line Adjustment Reason Code List (VVL) 3. Conditional 4. Value must be populated when the total paid amount is different from the total billed amount |
| 850 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(12) | 11 | 152 | 163 | 1. Value must be 12 characters or less 2. Mandatory |
| 851 | CRX119 | CRX.003.119 | CLAIM-LINE-STATUS | Claim Line Status | Conditional | The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. | CLAIM-STATUS | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 12 | 164 | 166 | 1. Value must be 3 characters or less 2. Value must be in Claim Status List (VVL) 3. Conditional 4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2" |
| 852 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(12) | 13 | 167 | 178 | 1. Value must be 12 digits or less 2. Value must be a valid National Drug Code 3. Mandatory 4. Value must have an associated Metric Decimal Quantity (CRX.003.144) 5. Value must have an associated Unit of Measure (CRX.003.133) |
| 853 | 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. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 14 | 179 | 191 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 854 | 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 care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 15 | 192 | 204 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 855 | CRX123 | CRX.003.123 | BENEFICIARY-COPAYMENT-PAID-AMOUNT | Beneficiary Copayment Paid Amount | Conditional | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(5)V99 | 16 | 205 | 211 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 856 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 17 | 212 | 224 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 857 | 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 sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 18 | 225 | 237 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 858 | 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. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 19 | 238 | 250 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Type of Claim value in [3,C,W], then value is mandatory and must be provided 4. Conditional |
| 859 | 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 deductible payments cannot be separated, fill this field with the combined payment amount and Medicare Coinsurance Payment is not required. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 20 | 251 | 263 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated if associated Crossover Indicator value equals "0" (not a crossover claim) 5. If value is greater than "0", then Crossover Indicator must be "1" |
| 860 | 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 deductible payments cannot be separated, populate the Medicare Deductible Amount. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 21 | 264 | 276 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Medicare Combined Deductible Indicator equals "1", then value must not be populated (or must be 99998) 4. Value must not be populated if Medicare Deductible Amount is not populated 5. Conditional |
| 861 | CRX129 | CRX.003.129 | MEDICARE-PAID-AMT | Medicare Paid Amount | Conditional | The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 22 | 277 | 289 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. If associated Crossover Indicator value equals "0", then the value must not be populated 4. Conditional 5. If value is populated, Crossover Indicator must be equal to "1" |
| 862 | CRX131 | CRX.003.131 | PRESCRIPTION-QUANTITY-ALLOWED | Prescription 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. For use with CLAIMRX claims/encounters. For CLAIMOT claims/encounters, use the Service Quantity Allowed field. For CLAIMIP and CLAIMLT claims/encounters, use the Revenue Center Quantity Actual field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(9)V(9) | 23 | 290 | 307 | 1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 863 | CRX132 | CRX.003.132 | PRESCRIPTION-QUANTITY-ACTUAL | Prescription Quantity Actual | Mandatory | The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line. For use with CLAIMRX claims/encounters. For CLAIMOT claims/encounters, use the Service Quantity Actual field. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(9)V(9) | 24 | 308 | 325 | 1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Mandatory |
| 864 | CRX133 | CRX.003.133 | UNIT-OF-MEASURE | Unit of Measure | Mandatory | A code to indicate the basis by which the quantity of the drug or supply is expressed. | NDC-UNIT-OF-MEASURE | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 25 | 326 | 327 | 1. Value must be 2 characters 2. Value must be in Unit of Measure List (VVL) 3. Mandatory |
| 865 | CRX134 | CRX.003.134 | TYPE-OF-SERVICE | Type of Service | Mandatory | A code to categorize the services provided to a Medicaid or CHIP enrollee. | TYPE-OF-SERVICE-RX | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 26 | 328 | 330 | 1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service RX List (VVL) |
| 866 | 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. 1915(c), 1915(i), 1915(j), and 1915(k) services). | HCBS-SERVICE-CODE | CRX00003 | CLAIM-LINE-RECORD-RX | X(1) | 27 | 331 | 331 | 1. Value must be 1 character 2. Value must be in HCBS Service Code List (VVL) 3. If value is in [1-7], then HCBS Taxonomy must be populated 4. Conditional |
| 867 | 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. The HCBS Taxonomic classification system was adopted by CMS in August 2012. To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting. Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as “extended state plan” services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment. The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state’s service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc. Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf. |
HCBS-TAXONOMY | CRX00003 | CLAIM-LINE-RECORD-RX | X(5) | 28 | 332 | 336 | 1. Value must be 5 characters or less 2. Value must be in HCBS Taxonomy Code List (VVL) 3. Conditional |
| 868 | CRX137 | CRX.003.137 | OTHER-TPL-COLLECTION | Other TPL Collection | Mandatory | 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. | OTHER-TPL-COLLECTION | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 29 | 337 | 339 | 1. Value must be 3 characters 2. Value must be in Other TPL Collection List (VVL) 3. Mandatory |
| 869 | CRX138 | CRX.003.138 | DAYS-SUPPLY | Days Supply | Mandatory | Number of days supply dispensed. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(5) | 30 | 340 | 344 | 1. Value must be 5 digits or less 2. Mandatory 3. Value should be between -365 and 365 |
| 870 | 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. | NEW-REFILL-IND | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 31 | 345 | 346 | 1. Value must be 2 characters 2. Value must be in New Refill Indicator List (VVL) 3. Mandatory |
| 871 | 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. | BRAND-GENERIC-IND | CRX00003 | CLAIM-LINE-RECORD-RX | X(1) | 32 | 347 | 347 | 1. Value must be 1 character 2. Value must be in Brand Generic Indicator List (VVL) 3. Mandatory |
| 872 | CRX141 | CRX.003.141 | DISPENSE-FEE-SUBMITTED | Dispense Fee Submitted | Mandatory | The charge to cover the cost of the professional dispensing fee for the prescription. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(6)V99 | 33 | 348 | 355 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value may include up to 6 digits to the left of the decimal point, and 2 digits to the right e.g. 123456.78 4. Mandatory |
| 873 | CRX142 | CRX.003.142 | PRESCRIPTION-NUM | Prescription Number | Mandatory | The unique identification number assigned by the pharmacy or supplier to the prescription. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(12) | 34 | 356 | 367 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 874 | 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. 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' (440-E5); and 'Result of Service Code' (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP 'Reasons of Service Code' (bytes 1 and 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 and 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP 'Result of Service Code' (bytes 5 and 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. | DRUG-UTILIZATION-CODE-E4, DRUG-UTILIZATION-CODE-E5, DRUG-UTILIZATION-CODE-E6 | CRX00003 | CLAIM-LINE-RECORD-RX | X(6) | 35 | 368 | 373 | 1. Value must be 6 characters or less 2. Characters 1 and 2 (2-character string) must be in Drug Utilization Reason for Service Code List (VVL) 3. Characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL) 4. Characters 5 and 6 (2-character string) must be in Drug Utilization Result of Service Code List (VVL) 5. Mandatory |
| 875 | CRX144 | CRX.003.144 | DTL-METRIC-DEC-QTY | Metric Decimal Quantity | Conditional | Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter). | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(7)V999 | 36 | 374 | 383 | 1. Value must be numeric 2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.890 3. Value must be populated when Compound Drug Indicator (CRX.002.086) equals "1" 4. Conditional |
| 876 | 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. | COMPOUND-DOSAGE-FORM | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 37 | 384 | 385 | 1. Value must be 2 characters 2. Value must be in Compound Dosage Form List (VVL) 3. Conditional |
| 877 | 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. | REBATE-ELIGIBLE-INDICATOR | CRX00003 | CLAIM-LINE-RECORD-RX | X(1) | 38 | 386 | 386 | 1. Value must be 1 character 2. Value must be in Rebate Eligible Indicator List (VVL) 3. Conditional |
| 878 | CRX149 | CRX.003.149 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 39 | 387 | 388 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 879 | CRX152 | CRX.003.152 | OTHER-INSURANCE-AMT | Other Insurance Amount | Conditional | The amount paid by insurance other than Medicare or Medicaid on this claim. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 40 | 389 | 401 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 880 | 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. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | 9(8) | 41 | 402 | 409 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CIP.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 881 | CRX158 | CRX.003.158 | SELF-DIRECTION-TYPE | Self Direction Type | Mandatory | This data element is not applicable to this file type. | SELF-DIRECTION-TYPE | CRX00003 | CLAIM-LINE-RECORD-RX | X(3) | 42 | 410 | 412 | 1. Value must be 3 characters 2. Value must be in Self Direction Type List (VVL) 3. Mandatory |
| 882 | 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). | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(18) | 43 | 413 | 430 | 1. Value must be 18 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 883 | CRX167 | CRX.003.167 | INGREDIENT-COST-SUBMITTED | Ingredient Cost Submitted | Conditional | The charge to cover the cost of ingredients for the prescription or drug. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 44 | 431 | 443 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 884 | CRX168 | CRX.003.168 | INGREDIENT-COST-PAID-AMT | Ingredient Cost Paid Amount | Conditional | The amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level towards the cost of ingredients for the prescription or drug. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 45 | 444 | 456 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 885 | CRX169 | CRX.003.169 | DISPENSE-FEE-PAID-AMT | Dispense Fee Paid Amount | Conditional | The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the cost of the pharmacy's professional dispensing fee for the prescription. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 46 | 457 | 469 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 886 | CRX170 | CRX.003.170 | PROFESSIONAL-SERVICE-FEE-SUBMITTED | Professional Service Fee Submitted | Conditional | The charge to cover the clinical services, not otherwise covered under the professional dispensing fee. (Example - not filling a prescription because of therapeutic duplication). | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 47 | 470 | 482 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 887 | CRX171 | CRX.003.171 | PROFESSIONAL-SERVICE-FEE-PAID-AMT | Professional Service Fee Paid Amount | Conditional | The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the costs of clinical services not otherwise covered under the professional dispensing fee. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 48 | 483 | 495 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 888 | CRX172 | CRX.003.172 | IHS-SERVICE-IND | IHS Service Indicator | Mandatory | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | IHS-SERVICE-IND | CRX00003 | CLAIM-LINE-RECORD-RX | X(1) | 49 | 496 | 496 | 1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 889 | CRX179 | CRX.003.179 | UNIQUE-DEVICE-IDENTIFIER | Unique Device Identifier | Conditional | An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(76) | 50 | 497 | 572 | 1. Value must not be more than 76 characters long 2. Conditional |
| 890 | CRX209 | CRX.003.209 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Conditional | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | CRX00003 | CLAIM-LINE-RECORD-RX | X(1) | 51 | 573 | 573 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 891 | CRX181 | CRX.003.181 | MBESCBES-FORM | MBESCBES Form | Conditional | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | CRX00003 | CLAIM-LINE-RECORD-RX | X(50) | 52 | 574 | 623 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 892 | CRX180 | CRX.003.180 | MBESCBES-CATEGORY-OF-SERVICE | 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 MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
CRX00003 | CLAIM-LINE-RECORD-RX | X(5) | 53 | 624 | 628 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 893 | CRX182 | CRX.003.182 | PROCEDURE-CODE | Procedure Code | Conditional | The procedure code (e.g., CPT, HCPCS, or other procedure code that is not an NDC or UDI) reported by a pharmacy on their NCPDP transaction. | PROCEDURE-CODE | CRX00003 | CLAIM-LINE-RECORD-RX | X(6) | 54 | 629 | 634 | 1. Value must not be more than 6 characters 2. Value must be in Procedure Code List (VVL) 3. Conditional |
| 894 | CRX183 | CRX.003.183 | PROCEDURE-CODE-MOD-1 | Procedure Code Modifier 1 | Conditional | The first modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 55 | 635 | 636 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 895 | CRX184 | CRX.003.184 | PROCEDURE-CODE-MOD-2 | Procedure Code Modifier 2 | Conditional | The second modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 56 | 637 | 638 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 896 | CRX185 | CRX.003.185 | PROCEDURE-CODE-MOD-3 | Procedure Code Modifier 3 | Conditional | The third modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 57 | 639 | 640 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 897 | CRX186 | CRX.003.186 | PROCEDURE-CODE-MOD-4 | Procedure Code Modifier 4 | Conditional | The fourth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 58 | 641 | 642 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 898 | CRX187 | CRX.003.187 | PROCEDURE-CODE-MOD-5 | Procedure Code Modifier 5 | Conditional | The fifth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 59 | 643 | 644 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 899 | CRX188 | CRX.003.188 | PROCEDURE-CODE-MOD-6 | Procedure Code Modifier 6 | Conditional | The sixth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 60 | 645 | 646 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 900 | CRX189 | CRX.003.189 | PROCEDURE-CODE-MOD-7 | Procedure Code Modifier 7 | Conditional | The seventh modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 61 | 647 | 648 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 901 | CRX190 | CRX.003.190 | PROCEDURE-CODE-MOD-8 | Procedure Code Modifier 8 | Conditional | The eighth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 62 | 649 | 650 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 902 | CRX191 | CRX.003.191 | PROCEDURE-CODE-MOD-9 | Procedure Code Modifier 9 | Conditional | The ninth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 63 | 651 | 652 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 903 | CRX192 | CRX.003.192 | PROCEDURE-CODE-MOD-10 | Procedure Code Modifier 10 | Conditional | The tenth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). | PROCEDURE-CODE-MOD | CRX00003 | CLAIM-LINE-RECORD-RX | X(2) | 64 | 653 | 654 | 1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 904 | CRX193 | CRX.003.193 | GME-AMOUNT-PAID | GME Amount Paid | Conditional | The amount included in the Medicaid Amount (CRX.003.125) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 65 | 655 | 667 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 905 | CRX194 | CRX.003.194 | SDP-ALLOWED-AMT | State Directed Payment Allowed Amount | Conditional | The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 66 | 668 | 680 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 906 | CRX195 | CRX.003.195 | SDP-PAID-AMT | State Directed Payment Paid Amount | Conditional | The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | S9(11)V99 | 67 | 681 | 693 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 907 | CRX153 | CRX.003.153 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CRX00003 | CLAIM-LINE-RECORD-RX | X(500) | 68 | 694 | 1193 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 908 | CRX196 | CRX.004.196 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | CRX00004 | CLAIM-DX-RX | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CRX00004" |
| 909 | CRX197 | CRX.004.197 | 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. | STATE | CRX00004 | CLAIM-DX-RX | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CRX.001.007) |
| 910 | CRX198 | CRX.004.198 | 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. | N/A | CRX00004 | CLAIM-DX-RX | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 911 | CRX199 | CRX.004.199 | ICN-ORIG | Original ICN | Mandatory | A unique number assigned by the state's payment system that identifies an original or adjustment claim. | N/A | CRX00004 | CLAIM-DX-RX | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 912 | CRX200 | CRX.004.200 | 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. | N/A | CRX00004 | CLAIM-DX-RX | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 913 | CRX201 | CRX.004.201 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | CRX00004 | CLAIM-DX-RX | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. If value is in [4,1] then Adjustment ICN must be populated 7. Value must equal "1", when associated Claim Status equals "686" 8. Value must match the adjustment indicator in the header (CRX.002.025) |
| 914 | CRX202 | CRX.004.202 | ADJUDICATION-DATE | Adjudication Date | Mandatory | The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. | N/A | CRX00004 | CLAIM-DX-RX | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CRX.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 915 | CRX203 | CRX.004.203 | DIAGNOSIS-TYPE | Diagnosis Type | Mandatory | Indicates the context of the diagnosis code from the provider's claim (i.e., an NCPDP claim can have up to 5 diagnosis codes). The type of diagnosis code (e.g., principal, admitting, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number. | DIAGNOSIS-TYPE | CRX00004 | CLAIM-DX-RX | X(1) | 8 | 131 | 131 | 1. Value must be 1 character 2. Value must be in Diagnosis Type Code List (VVL) 3. Value must be "D" 4. Mandatory |
| 916 | CRX204 | CRX.004.204 | DIAGNOSIS-SEQUENCE-NUMBER | Diagnosis Sequence Number | Mandatory | The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an NCPDP claim can have up to 5 diagnosis codes). | N/A | CRX00004 | CLAIM-DX-RX | 9(2) | 9 | 132 | 133 | 1. Value must be in [01-24] 2. Mandatory |
| 917 | CRX205 | CRX.004.205 | DIAGNOSIS-CODE-FLAG | Diagnosis Code Flag | Mandatory | Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. | DIAGNOSIS-CODE-FLAG | CRX00004 | CLAIM-DX-RX | X(1) | 10 | 134 | 134 | 1. Value must be 1 character 2. Value must be in Diagnosis Code Flag List (VVL) 3. Mandatory |
| 918 | CRX206 | CRX.004.206 | DIAGNOSIS-CODE | Diagnosis Code | Mandatory | ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'. | DIAGNOSIS-CODE | CRX00004 | CLAIM-DX-RX | X(7) | 11 | 135 | 141 | 1. Value must be a minimum of 3 characters 2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must not contain a decimal point 5. Mandatory |
| 919 | CRX207 | CRX.004.207 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | CRX00004 | CLAIM-DX-RX | X(500) | 12 | 142 | 641 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 920 | ELG001 | ELG.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00001" |
| 921 | 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. | DATA-DICTIONARY-VERSION | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 922 | 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. | SUBMISSION-TRANSACTION-TYPE | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(1) | 3 | 19 | 19 | 1. Value must be 1 characters 2. Value must be in Submission Transaction Type List (VVL) 3. Mandatory |
| 923 | ELG004 | ELG.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 924 | 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. | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 925 | ELG006 | ELG.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(8) | 6 | 32 | 39 | 1. Value must equal "ELIGIBLE" 2. Mandatory |
| 926 | 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. | STATE | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same for all records |
| 927 | ELG008 | ELG.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 928 | 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. | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 929 | 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. | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 930 | 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. | FILE-STATUS-INDICATOR | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 931 | 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 files. | SSN-INDICATOR | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 932 | 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. | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 933 | ELG272 | ELG.001.272 | FILE-SUBMISSION-METHOD | File Submission Method | Mandatory | The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. | FILE-SUBMISSION-METHOD | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(2) | 14 | 79 | 80 | 1. Value must be 2 characters 2. Value must be in File Submission Method List (VVL) 3. Mandatory |
| 934 | 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 original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(4) | 15 | 81 | 84 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 935 | ELG014 | ELG.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00001 | FILE-HEADER-RECORD-ELIGIBILITY | X(500) | 16 | 85 | 584 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 936 | ELG016 | ELG.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00002" |
| 937 | 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. | STATE | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 938 | 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. | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 939 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 940 | 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). | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(30) | 5 | 42 | 71 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 941 | 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). | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(30) | 6 | 72 | 101 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 942 | 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). | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(1) | 7 | 102 | 102 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 943 | ELG023 | ELG.002.023 | SEX | Sex | Mandatory | Either individual's biological sex or their self-identified sex. | SEX | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(1) | 8 | 103 | 103 | 1. Value must be 1 character 2. Value must be in Sex List (VVL) 3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal "1" 4. Mandatory |
| 944 | ELG024 | ELG.002.024 | DATE-OF-BIRTH | Date of Birth | Mandatory | An individual's date of birth. | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 9 | 104 | 111 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. 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 mothers date of birth 3. 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 4. Value must be less than or equal to associated Date File Created (ELG.001.008) value 5. Mandatory 6. 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 |
| 945 | ELG025 | ELG.002.025 | DATE-OF-DEATH | Date of Death | Conditional | The date an individual died on. | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 10 | 112 | 119 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. If populated, value must be on or after individual's Date of Birth 4. Value must be less than or equal to associated Date File Created (ELG.001.008) value 5. There must never be more than one Date of Death value reported across Primary Demographic segments that have the same MSIS Identification number 6. When populated, Procedure Code Dates on a claim must be less than or equal to this value 7. When populated, Admission Date on a claim must be less than or equal to this value 8. When populated, Discharge Date on a claim must be less than or equal to this value 9. When populated, Ending Date of Service on a claim must be less than or equal to this value 10. When populated, value must be less than or equal to Enrollment End Date (ELG.021.254) 11. When populated, value minus Date of Birth (ELG.002.024) is less than or equal to 125 years |
| 946 | 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. | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 11 | 120 | 127 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 947 | 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. | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 12 | 128 | 135 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 948 | ELG028 | ELG.002.028 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00002 | PRIMARY-DEMOGRAPHICS-ELIGIBILITY | X(500) | 13 | 136 | 635 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 949 | ELG030 | ELG.003.030 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00003" |
| 950 | 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. | STATE | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 951 | 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. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 952 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 953 | ELG034 | ELG.003.034 | MARITAL-STATUS | Marital Status | Conditional | A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
MARITAL-STATUS | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(2) | 5 | 42 | 43 | 1. Value must be 2 characters 2. Value must be in Marital Status List (VVL) 3. Conditional |
| 954 | 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. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(50) | 6 | 44 | 93 | 1. If associated Marital Status (ELG.003.035) equals "14" (Other), then value is mandatory and must be provided 2. Value must be 50 characters or less 3. Value must not contain a pipe or asterisk symbol 4. Conditional |
| 955 | 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 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 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. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(9) | 7 | 94 | 102 | 1. Value must be 9-digit number 2. For any individual, the value must be the same over all segment effective and end dates 3. (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 4. Value can only be reported with one MSIS Identification Number (ELG.002.019) 5. Conditional 6. (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) |
| 956 | 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). | SSN-VERIFICATION-FLAG | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 8 | 103 | 103 | 1. Value must be 1 character 2. Value must be in SSN Verification Flag List (VVL) 3. Mandatory |
| 957 | ELG038 | ELG.003.038 | INCOME-CODE | Income Code | Conditional | A code indicating the federal poverty level range in which the family income falls. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group. A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
INCOME-CODE | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(2) | 9 | 104 | 105 | 1. Value must be 2 characters 2. Value must be in Income Code List (VVL) 3. Conditional |
| 958 | 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. | VETERAN-IND | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 10 | 106 | 106 | 1. Value must be 1 character 2. Value must be in Veteran Indicator List (VVL) 3. Conditional 4. Value must be populated when Immigration Status (ELG.003.042) is in [1,2,3] |
| 959 | ELG040 | ELG.003.040 | CITIZENSHIP-IND | Citizenship Indicator | Mandatory | Indicates if the individual is identified as a U.S. Citizen. | CITIZENSHIP-IND | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 11 | 107 | 107 | 1. Value must be 1 character 2. Value must be in [0,1,2] 3. Value must be in Citizenship Indicator List (VVL) 4. If value equals "0", then associated Immigration Status (ELG.003.042) value must be in [1,2,3] 5. If value is coded as "1", then associated Immigration Status (ELG.003.042) value must equal "8" 6. Mandatory |
| 960 | ELG041 | ELG.003.041 | CITIZENSHIP-VERIFICATION-FLAG | Citizenship Verification Flag | Conditional | Indicates the individual is enrolled in Medicaid pending citizenship verification. | CITIZENSHIP-VERIFICATION-FLAG | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 12 | 108 | 108 | 1. Value must be 1 character 2. Value must be in Citizenship Verification Flag List (VVL) 3. Value must be populated when Citizenship Indicator (ELG.003.040) equals "1" (US Citizen) 4. Conditional |
| 961 | ELG042 | ELG.003.042 | IMMIGRATION-STATUS | Immigration Status | Mandatory | The immigration status of the individual. | IMMIGRATION-STATUS | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 13 | 109 | 109 | 1. Value must be 1 character 2. Value must be in Immigration Status List (VVL) 3. If associated Citizenship Indicator (ELG.003.040) value equals "0", then value must be in [1,2,3] 4. If associated Citizenship Indicator (ELG.003.040) value equals "1", then value must equal "8" 5. Mandatory |
| 962 | ELG043 | ELG.003.043 | IMMIGRATION-VERIFICATION-FLAG | Immigration Verification Flag | Conditional | Indicates the individual is enrolled in Medicaid pending immigration verification. | IMMIGRATION-VERIFICATION-FLAG | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 14 | 110 | 110 | 1. Value must be 1 character 2. Value must be in Immigration Verification Flag List (VVL) 3. Conditional |
| 963 | 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. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified alien." | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 15 | 111 | 118 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. If Immigration Status (ELG.003.042) equals "8" (U.S. Citizen), then value should not be populated |
| 964 | ELG045 | ELG.003.045 | ENGL-PROF-CODE | English Proficiency Code | Conditional | A code indicating the level of spoken English proficiency by the individual. | ENGL-PROF-CODE | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 16 | 119 | 119 | 1. Value must be 1 character 2. Value must be in Primary Language English Proficiency Code List (VVL) 3. Conditional |
| 965 | ELG046 | ELG.003.046 | PREFERRED-LANGUAGE-CODE | Primary Language Code | Conditional | A code indicating the language that is the individuals' preferred spoken or written language. | PREFERRED-LANGUAGE-CODE | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(3) | 17 | 120 | 122 | 1. Value must be 3 characters 2. Value must be in Primary Language Code List (VVL) 3. Conditional |
| 966 | ELG047 | ELG.003.047 | HOUSEHOLD-SIZE | Household Size | Mandatory | Household Size used in the Medicaid or CHIP eligibility determination process. | HOUSEHOLD-SIZE | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(2) | 18 | 123 | 124 | 1. Value must be 2 characters 2. Value must be in Household Size List (VVL) 3. Mandatory |
| 967 | 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. | PREGNANCY-IND | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 19 | 125 | 125 | 1. Value must be 1 character 2. Value must be in Pregnancy Indicator List (VVL) 3. Conditional |
| 968 | 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 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 and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based). | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(12) | 20 | 126 | 137 | 1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value is "00", then value must not be populated. 5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value for either HICN or MBI is mandatory and must be provided |
| 969 | 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 over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(12) | 21 | 138 | 149 | 1. Conditional 2. Value must be an 11-character string 3. Character 1 must be numeric values 1 thru 9 4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 6. Character 4 must be numeric values 0 thru 9 7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z) 9. Character 7 must be numeric values 0 thru 9 10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z) 12. Character 10 must be numeric values 0 thru 9 13. Character 11 must be numeric values 0 thru 9 14. Value must not contain a pipe or asterisk symbols 15. 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 16. (Medicare Enrolled) if associated Dual Eligible Code value (ELG.005.085) is in [01,02,03,04,05,06,08,09,10], then the value for either HICN or MBI is mandatory and must be provided |
| 970 | ELG054 | ELG.003.054 | CHIP-CODE | CHIP Code | Mandatory | A code used to distinguish among Medicaid, Medicaid Expansion CHIP, and Separate CHIP populations. | CHIP-CODE | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(1) | 22 | 150 | 150 | 1. Value must be in CHIP Code List (VVL) 2. If value is in [2,3], then associated Eligibility Group (ELG.005.087) value must be in [07,31,61,62,63,64,65,66,67,68] 3. If value equals "1", then associated Eligibility Group (ELG.005.087) value must not be in [61,62,63,64,65,66,67,68] 4. Value must be 1 character 5. Mandatory |
| 971 | 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. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 23 | 151 | 158 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99]\ |
| 972 | 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. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 24 | 159 | 166 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 973 | ELG269 | ELG.003.269 | ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE | Eligible Federal Poverty Level Percentage | Conditional | This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group. A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | 9(3) | 25 | 167 | 169 | 1. Value must be between 000 and 400 inclusively 2. Conditional |
| 974 | ELG273 | ELG.003.273 | APPLICATION-SIGNATURE-DATE | Application Signature Date | Conditional | The date that a beneficiary signed their Medicaid or CHIP application. If the beneficiary was deemed eligible via an administrative determination then a signature may not be applicable/available. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | 9(8) | 26 | 170 | 177 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. Value must be less than the Variable Demographic Element End Date |
| 975 | ELG059 | ELG.003.059 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00003 | VARIABLE-DEMOGRAPHICS-ELIGIBILITY | X(500) | 27 | 178 | 677 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 976 | ELG061 | ELG.004.061 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00004" |
| 977 | 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. | STATE | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 978 | 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. | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 979 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 980 | ELG065 | ELG.004.065 | ELIGIBLE-ADDR-TYPE | Eligible Address Type | Mandatory | The type of address and contact information for the eligible submitted in the record segment. | ELIGIBLE-ADDR-TYPE | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(2) | 5 | 42 | 43 | 1. Value must be 2 characters 2. Value must be in Eligible Address Type List (VVL) 3. Mandatory |
| 981 | 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.). | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(60) | 6 | 44 | 103 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory |
| 982 | 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.). | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(60) | 7 | 104 | 163 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s) 3. There must be an Address Line 1 in order to have an Address Line 2 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 983 | 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.). | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(60) | 8 | 164 | 223 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s) 3. If Address Line 2 is not populated, then value should not be populated 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 984 | 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.). | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(28) | 9 | 224 | 251 | 1. Value must be 28 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 985 | 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 eligible to receive healthcare services resides. (The state for the type of address indicated in Address Type.) | STATE | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(2) | 10 | 252 | 253 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 986 | 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.) | ZIP-CODE | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(9) | 11 | 254 | 262 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 987 | ELG072 | ELG.004.072 | ELIGIBLE-COUNTY-CODE | Eligible County Code | Mandatory | Standard ANSI code used to identify a specific U.S. County. | COUNTY | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(3) | 12 | 263 | 265 | 1. Value must be 3 characters 2. Value must be in US County Code List (VVL) 3. Mandatory |
| 988 | ELG073 | ELG.004.073 | ELIGIBLE-PHONE-NUM | Eligible Phone Number | Conditional | Phone number for a given entity (e.g. person, organization, agency). | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(10) | 13 | 266 | 275 | 1. Value must be 10-digit number 2. Conditional |
| 989 | 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. | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(100) | 14 | 276 | 375 | 1. Value must not contain a pipe or asterisk symbol 2. Value must be 100 characters or less 3. Conditional |
| 990 | 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. | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | 9(8) | 15 | 376 | 383 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 991 | 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. | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | 9(8) | 16 | 384 | 391 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 992 | ELG077 | ELG.004.077 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00004 | ELIGIBLE-CONTACT-INFORMATION | X(500) | 17 | 392 | 891 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 993 | ELG079 | ELG.005.079 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00005 | ELIGIBILITY-DETERMINANTS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00005" |
| 994 | 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. | STATE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 995 | 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. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 996 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 997 | 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 number, but a unique identification number. A warning for longitudinal research efforts: a case numbers associated with an individual may change over time. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(12) | 5 | 42 | 53 | 1. Value must be 12 characters or less 2. Value must not contain a pipe symbol 3. Mandatory |
| 998 | ELG085 | ELG.005.085 | DUAL-ELIGIBLE-CODE | Dual Eligible Code | Mandatory | Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits. | DUAL-ELIGIBLE-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(2) | 6 | 54 | 55 | 1. Value must be 2 characters 2. Value must be in Dual Eligible Code List (VVL) 3. If value equals "05", then Eligibility Group (ELG.005.087) must be "24" 4. If value equals "06", then Eligibility Group (ELG.005.087) must be "26" 5. If Dual Eligible Code (ELG.005.085) is in [01,02,03,04,05,06,08,09,10], then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes) 6. Mandatory 7. A partial dual eligible (values="01", "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3" 8. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated. 9. Value must be 2 characters 10. If value is in [08,10] then Restricted Benefits Code (ELG.005.097) must be "1" 11. If value equals "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated 12. 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 13. If value equals "01", then Eligibility Group (ELG.005.087) must be "23" 14. If value equals "03", then Eligibility Group (ELG.005.087) must be "25" |
| 999 | 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 end dates. It is expected that an enrollees' eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0. | PRIMARY-ELIGIBILITY-GROUP-IND | ELG00005 | ELIGIBILITY-DETERMINANTS | X(1) | 7 | 56 | 56 | 1. Value must be 1 character 2. Value must be in Primary Eligibility Group Indicator List (VVL) 3. Mandatory |
| 1000 | 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). | ELIGIBILITY-GROUP | ELG00005 | ELIGIBILITY-DETERMINANTS | X(2) | 8 | 57 | 58 | 1. Value must be 2 characters 2. Value must be in Eligibility Group List (VVL) 3. If value is "26", then Dual Eligible Code value must be "06" 4. Conditional 5. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014. 6. If value is in [ 72,73,74,75], then associated Restricted Benefits Code value must be in [1,7] and State Plan Option Type must equal "06" 7. If associated CHIP Code value equals "2", then value must be in [07,31,61] 8. If associated CHIP Code value equals "3", then value must be in [61,62,63,64,65,66,67,68] 9. If value is "23", then Dual Eligible Code value must be in [01,02] 10. If value is "25", then Dual Eligible Code value must be in [03,04] 11. If value is "24", then Dual Eligible Code value must be "05" |
| 1001 | ELG088 | ELG.005.088 | LEVEL-OF-CARE-STATUS | Level Of Care Status | Mandatory | The level of care required to meet an individual's needs and to determine LTSS program eligibility. | LEVEL-OF-CARE-STATUS | ELG00005 | ELIGIBILITY-DETERMINANTS | X(3) | 9 | 59 | 61 | 1. Value must be 3 characters 2. Value must be in Level of Care Status List (VVL) 3. Mandatory |
| 1002 | 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). | SSDI-IND | ELG00005 | ELIGIBILITY-DETERMINANTS | X(1) | 10 | 62 | 62 | 1. Value must be 1 character 2. Value must be in SSDI Indicator List (VVL) 3. Conditional |
| 1003 | 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). | SSI-IND | ELG00005 | ELIGIBILITY-DETERMINANTS | X(1) | 11 | 63 | 63 | 1. Value must be 1 character 2. Value must be in SSI Indicator List (VVL) 3. Conditional 4. Value must equal "0" when SSI status (ELG.005.092) equals "000" or "003" or is not populated 5. Value must equal "1" when SSI status (ELG.005.092) equals "001" or "002" |
| 1004 | ELG091 | ELG.005.091 | SSI-STATE-SUPPLEMENT-STATUS-CODE | SSI State Supplement Status Code | Conditional | Indicates the individual's State Supplemental Income Status. | SSI-STATE-SUPPLEMENT-STATUS-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(3) | 12 | 64 | 66 | 1. Value must be 3 characters 2. Value must be in SSI State Supplement Status Code List (VVL) 3. (individual not receiving Federal SSI) If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002" 4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1" 5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" 6. Conditional |
| 1005 | ELG092 | ELG.005.092 | SSI-STATUS | SSI Status | Conditional | Indicates the individual's SSI Status. | SSI-STATUS | ELG00005 | ELIGIBILITY-DETERMINANTS | X(3) | 13 | 67 | 69 | 1. Value must be 3 characters 2. Value must be in SSI Status List (VVL) 3. Conditional 4. When value is "001" or "002", then SSI Indicator must be "1" 5. When value is "000" or "003" or not populate, then SSI Indicator must be "0" |
| 1006 | 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 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). | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(6) | 14 | 70 | 75 | 1. Value must be 6 characters or less 2. Mandatory |
| 1007 | 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 State CHIP Program. | CONCEPTION-TO-BIRTH-IND | ELG00005 | ELIGIBILITY-DETERMINANTS | X(1) | 15 | 76 | 76 | 1. Value must be 1 character 2. Value must be in Conception to Birth Indicator List (VVL) 3. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64" 4. If the value is equal to "1", then any associated claims must indicate the Program Type equals "14" (State Plan CHIP) 5. 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) 6. Conditional |
| 1008 | ELG095 | ELG.005.095 | ELIGIBILITY-TERMINATION-REASON | Eligibility Termination Reason | Conditional | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21'; (Other) '22'; (Unknown), then the state should not report the co-occurring value '21'; and/or '22'; to T-MSIS. If there are multiple co-occurring distinct values between '01'; and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01'; through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. | ELIGIBILITY-TERMINATION-REASON | ELG00005 | ELIGIBILITY-DETERMINANTS | X(2) | 16 | 77 | 78 | 1. Value must be 2 characters 2. Value must be in Eligibility Change Reason List (VVL) 3. Conditional |
| 1009 | 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. | RESTRICTED-BENEFITS-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(1) | 17 | 79 | 79 | 1. Value must be 1 character 2. Value must be in Restricted Benefits Code List (VVL) 3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24" 4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26" 5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23" 6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25" 7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00" 8. Mandatory 9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70] 10. If value is in [1,7] then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06" 11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F" 12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1" 13. 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 14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23" 15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25" 16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
| 1010 | 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. | TANF-CASH-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(1) | 18 | 80 | 80 | 1. Value must be 1 character 2. Value must be in TANF Cash Code List (VVL) 3. Conditional |
| 1011 | 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. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | 9(8) | 19 | 81 | 88 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1012 | 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. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | 9(8) | 20 | 89 | 96 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1013 | ELG274 | ELG.005.274 | ELIGIBILITY-REDETERMINATION-DATE | Eligibility Redetermination Date | Conditional | The date by which a person's Medicaid or CHIP eligibility must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | 9(8) | 21 | 97 | 104 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. Value must be greater than the Eligibility Determinant Effective Date |
| 1014 | ELG275 | ELG.005.275 | ELIGIBILITY-EXTENSION-CODE | Eligibility Extension Code | Conditional | A code to identify the authority used to extend eligibility during the period of coverage. This code should correspond to the eligibility characteristics, including eligibility redetermination date, with which the code is being reported. | ELIGIBILITY-EXTENSION-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(3) | 22 | 105 | 107 | 1. Value must be 3 characters or less 2. Value must be in Eligibility Extension Code List (VVL) 3. Conditional |
| 1015 | ELG276 | ELG.005.276 | ELIGIBILITY-EXTENSION-OTHER-TEXT | Eligibility Extension Other Text | Conditional | A free-form text field where a state can identify the “other” authority used to extend eligibility; required when 995 is used. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(50) | 23 | 108 | 157 | 1. Value must be 50 characters or less 2. Conditional 3. If Eligibility Extension Code is "Other", then value must be populated |
| 1016 | ELG277 | ELG.005.277 | CONTINUOUS-ELIGIBILITY-CODE | Continuous Eligibility Code | Conditional | A code to identify the authority used to provide continuous eligibility during the period of coverage | CONTINUOUS-ELIGIBILITY-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(3) | 24 | 158 | 160 | 1. Value must be 3 characters 2. Value must be in Continuous Eligibility Code List (VVL) 3. Conditional |
| 1017 | ELG278 | ELG.005.278 | CONTINUOUS-ELIGIBILITY-OTHER-TEXT | Continuous Eligibility Other Text | Conditional | A free-form text field where a state can identify the "other" authority used to provide continuous eligibility. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(50) | 25 | 161 | 210 | 1. Value must not be more than 50 characters long 2. Conditional 3. If Continuous Eligibility Code is "Other", then value must be populated |
| 1018 | ELG279 | ELG.005.279 | INCOME-STANDARD-CODE | Income Standard Code | Conditional | An indicator that identifies the income standard used by the state to assign the corresponding primary eligibility group. | INCOME-STANDARD-CODE | ELG00005 | ELIGIBILITY-DETERMINANTS | X(2) | 26 | 211 | 212 | 1. Value must be 2 characters 2. Value must be in Income Standard Code List (VVL) 3. Conditional |
| 1019 | ELG280 | ELG.005.280 | INCOME-STANDARD-OTHER-TEXT | Income Standard Other Text | Conditional | A free-form text field where a state can identify the "other" income standard used to assign the corresponding primary eligibility group. Required when "Other" is reported to Income Standard Code. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(50) | 27 | 213 | 262 | 1. Value must be 50 characters or less 2. Conditional 3. If Income Standard Code equals "Other", then value must be populated |
| 1020 | ELG281 | ELG.005.281 | ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT | Eligibility Termination Reason Other Type Text | Conditional | Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(100) | 28 | 263 | 362 | 1. Value must be 100 characters or less 2. Value must be populated when Eligibility Termination Reason equals "22" (Other) 3. Value must not be populated when Eligibility Termination Reason does not equal "22" (Other) 4. Conditional |
| 1021 | ELG101 | ELG.005.101 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00005 | ELIGIBILITY-DETERMINANTS | X(500) | 29 | 363 | 862 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1022 | ELG103 | ELG.006.103 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00006" |
| 1023 | 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. | STATE | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1024 | 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. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1025 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1026 | 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. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | X(100) | 5 | 42 | 141 | 1. Value must be 100 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1027 | 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. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | X(100) | 6 | 142 | 241 | 1. Value must not contain a pipe or asterisk symbols 2. Value must 100 characters or less 3. Mandatory |
| 1028 | 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. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | 9(8) | 7 | 242 | 249 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1029 | 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. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | 9(8) | 8 | 250 | 257 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1030 | ELG111 | ELG.006.111 | 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. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | 9(8) | 9 | 258 | 265 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 1031 | ELG112 | ELG.006.112 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00006 | HEALTH-HOME-SPA-PARTICIPATION-INFORMATION | X(500) | 10 | 266 | 765 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1032 | ELG114 | ELG.007.114 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00007" |
| 1033 | 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. | STATE | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1034 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1035 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1036 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(100) | 5 | 42 | 141 | 1. Value must be 100 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1037 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(100) | 6 | 142 | 241 | 1. Value must not contain a pipe or asterisk symbols 2. Value must 100 characters or less 3. Mandatory |
| 1038 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(30) | 7 | 242 | 271 | 1. Value must be 30 characters or less 2. Value must match Provider Identifier (PRV.005.081) 3. Mandatory |
| 1039 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | 9(8) | 8 | 272 | 279 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1040 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | 9(8) | 9 | 280 | 287 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1041 | 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. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | 9(8) | 10 | 288 | 295 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 1042 | ELG124 | ELG.007.124 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00007 | HEALTH-HOME-SPA-PROVIDERS | X(500) | 11 | 296 | 795 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1043 | ELG126 | ELG.008.126 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00008" |
| 1044 | 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. | STATE | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1045 | 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. | N/A | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1046 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1047 | 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. | HEALTH-HOME-CHRONIC-CONDITION | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in Health Home Chronic Condition List (VVL) 3. If value equals "H", associated Health Home Chronic Condition Other Explanation must be provided 4. Mandatory |
| 1048 | 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 data element. | N/A | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | X(50) | 6 | 43 | 92 | 1. Value must be 50 characters or less 2. If associated Health Home Chronic Condition (ELG.008.130) value equals "H", the value must be populated 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1049 | 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. | N/A | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | 9(8) | 7 | 93 | 100 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1050 | 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. | N/A | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | 9(8) | 8 | 101 | 108 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1051 | ELG134 | ELG.008.134 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00008 | HEALTH-HOME-CHRONIC-CONDITIONS | X(500) | 9 | 109 | 608 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1052 | ELG136 | ELG.009.136 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00009 | LOCK-IN-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00009" |
| 1053 | 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. | STATE | ELG00009 | LOCK-IN-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1054 | 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. | N/A | ELG00009 | LOCK-IN-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1055 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00009 | LOCK-IN-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1056 | 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. | N/A | ELG00009 | LOCK-IN-INFORMATION | X(30) | 5 | 42 | 71 | 1. Value must be 30 characters or less 2. Mandatory |
| 1057 | 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. | PROV-TYPE | ELG00009 | LOCK-IN-INFORMATION | X(2) | 6 | 72 | 73 | 1. Value must be 2 characters 2. Value must be in Provider Type Code List (VVL) 3. Mandatory |
| 1058 | 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. | N/A | ELG00009 | LOCK-IN-INFORMATION | 9(8) | 7 | 74 | 81 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1059 | 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. | N/A | ELG00009 | LOCK-IN-INFORMATION | 9(8) | 8 | 82 | 89 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1060 | ELG270 | ELG.009.270 | LOCKED-IN-SRVCS | Locked In Services | Conditional | The type(s) of services that are locked-in. | TYPE-OF-SERVICE | ELG00009 | LOCK-IN-INFORMATION | X(3) | 9 | 90 | 92 | 1. Value must be 3 characters 2. Conditional 3. Value must be in Type of Service List (VVL) |
| 1061 | ELG144 | ELG.009.144 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00009 | LOCK-IN-INFORMATION | X(500) | 10 | 93 | 592 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1062 | ELG146 | ELG.010.146 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00010 | MFP-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00010" |
| 1063 | 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. | STATE | ELG00010 | MFP-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1064 | 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. | N/A | ELG00010 | MFP-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1065 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00010 | MFP-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1066 | 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. | MFP-LIVES-WITH-FAMILY | ELG00010 | MFP-INFORMATION | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in MFP Lives with Family List (VVL) 3. Mandatory |
| 1067 | 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. | MFP-QUALIFIED-INSTITUTION | ELG00010 | MFP-INFORMATION | X(2) | 6 | 43 | 44 | 1. Value must be 2 characters 2. Value must be in MFP Qualified Institution List (VVL) 3. Mandatory |
| 1068 | ELG152 | ELG.010.152 | MFP-QUALIFIED-RESIDENCE | MFP Qualified Residence | Mandatory | A code indicating the type of qualified residence. | MFP-QUALIFIED-RESIDENCE | ELG00010 | MFP-INFORMATION | X(2) | 7 | 45 | 46 | 1. Value must be 2 characters 2. Value must be in MFP Qualified Residence List (VVL) 3. Mandatory |
| 1069 | 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. | MFP-REASON-PARTICIPATION-ENDED | ELG00010 | MFP-INFORMATION | X(2) | 8 | 47 | 48 | 1. Value must be 2 characters 2. Value must be in MFP Reason Participation Ended List (VVL) 3. Conditional 4. Value must not be populated when Enrollment End Date equals "9999-12-31" 5. Value must be populated when Enrollment End Date does not equal "9999-12-31" |
| 1070 | 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. | MFP-REINSTITUTIONALIZED-REASON | ELG00010 | MFP-INFORMATION | X(2) | 9 | 49 | 50 | 1. Value must be 2 characters 2. Value must be in MFP Reinstitutionalized Reason List (VVL) 3. Conditional |
| 1071 | 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. | N/A | ELG00010 | MFP-INFORMATION | 9(8) | 10 | 51 | 58 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1072 | 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. | N/A | ELG00010 | MFP-INFORMATION | 9(8) | 11 | 59 | 66 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1073 | ELG157 | ELG.010.157 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00010 | MFP-INFORMATION | X(500) | 12 | 67 | 566 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1074 | ELG159 | ELG.011.159 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00011" |
| 1075 | 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. | STATE | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1076 | 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. | N/A | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1077 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1078 | 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. | STATE-PLAN-OPTION-TYPE | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | X(2) | 5 | 42 | 43 | 1. Value must be 2 characters 2. Value must be in State Plan Option Type List (VVL) 3. If associated Eligibility Group (ELG.005.087) value is in [72,73,74, 75], and Restricted Benefits Code (ELG.DE.097) is in [1,7], then value must be "06" 4. Mandatory |
| 1079 | 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. | N/A | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | 9(8) | 6 | 44 | 51 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1080 | 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. | N/A | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | 9(8) | 7 | 52 | 59 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1081 | ELG166 | ELG.011.166 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00011 | STATE-PLAN-OPTION-PARTICIPATION | X(500) | 8 | 60 | 559 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1082 | ELG168 | ELG.012.168 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00012 | WAIVER-PARTICIPATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00012" |
| 1083 | 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. | STATE | ELG00012 | WAIVER-PARTICIPATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1084 | 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. | N/A | ELG00012 | WAIVER-PARTICIPATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1085 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00012 | WAIVER-PARTICIPATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1086 | 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | ELG00012 | WAIVER-PARTICIPATION | X(20) | 5 | 42 | 61 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Value must have a corresponding value in Waiver Type (ELG.012.173) 7. Mandatory |
| 1087 | 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. | WAIVER-TYPE | ELG00012 | WAIVER-PARTICIPATION | X(2) | 6 | 62 | 63 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID (ELG.012.172) 4. Mandatory |
| 1088 | 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. | N/A | ELG00012 | WAIVER-PARTICIPATION | 9(8) | 7 | 64 | 71 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1089 | 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. | N/A | ELG00012 | WAIVER-PARTICIPATION | 9(8) | 8 | 72 | 79 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1090 | ELG176 | ELG.012.176 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00012 | WAIVER-PARTICIPATION | X(500) | 9 | 80 | 579 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1091 | ELG178 | ELG.013.178 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00013 | LTSS-PARTICIPATION | X(8) | 1 | 1 | 8 | 1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00013" |
| 1092 | 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. | STATE | ELG00013 | LTSS-PARTICIPATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1093 | 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. | N/A | ELG00013 | LTSS-PARTICIPATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1094 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00013 | LTSS-PARTICIPATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1095 | ELG182 | ELG.013.182 | LTSS-LEVEL-CARE | LTSS Level of Care | Mandatory | The level of care provided to the individual by the long term care facility. | LTSS-LEVEL-CARE | ELG00013 | LTSS-PARTICIPATION | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in LTSS Level of Care List (VVL) 3. Mandatory |
| 1096 | 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. | N/A | ELG00013 | LTSS-PARTICIPATION | X(30) | 6 | 43 | 72 | 1. Value must be 30 characters or less 2. Mandatory |
| 1097 | 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. | N/A | ELG00013 | LTSS-PARTICIPATION | 9(8) | 7 | 73 | 80 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1098 | 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. | N/A | ELG00013 | LTSS-PARTICIPATION | 9(8) | 8 | 81 | 88 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1099 | ELG186 | ELG.013.186 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00013 | LTSS-PARTICIPATION | X(500) | 9 | 89 | 588 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1100 | ELG188 | ELG.014.188 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00014 | MANAGED-CARE-PARTICIPATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00014" |
| 1101 | 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. | STATE | ELG00014 | MANAGED-CARE-PARTICIPATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1102 | 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. | N/A | ELG00014 | MANAGED-CARE-PARTICIPATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1103 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00014 | MANAGED-CARE-PARTICIPATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1104 | 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. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-eligible-file-managed-care/ See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-guidance-primary-care-case-management-reporting-updated/ |
N/A | ELG00014 | MANAGED-CARE-PARTICIPATION | X(12) | 5 | 42 | 53 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Value reported must match the value reported on State Plan Identification Number (MCR.002.019) 4. Mandatory |
| 1105 | 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. 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" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/ |
MANAGED-CARE-PLAN-TYPE | ELG00014 | MANAGED-CARE-PARTICIPATION | X(2) | 6 | 54 | 55 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. Mandatory 4. Value must equal the Managed Care Plan Type (MCR.002.024) associated with the State Plan Identification Number (MCR.002.018) |
| 1106 | 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. | N/A | ELG00014 | MANAGED-CARE-PARTICIPATION | 9(8) | 7 | 56 | 63 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1107 | 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. | N/A | ELG00014 | MANAGED-CARE-PARTICIPATION | 9(8) | 8 | 64 | 71 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1108 | ELG198 | ELG.014.198 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00014 | MANAGED-CARE-PARTICIPATION | X(500) | 9 | 72 | 571 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1109 | ELG200 | ELG.015.200 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00015 | ETHNICITY-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00015" |
| 1110 | 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. | STATE | ELG00015 | ETHNICITY-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1111 | 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. | N/A | ELG00015 | ETHNICITY-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1112 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00015 | ETHNICITY-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1113 | 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. Ethnicity Code clarifications: If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified." NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. |
ETHNICITY-CODE | ELG00015 | ETHNICITY-INFORMATION | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in Ethnicity Code List (VVL) 3. Mandatory |
| 1114 | 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. | N/A | ELG00015 | ETHNICITY-INFORMATION | 9(8) | 6 | 43 | 50 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1115 | 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. | N/A | ELG00015 | ETHNICITY-INFORMATION | 9(8) | 7 | 51 | 58 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1116 | ELG271 | ELG.015.271 | ETHNICITY-OTHER | Ethnicity Other | Conditional | A freeform field to document the ethnicity of the beneficiary when the beneficiary identifies themselves as Another Hispanic, Latino, or Spanish origin (ethnicity code 4). | N/A | ELG00015 | ETHNICITY-INFORMATION | X(25) | 8 | 59 | 83 | 1. Value must be 25 characters or less 2. If Ethnicity Code (ELG.015.204) equals "4" (Other), then value must be populated 3. Conditional |
| 1117 | ELG207 | ELG.015.207 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00015 | ETHNICITY-INFORMATION | X(500) | 9 | 84 | 583 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1118 | ELG209 | ELG.016.209 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00016 | RACE-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00016" |
| 1119 | 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. | STATE | ELG00016 | RACE-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1120 | 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. | N/A | ELG00016 | RACE-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1121 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00016 | RACE-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1122 | 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. Race Code clarifications: If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown". If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," "Unspecified" or "Unknown". If state has beneficiaries coded in their database as "Other" with no additional detail or in a category that is not available in the code set provided, then code them in T-MSIS as "Other" (valid value "018"), but only use "Other" if the use of "Other Asian" or "Other Pacific Islander" are not appropriate. DO NOT USE "Unspecified" or "Unknown". The "Other" valid value was added to T-MSIS to better align T-MSIS with the single-streamlined application and to accommodate some atypical states, despite the requirements of Section 4302 of the ACA. NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese). NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question. |
RACE | ELG00016 | RACE-INFORMATION | X(3) | 5 | 42 | 44 | 1. Value must be 3 characters 2. Value must be in Race List (VVL) 3. Mandatory |
| 1123 | 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). | N/A | ELG00016 | RACE-INFORMATION | X(25) | 6 | 45 | 69 | 1. Value must be 25 characters or less 2. If associated Race (ELG.016.213) value is in [010,015,018], then value must be populated 3. Value must not contain a pipe or asterisk symbol 4. Conditional |
| 1124 | ELG215 | ELG.016.215 | AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR | American Indian Alaska 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: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the 'Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? | AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR | ELG00016 | RACE-INFORMATION | X(1) | 7 | 70 | 70 | 1. Value must be 1 character 2. Value must be in American Indian Alaskan Native Indicator List (VVL) 3. Conditional |
| 1125 | 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. | N/A | ELG00016 | RACE-INFORMATION | 9(8) | 8 | 71 | 78 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1126 | 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. | N/A | ELG00016 | RACE-INFORMATION | 9(8) | 9 | 79 | 86 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1127 | ELG218 | ELG.016.218 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00016 | RACE-INFORMATION | X(500) | 10 | 87 | 586 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1128 | ELG220 | ELG.017.220 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00017 | DISABILITY-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00017" |
| 1129 | 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. | STATE | ELG00017 | DISABILITY-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1130 | 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. | N/A | ELG00017 | DISABILITY-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1131 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00017 | DISABILITY-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1132 | ELG224 | ELG.017.224 | DISABILITY-TYPE-CODE | Disability Type Code | Mandatory | A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act. | DISABILITY-TYPE-CODE | ELG00017 | DISABILITY-INFORMATION | X(2) | 5 | 42 | 43 | 1. Value must be 2 characters 2. Value must be in Disability Type Code List (VVL) 3. Mandatory |
| 1133 | 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. | N/A | ELG00017 | DISABILITY-INFORMATION | 9(8) | 6 | 44 | 51 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1134 | 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. | N/A | ELG00017 | DISABILITY-INFORMATION | 9(8) | 7 | 52 | 59 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1135 | ELG227 | ELG.017.227 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00017 | DISABILITY-INFORMATION | X(500) | 8 | 60 | 559 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1136 | ELG229 | ELG.018.229 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00018" |
| 1137 | 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. | STATE | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1138 | 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. | N/A | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1139 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1140 | ELG233 | ELG.018.233 | 1115A-DEMONSTRATION-IND | 1115A Demonstration Indicator | Conditional | Indicates that the individual participates in an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. | 1115A-DEMONSTRATION-IND | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in 1115A Demonstration Indicator List (VVL) 3. Conditional |
| 1141 | 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. | N/A | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | 9(8) | 6 | 43 | 50 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1142 | 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. | N/A | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | 9(8) | 7 | 51 | 58 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1143 | ELG236 | ELG.018.236 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00018 | 1115A-DEMONSTRATION-INFORMATION | X(500) | 8 | 59 | 558 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1144 | ELG238 | ELG.020.238 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00020" |
| 1145 | 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. | STATE | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1146 | 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. | N/A | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1147 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1148 | 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. | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | X(3) | 5 | 42 | 44 | 1. Value must be 3 characters 2. Value must be in HCBS Chronic Condition Non Health Home Code List (VVL) 3. Mandatory |
| 1149 | 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. | N/A | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | 9(8) | 6 | 45 | 52 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1150 | 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. | N/A | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | 9(8) | 7 | 53 | 60 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1151 | ELG245 | ELG.020.245 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00020 | HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME | X(500) | 8 | 61 | 560 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1152 | ELG248 | ELG.021.248 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00021" |
| 1153 | 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. | STATE | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1154 | 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. | N/A | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1155 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1156 | 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. | ENROLLMENT-TYPE | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | X(1) | 5 | 42 | 42 | 1. Value must be in Enrollment Type List (VVL) 2. Value must be 1 character 3. If value equals "1", then associated CHIP Code (ELG.003.054) value must be in [1, 2] 4. If value equals "2", then associated CHIP Code (ELG.003.054) value must be "3" 5. A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.) 6. Mandatory |
| 1157 | 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. | N/A | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | 9(8) | 6 | 43 | 50 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1158 | 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. | N/A | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | 9(8) | 7 | 51 | 58 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1159 | ELG255 | ELG.021.255 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00021 | ENROLLMENT-TIME-SPAN-SEGMENT | X(500) | 8 | 59 | 558 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1160 | ELG257 | ELG.022.257 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00022 | ELG-IDENTIFIERS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00022" |
| 1161 | 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. | STATE | ELG00022 | ELG-IDENTIFIERS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1162 | 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. | N/A | ELG00022 | ELG-IDENTIFIERS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1163 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00022 | ELG-IDENTIFIERS | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1164 | 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. | ELG-IDENTIFIER-TYPE | ELG00022 | ELG-IDENTIFIERS | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in Eligible Identifier Type List (VVL) 3. Mandatory |
| 1165 | ELG262 | ELG.022.262 | ELG-IDENTIFIER-ISSUING-ENTITY-ID | Eligible Identifier Issuing Entity Identifier | Situational | This data element is reserved for future use. | N/A | ELG00022 | ELG-IDENTIFIERS | X(18) | 6 | 43 | 60 | 1. Value must be 18 characters or less 2. Situational |
| 1166 | 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. | N/A | ELG00022 | ELG-IDENTIFIERS | 9(8) | 7 | 61 | 68 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1167 | 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. | N/A | ELG00022 | ELG-IDENTIFIERS | 9(8) | 8 | 69 | 76 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1168 | 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 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. 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. 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 assigned a different MSIS Identification Number. 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. 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 new MSIS Identification Number is issued. |
N/A | ELG00022 | ELG-IDENTIFIERS | X(20) | 9 | 77 | 96 | 1. Value must be 20 characters or less 2. Mandatory 3. Must not contain a pipe symbol |
| 1169 | 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 Eligible 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 'Unmerge'. | REASON-FOR-CHANGE | ELG00022 | ELG-IDENTIFIERS | X(10) | 10 | 97 | 106 | 1. Value must be 10 characters or less 2. Value must be in Reason for Change List (VVL) 3. Conditional 4. (Old MSIS Identification Number) value must be populated when Eligible Identifier Type (ELG.022.261) equals "2" |
| 1170 | ELG267 | ELG.022.267 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00022 | ELG-IDENTIFIERS | X(500) | 11 | 107 | 606 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1171 | ELG282 | ELG.023.282 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements, so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | ELG00023 | SOGI | X(8) |
1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00023" |
| 1172 | ELG283 | ELG.023.283 | 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. | STATE | ELG00023 | SOGI | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 1173 | ELG284 | ELG.023.284 | 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. | N/A | ELG00023 | SOGI | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1174 | ELG285 | ELG.023.285 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | ELG00023 | SOGI | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1175 | ELG286 | ELG.023.286 | SEX-ASSIGNED-AT-BIRTH | Sex Assigned at Birth | Conditional | This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sex assigned at birth (e.g., according to an original birth certificate or similar document). T-MSIS does not define or maintain these questions or responses. They are defined and maintained via the CMS single streamlined application and state Medicaid and CHIP agencies. T-MSIS is intended to reflect those sources and may be updated periodically as necessary to align with national standards and common practices. For more information, see: https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf. | SEX-ASSIGNED-AT-BIRTH | ELG00023 | SOGI | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in Sex Assigned at Birth List (VVL) 3. Conditional |
| 1176 | ELG287 | ELG.023.287 | SEX-ASSIGNED-AT-BIRTH-OTHER-TEXT | Sex Assigned at Birth Other Text | Conditional | This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sex assigned at birth (e.g., according to an original birth certificate or similar document), if their response is not reflected by the values available for Sex Assigned at Birth. | N/A | ELG00023 | SOGI | X(100) | 6 | 43 | 142 | 1. Value must be 100 characters or less 2. Conditional 3. If Sex Assigned at Birth equals "5" (Other), then value must be populated |
| 1177 | ELG288 | ELG.023.288 | GENDER-IDENTITY | Gender Identity | Conditional | This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s gender identify-MSIS does not define or maintain these questions or responses. They are defined and maintained via the CMS single streamlined application and state Medicaid and CHIP agencies. T-MSIS is intended to reflect those sources and may be updated periodically as necessary to align with national standards and common practices. For more information, see https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf. | GENDER-IDENTITY | ELG00023 | SOGI | X(1) | 7 | 143 | 143 | 1. Value must be 1 character 2. Value must be in Gender Identity List (VVL) 3. Conditional |
| 1178 | ELG289 | ELG.023.289 | GENDER-IDENTITY-OTHER-TEXT | Gender Identity Other Text | Conditional | This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s gender identify if their response is not reflected by the values available for Gender Identity. | N/A | ELG00023 | SOGI | X(100) | 8 | 144 | 243 | 1. Value must be 100 characters or less 2. Conditional 3. If Gender Identity equals "7" (Other), then value must be populated |
| 1179 | ELG290 | ELG.023.290 | SEXUAL-ORIENTATION | Sexual Orientation | Conditional | This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sexual orientation-MSIS does not define or maintain these questions or responses. They are defined and maintained via the CMS single streamlined application and state Medicaid and CHIP agencies. T-MSIS is intended to reflect those sources and may be updated periodically as necessary to align with national standards and common practices. For more information, see https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf. | SEXUAL-ORIENTATION | ELG00023 | SOGI | X(1) | 9 | 244 | 244 | 1. Value must be 1 character 2. Value must be in Sexual Orientation List (VVL) 3. Conditional |
| 1180 | ELG291 | ELG.023.291 | SEXUAL-ORIENTATION-OTHER-TEXT | Sexual Orientation Other Text | Conditional | This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sexual orientation if their response is not reflected by the values available for Sexual Orientation. | N/A | ELG00023 | SOGI | X(100) | 10 | 245 | 344 | 1. Value must be 100 characters or less 2. Conditional 3. If Sex Orientation equals "6" (Other), then value must be populated |
| 1181 | ELG292 | ELG.023.292 | SOGI-EFF-DATE | SOGI Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | N/A | ELG00023 | SOGI | 9(8) | 11 | 345 | 352 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be "20" |
| 1182 | ELG293 | ELG.023.293 | SOGI-END-DATE | SOGI End Date | Mandatory | The last calendar day on which all the other data elements in the same segment were effective. | N/A | ELG00023 | SOGI | 9(8) | 12 | 353 | 360 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [20,99] |
| 1183 | ELG294 | ELG.023.294 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | ELG00023 | SOGI | X(500) | 13 | 361 | 860 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1184 | FTX001 | FTX.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00001 | FILE-HEADER-RECORD-FTX | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00001" |
| 1185 | FTX002 | FTX.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. | DATA-DICTIONARY-VERSION | FTX00001 | FILE-HEADER-RECORD-FTX | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 1186 | FTX003 | FTX.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. | SUBMISSION-TRANSACTION-TYPE | FTX00001 | FILE-HEADER-RECORD-FTX | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Submission Transaction Type List (VVL) 3. Mandatory |
| 1187 | FTX004 | FTX.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | FTX00001 | FILE-HEADER-RECORD-FTX | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 1188 | FTX005 | FTX.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. | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 1189 | FTX006 | FTX.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | X(8) | 6 | 32 | 39 | 1. Value must equal "FINTRANS" 2. Mandatory |
| 1190 | FTX007 | FTX.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. | STATE | FTX00001 | FILE-HEADER-RECORD-FTX | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1191 | FTX008 | FTX.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 1192 | FTX009 | FTX.001.009 | START-OF-TIME-PERIOD | Start of Time Period | Mandatory | 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. | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 1193 | FTX010 | FTX.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. | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 1194 | FTX011 | FTX.001.011 | FILE-STATUS-INDICATOR | File Status Indicator | Mandatory | A code to indicate whether the records in the file are test or production records. | FILE-STATUS-INDICATOR | FTX00001 | FILE-HEADER-RECORD-FTX | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. Value must be in File Status Indicator List (VVL) 3. For production files, value must be equal to "P" 4. Mandatory |
| 1195 | FTX012 | FTX.001.012 | SSN-INDICATOR | SSN Indicator | Mandatory | 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 | SSN-INDICATOR | FTX00001 | FILE-HEADER-RECORD-FTX | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 1196 | FTX013 | FTX.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. | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 1197 | FTX014 | FTX.001.014 | 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 original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | X(4) | 14 | 79 | 82 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 1198 | FTX015 | FTX.001.015 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00001 | FILE-HEADER-RECORD-FTX | X(500) | 15 | 83 | 582 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1199 | FTX017 | FTX.002.017 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00002" |
| 1200 | FTX018 | FTX.002.018 | 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. | STATE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1201 | FTX019 | FTX.002.019 | 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. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1202 | FTX020 | FTX.002.020 | ICN-ORIG | Original ICN | Conditional | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1203 | FTX021 | FTX.002.021 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1204 | FTX023 | FTX.002.023 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1205 | FTX024 | FTX.002.024 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1206 | FTX025 | FTX.002.025 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1207 | FTX026 | FTX.002.026 | 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. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1208 | FTX027 | FTX.002.027 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1209 | FTX028 | FTX.002.028 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer. |
N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1210 | FTX029 | FTX.002.029 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 1211 | FTX030 | FTX.002.030 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1212 | FTX031 | FTX.002.031 | PAYER-MCR-PLAN-TYPE | Payer MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 14 | 299 | 300 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payer ID Type equals "02", then value must be populated 4. If Payer ID Type does not equal "02", then value must not be populated 5. Conditional |
| 1213 | FTX032 | FTX.002.032 | PAYER-MCR-PLAN-TYPE-OTHER-TEXT | Payer MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other". | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 15 | 301 | 400 | 1. Value must be 100 characters or less 2. Value must be populated when Payer MCR Plan Type equals "95" 3. Conditional |
| 1214 | FTX033 | FTX.002.033 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver. |
N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(30) | 16 | 401 | 430 | 1. Value must be 30 characters or less 2. Mandatory |
| 1215 | FTX034 | FTX.002.034 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1216 | FTX035 | FTX.002.035 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1217 | FTX036 | FTX.002.036 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 19 | 533 | 534 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1218 | FTX037 | FTX.002.037 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 20 | 535 | 634 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1219 | FTX038 | FTX.002.038 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver. |
N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(30) | 21 | 635 | 664 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1220 | FTX039 | FTX.002.039 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 22 | 665 | 666 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1221 | FTX040 | FTX.002.040 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 23 | 667 | 766 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1222 | FTX041 | FTX.002.041 | CONTRACT-ID | Contract Identifier | Conditional | Managed care plan contract ID | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 24 | 767 | 866 | 1. Value must be 100 characters or less 2. Conditional 3. If Subcapitation Indicator equals "01", then value must be populated |
| 1223 | FTX042 | FTX.002.042 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(20) | 25 | 867 | 886 | 1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal "1", there must be a valid record of type Enrollment Time Span where the Capitation Period Start Date is equal to or greater than Enrollment Start Date and Capitation Period End Date is less than or equal to Enrollment End Date |
| 1224 | FTX043 | FTX.002.043 | CAPITATION-PERIOD-START-DATE | Capitation Period Start Date | Mandatory | The date representing the beginning of the period covered by the capitation or sub-capitation payment or recoupment; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | 9(8) | 26 | 887 | 894 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Capitation Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1225 | FTX044 | FTX.002.044 | CAPITATION-PERIOD-END-DATE | Capitation Period End Date | Mandatory | The date representing the end of the period covered by the capitation or sub-capitation payment or recoupment; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | 9(8) | 27 | 895 | 902 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Capitation Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1226 | FTX045 | FTX.002.045 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 28 | 903 | 904 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1227 | FTX048 | FTX.002.048 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Conditional | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(1) | 29 | 905 | 905 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 1228 | FTX047 | FTX.002.047 | MBESCBES-FORM | MBESCBES Form | Conditional | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(50) | 30 | 906 | 955 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. If Subcapitation Indicator equals "01", then value must be populated 6. Conditional |
| 1229 | FTX046 | FTX.002.046 | MBESCBES-CATEGORY-OF-SERVICE | 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 MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(5) | 31 | 956 | 960 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. If Subcapitation Indicator equals "01", then value must be populated 11. Conditional 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 1230 | FTX049 | FTX.002.049 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(20) | 32 | 961 | 980 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1231 | FTX050 | FTX.002.050 | 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 transaction is submitted. | WAIVER-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 33 | 981 | 982 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period 5. Conditional |
| 1232 | FTX051 | FTX.002.051 | FUNDING-CODE | Funding Code | Conditional | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 34 | 983 | 984 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 1233 | FTX052 | FTX.002.052 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Conditional | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 35 | 985 | 986 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 1234 | FTX053 | FTX.002.053 | SDP-IND | State Directed Payment Indicator | Mandatory | Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. | SDP-IND | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(1) | 36 | 987 | 987 | 1. Value must be 1 character 2. Value must be in State Directed Payment Indicator List (VVL) 3. Mandatory |
| 1235 | FTX054 | FTX.002.054 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 37 | 988 | 989 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1236 | FTX055 | FTX.002.055 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types |
N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(15) | 38 | 990 | 1004 | 1. Value must be 15 characters or less 2. Conditional |
| 1237 | FTX056 | FTX.002.056 | SUBCAPITATION-IND | Subcapitation Ind | Mandatory | Indicates whether the transaction represents a sub-capitation payment between a managed care plan and a sub-capitated entity or sub-capitated network provider or not. A sub-capitation payment could also be between a sub-capitated entity and another sub-capitated entity or sub-capitated network provider. | SUBCAPITATION-IND | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(1) | 39 | 1005 | 1005 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 1238 | FTX057 | FTX.002.057 | PAYMENT-CAT-XREF | Payment Cat Xref | Conditional | Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(50) | 40 | 1006 | 1055 | 1. Value must be 50 characters or less 2. If Subcapitation Indicator equals "01", then value must be populated 3. Conditional |
| 1239 | FTX058 | FTX.002.058 | RATE-CELL-DESCRIPTION-TEXT | Rate Cell Description Text | Conditional | This is the description of the rate cell from the rate setting process that applies to the capitation payment. For example, a rate cell may represent the monthly capitation rate paid for adults with chronic conditions who live in a rural area. If the rate paid for this capitation payment is based on the rate cell for adults with chronic conditions who live in a rural area, then the rate cell description could be "Adults with chronic conditions living in a rural area." | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 41 | 1056 | 1155 | 1. Value must be 100 characters or less 2. Conditional |
| 1240 | FTX059 | FTX.002.059 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Conditional | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(2) | 42 | 1156 | 1157 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 1241 | FTX060 | FTX.002.060 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(100) | 43 | 1158 | 1257 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1242 | FTX061 | FTX.002.061 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(500) | 44 | 1258 | 1757 | 1. Value must be 500 characters or less 2. Conditional |
| 1243 | FTX062 | FTX.002.062 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00002 | INDIVIDUAL-CAPITATION-PMPM | X(500) | 45 | 1758 | 2257 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1244 | FTX064 | FTX.003.064 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00003" |
| 1245 | FTX065 | FTX.003.065 | 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. | STATE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1246 | FTX066 | FTX.003.066 | 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. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1247 | FTX067 | FTX.003.067 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1248 | FTX068 | FTX.003.068 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1249 | FTX070 | FTX.003.070 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1250 | FTX071 | FTX.003.071 | PAYMENT-OR-RECOUPMENT-DATE | Payment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1251 | FTX072 | FTX.003.072 | PAYMENT-AMOUNT | Payment Amount | Mandatory | The dollar amount being paid to the payee. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1252 | FTX073 | FTX.003.073 | 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. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1253 | FTX074 | FTX.003.074 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1254 | FTX075 | FTX.003.075 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer. |
N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1255 | FTX076 | FTX.003.076 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) |
| 1256 | FTX077 | FTX.003.077 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1257 | FTX078 | FTX.003.078 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver. |
N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Mandatory |
| 1258 | FTX079 | FTX.003.079 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1259 | FTX080 | FTX.003.080 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1260 | FTX081 | FTX.003.081 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver. |
N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(30) | 17 | 431 | 460 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1261 | FTX082 | FTX.003.082 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 18 | 461 | 462 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1262 | FTX083 | FTX.003.083 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(100) | 19 | 463 | 562 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1263 | FTX084 | FTX.003.084 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier Identification Number | Mandatory | The state-assigned identification number of the Third Party Liability (TPL) Entity. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(12) | 20 | 563 | 574 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1264 | FTX085 | FTX.003.085 | INSURANCE-PLAN-ID | Insurance Plan Identifier | 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. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(20) | 21 | 575 | 594 | 1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 1265 | FTX086 | FTX.003.086 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(20) | 22 | 595 | 614 | 1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal "1", there must be a valid record of type Enrollment Time Span where the Payment Period Start Date is equal to or greater than Enrollment Start Date and Payment Period End Date is less than or equal to Enrollment End Date. |
| 1266 | FTX087 | FTX.003.087 | MEMBER-ID | Member Identifier | Conditional | Member identification number as it appears on the card issued by the TPL insurance carrier. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(20) | 23 | 615 | 634 | 1. Value must be 20 characters or less 2. Conditional |
| 1267 | FTX088 | FTX.003.088 | PREMIUM-PERIOD-START-DATE | Premium Period Start Date | Mandatory | The date representing the beginning of the period covered by the premium payment or recoupment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | 9(8) | 24 | 635 | 642 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Coverage Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1268 | FTX089 | FTX.003.089 | PREMIUM-PERIOD-END-DATE | Premium Period End Date | Mandatory | The date representing the end of the period covered by the premium payment or recoupment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | 9(8) | 25 | 643 | 650 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Premium Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1269 | FTX090 | FTX.003.090 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 26 | 651 | 652 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1270 | FTX093 | FTX.003.093 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(1) | 27 | 653 | 653 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1271 | FTX092 | FTX.003.092 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(50) | 28 | 654 | 703 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1272 | FTX091 | FTX.003.091 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(5) | 29 | 704 | 708 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1273 | FTX094 | FTX.003.094 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(20) | 30 | 709 | 728 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1274 | FTX095 | FTX.003.095 | 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 transaction is submitted. | WAIVER-TYPE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 31 | 729 | 730 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period 5. Conditional |
| 1275 | FTX096 | FTX.003.096 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 32 | 731 | 732 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1276 | FTX097 | FTX.003.097 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 33 | 733 | 734 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share List (VVL) 3. Mandatory |
| 1277 | FTX098 | FTX.003.098 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 34 | 735 | 736 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1278 | FTX099 | FTX.003.099 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(15) | 35 | 737 | 751 | 1. Value must be 15 characters or less 2. Conditional |
| 1279 | FTX100 | FTX.003.100 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(2) | 36 | 752 | 753 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1280 | FTX101 | FTX.003.101 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(100) | 37 | 754 | 853 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1281 | FTX102 | FTX.003.102 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(500) | 38 | 854 | 1353 | 1. Value must be 500 characters or less 2. Conditional |
| 1282 | FTX103 | FTX.003.103 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00003 | INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT | X(500) | 39 | 1354 | 1853 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1283 | FTX105 | FTX.004.105 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00004" |
| 1284 | FTX106 | FTX.004.106 | 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. | STATE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1285 | FTX107 | FTX.004.107 | 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. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1286 | FTX108 | FTX.004.108 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1287 | FTX109 | FTX.004.109 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1288 | FTX111 | FTX.004.111 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1289 | FTX112 | FTX.004.112 | PAYMENT-DATE | Payment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be equal to "20" 3. Mandatory |
| 1290 | FTX113 | FTX.004.113 | PAYMENT-AMOUNT | Payment Amount | Mandatory | The dollar amount being paid to the payee. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1291 | FTX114 | FTX.004.114 | 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. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1292 | FTX115 | FTX.004.115 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1293 | FTX116 | FTX.004.116 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer. |
N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1294 | FTX117 | FTX.004.117 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) |
| 1295 | FTX118 | FTX.004.118 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1296 | FTX119 | FTX.004.119 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver. |
N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Mandatory |
| 1297 | FTX120 | FTX.004.120 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1298 | FTX121 | FTX.004.121 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1299 | FTX122 | FTX.004.122 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver. |
N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(30) | 17 | 431 | 460 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1300 | FTX123 | FTX.004.123 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 18 | 461 | 462 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1301 | FTX124 | FTX.004.124 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(100) | 19 | 463 | 562 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1302 | FTX125 | FTX.004.125 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier Identification Number | Mandatory | The state-assigned identification number of the Third Party Liability (TPL) Entity. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(12) | 20 | 563 | 574 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1303 | FTX126 | FTX.004.126 | INSURANCE-PLAN-ID | Insurance Plan Identifier | 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. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(20) | 21 | 575 | 594 | 1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 1304 | FTX127 | FTX.004.127 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Conditional | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ MSIS-IDENTIFICATION-NUM is conditional in the FTX00004 segment because some members of a private group policy may not be eligible for Medicaid or CHIP, though at least one member of the group policy must be eligible for Medicaid or CHIP. There should be one FTX00004 segment for each member of the group policy for which the premium assistance payment is being paid, regardless of whether the member of the group policy was eligible for and enrolled in Medicaid or CHIP. |
N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(20) | 22 | 595 | 614 | 1. Value must be 20 characters or less 2. Conditional 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal "1", there must be a valid record of type Enrollment Time Span where the Premium Period Start Date is equal to or greater than Enrollment Start Date and Premium Period End Date is less than or equal to Enrollment End Date |
| 1305 | FTX128 | FTX.004.128 | SSN | SSN | Conditional | The SSN of the member of the group insurance policy. Each FTX00004 segment represents a different member of a given group insurance policy. Typically all members of the group insurance policy will have both an MSIS ID and an SSN. Under some circumstances, it’s possible that or more members of a group insurance policy do not have an MSIS ID, but do have an SSN, if they are included on the group insurance policy but not eligible for Medicaid or CHIP. It’s also possible that one or more members of a group insurance policy do not have an SSN. If a member of a group insurance policy does not have an SSN, leave this field blank. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(9) | 23 | 615 | 623 | 1. Value must be 9-digit number 2. Conditional |
| 1306 | FTX129 | FTX.004.129 | MEMBER-ID | Member Identifier | Conditional | Member identification number as it appears on the card issued by the TPL insurance carrier. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(20) | 24 | 624 | 643 | 1. Value must be 20 characters or less 2. Conditional |
| 1307 | FTX130 | FTX.004.130 | GROUP-NUM | Group Num | Conditional | The group number of the TPL health insurance policy. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(16) | 25 | 644 | 659 | 1. Value must be 16 characters or less 2. Value must not contain a pipe symbol 3. Conditional |
| 1308 | FTX131 | FTX.004.131 | POLICY-OWNER-CODE | Policy Owner Code | Conditional | This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary. | POLICY-OWNER-CODE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 26 | 660 | 661 | 1. Value must be 2 characters 2. Value must be in Policy Owner Code List (VVL) 3. Conditional |
| 1309 | FTX132 | FTX.004.132 | PREMIUM-PERIOD-START-DATE | Premium Period Start Date | Mandatory | The date representing the beginning of the period covered by the premium payment or recoupment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | 9(8) | 27 | 662 | 669 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Premium Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1310 | FTX133 | FTX.004.133 | PREMIUM-PERIOD-END-DATE | Premium Period End Date | Mandatory | The date representing the end of the period covered by the premium payment or recoupment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | 9(8) | 28 | 670 | 677 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Premium Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1311 | FTX134 | FTX.004.134 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Conditional | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 29 | 678 | 679 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. If Policy Owner Code equals "01", then value must be populated 4. Conditional |
| 1312 | FTX137 | FTX.004.137 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Conditional | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(1) | 30 | 680 | 680 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. If Policy Owner Code equals "01", then value must be populated 4. Conditional |
| 1313 | FTX136 | FTX.004.136 | MBESCBES-FORM | MBESCBES Form | Conditional | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(50) | 31 | 681 | 730 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. If Policy Owner Code equals "01", then value must be populated 6. Conditional |
| 1314 | FTX135 | FTX.004.135 | MBESCBES-CATEGORY-OF-SERVICE | 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 MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(5) | 32 | 731 | 735 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. If Policy Owner Code equals "01", then value must be populated 11. Conditional 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 1315 | FTX138 | FTX.004.138 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(20) | 33 | 736 | 755 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1316 | FTX139 | FTX.004.139 | 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 transaction is submitted. | WAIVER-TYPE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 34 | 756 | 757 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period 5. Conditional |
| 1317 | FTX140 | FTX.004.140 | FUNDING-CODE | Funding Code | Conditional | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 35 | 758 | 759 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Policy Owner Code equals "01", then value must be populated 4. Conditional |
| 1318 | FTX141 | FTX.004.141 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 36 | 760 | 761 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share List (VVL) 3. If Policy Owner Code equals "01", then value must be populated 4. Mandatory |
| 1319 | FTX142 | FTX.004.142 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 37 | 762 | 763 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1320 | FTX143 | FTX.004.143 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(15) | 38 | 764 | 778 | 1. Value must be 15 characters or less 2. Conditional |
| 1321 | FTX144 | FTX.004.144 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Conditional | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(2) | 39 | 779 | 780 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. If Policy Owner Code equals "01", then value must be populated 4. Conditional |
| 1322 | FTX145 | FTX.004.145 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(100) | 40 | 781 | 880 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1323 | FTX146 | FTX.004.146 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(500) | 41 | 881 | 1380 | 1. Value must be 500 characters or less 2. Conditional |
| 1324 | FTX147 | FTX.004.147 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00004 | GROUP-INSURANCE-PREMIUM-PAYMENT | X(500) | 42 | 1381 | 1880 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1325 | FTX149 | FTX.005.149 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00005 | COST-SHARING-OFFSET | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00005" |
| 1326 | FTX150 | FTX.005.150 | 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. | STATE | FTX00005 | COST-SHARING-OFFSET | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1327 | FTX151 | FTX.005.151 | 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. | N/A | FTX00005 | COST-SHARING-OFFSET | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1328 | FTX152 | FTX.005.152 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00005 | COST-SHARING-OFFSET | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1329 | FTX153 | FTX.005.153 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00005 | COST-SHARING-OFFSET | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1330 | FTX155 | FTX.005.155 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00005 | COST-SHARING-OFFSET | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1331 | FTX156 | FTX.005.156 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00005 | COST-SHARING-OFFSET | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1332 | FTX157 | FTX.005.157 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00005 | COST-SHARING-OFFSET | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1333 | FTX158 | FTX.005.158 | 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. | N/A | FTX00005 | COST-SHARING-OFFSET | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1334 | FTX159 | FTX.005.159 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00005 | COST-SHARING-OFFSET | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1335 | FTX160 | FTX.005.160 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. For beneficiary Cost Sharing Offset, the payer is always the state and the payee is always a beneficiary. |
N/A | FTX00005 | COST-SHARING-OFFSET | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Value must equal Submitting State (FTX.001.007) 3. Mandatory |
| 1336 | FTX161 | FTX.005.161 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00005 | COST-SHARING-OFFSET | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) |
| 1337 | FTX162 | FTX.005.162 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00005 | COST-SHARING-OFFSET | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1338 | FTX163 | FTX.005.163 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. For beneficiary Cost Sharing Offset, the beneficiary is always the payee. |
N/A | FTX00005 | COST-SHARING-OFFSET | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Value must equal MSIS Identification Number (ELG.002.019) 3. Mandatory |
| 1339 | FTX164 | FTX.005.164 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00005 | COST-SHARING-OFFSET | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1340 | FTX165 | FTX.005.165 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00005 | COST-SHARING-OFFSET | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1341 | FTX166 | FTX.005.166 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00005 | COST-SHARING-OFFSET | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1342 | FTX167 | FTX.005.167 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00005 | COST-SHARING-OFFSET | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1343 | FTX168 | FTX.005.168 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. |
N/A | FTX00005 | COST-SHARING-OFFSET | X(30) | 19 | 533 | 562 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1344 | FTX169 | FTX.005.169 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00005 | COST-SHARING-OFFSET | X(2) | 20 | 563 | 564 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1345 | FTX170 | FTX.005.170 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00005 | COST-SHARING-OFFSET | X(100) | 21 | 565 | 664 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1346 | FTX171 | FTX.005.171 | CONTRACT-ID | Contract Identifier | Conditional | Managed care plan contract ID | N/A | FTX00005 | COST-SHARING-OFFSET | X(100) | 22 | 665 | 764 | 1. Value must be 100 characters or less 2. Conditional 3. If Offset Transaction Type equals "1", value must be populated |
| 1347 | FTX172 | FTX.005.172 | INSURANCE-PLAN-ID | Insurance Plan Identifier | 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. | N/A | FTX00005 | COST-SHARING-OFFSET | X(20) | 23 | 765 | 784 | 1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 1348 | FTX173 | FTX.005.173 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Mandatory | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | FTX00005 | COST-SHARING-OFFSET | X(20) | 24 | 785 | 804 | 1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal "1", there must be a valid record of type Enrollment Time Span where the Coverage Period Start Date is equal to or greater than Enrollment Start Date and Coverage Period End Date is less than or equal to Enrollment End Date |
| 1349 | FTX174 | FTX.005.174 | COVERAGE-PERIOD-START-DATE | Coverage Period Start Date | Mandatory | The date representing the beginning of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the beginning of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them. | N/A | FTX00005 | COST-SHARING-OFFSET | 9(8) | 25 | 805 | 812 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Cost Settlement Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1350 | FTX175 | FTX.005.175 | COVERAGE-PERIOD-END-DATE | Coverage Period End Date | Mandatory | The date representing the end of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the end of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them. | N/A | FTX00005 | COST-SHARING-OFFSET | 9(8) | 26 | 813 | 820 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Cost Settlement Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1351 | FTX176 | FTX.005.176 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00005 | COST-SHARING-OFFSET | X(2) | 27 | 821 | 822 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1352 | FTX179 | FTX.005.179 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00005 | COST-SHARING-OFFSET | X(1) | 28 | 823 | 823 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1353 | FTX178 | FTX.005.178 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00005 | COST-SHARING-OFFSET | X(50) | 29 | 824 | 873 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1354 | FTX177 | FTX.005.177 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00005 | COST-SHARING-OFFSET | X(5) | 30 | 874 | 878 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1355 | FTX180 | FTX.005.180 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00005 | COST-SHARING-OFFSET | X(20) | 31 | 879 | 898 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1356 | FTX181 | FTX.005.181 | 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 transaction is submitted. | WAIVER-TYPE | FTX00005 | COST-SHARING-OFFSET | X(2) | 32 | 899 | 900 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Conditional |
| 1357 | FTX182 | FTX.005.182 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00005 | COST-SHARING-OFFSET | X(2) | 33 | 901 | 902 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1358 | FTX183 | FTX.005.183 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00005 | COST-SHARING-OFFSET | X(2) | 34 | 903 | 904 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share (VVL) 3. Mandatory |
| 1359 | FTX184 | FTX.005.184 | OFFSET-TRANS-TYPE | Offset Trans Type | Conditional | This indicates the type of payment that the beneficiary cost-sharing is/was offsetting. | OFFSET-TRANS-TYPE | FTX00005 | COST-SHARING-OFFSET | X(1) | 35 | 905 | 905 | 1. Value must be 1 character 2. Value must be in Offset Transaction Type List (VVL) 3. Conditional |
| 1360 | FTX185 | FTX.005.185 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00005 | COST-SHARING-OFFSET | X(2) | 36 | 906 | 907 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1361 | FTX186 | FTX.005.186 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00005 | COST-SHARING-OFFSET | X(15) | 37 | 908 | 922 | 1. Value must be 15 characters or less 2. Conditional |
| 1362 | FTX187 | FTX.005.187 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00005 | COST-SHARING-OFFSET | X(2) | 38 | 923 | 924 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1363 | FTX188 | FTX.005.188 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00005 | COST-SHARING-OFFSET | X(100) | 39 | 925 | 1024 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1364 | FTX189 | FTX.005.189 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00005 | COST-SHARING-OFFSET | X(500) | 40 | 1025 | 1524 | 1. Value must be 500 characters or less 2. Conditional |
| 1365 | FTX190 | FTX.005.190 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00005 | COST-SHARING-OFFSET | X(500) | 41 | 1525 | 2024 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1366 | FTX192 | FTX.006.192 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00006 | VALUE-BASED-PAYMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00005" |
| 1367 | FTX193 | FTX.006.193 | 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. | STATE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1368 | FTX194 | FTX.006.194 | 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. | N/A | FTX00006 | VALUE-BASED-PAYMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1369 | FTX195 | FTX.006.195 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1370 | FTX196 | FTX.006.196 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1371 | FTX198 | FTX.006.198 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00006 | VALUE-BASED-PAYMENT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1372 | FTX199 | FTX.006.199 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00006 | VALUE-BASED-PAYMENT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1373 | FTX200 | FTX.006.200 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00006 | VALUE-BASED-PAYMENT | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1374 | FTX201 | FTX.006.201 | 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. | N/A | FTX00006 | VALUE-BASED-PAYMENT | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1375 | FTX202 | FTX.006.202 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1376 | FTX203 | FTX.006.203 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. |
N/A | FTX00006 | VALUE-BASED-PAYMENT | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1377 | FTX204 | FTX.006.204 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 1378 | FTX205 | FTX.006.205 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1379 | FTX206 | FTX.006.206 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Mandatory |
| 1380 | FTX207 | FTX.006.207 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1381 | FTX208 | FTX.006.208 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1382 | FTX209 | FTX.006.209 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1383 | FTX210 | FTX.006.210 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1384 | FTX211 | FTX.006.211 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. |
N/A | FTX00006 | VALUE-BASED-PAYMENT | X(30) | 19 | 533 | 562 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1385 | FTX212 | FTX.006.212 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 20 | 563 | 564 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1386 | FTX213 | FTX.006.213 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(100) | 21 | 565 | 664 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1387 | FTX214 | FTX.006.214 | CONTRACT-ID | Contract Identifier | Conditional | Managed care plan contract ID | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(100) | 22 | 665 | 764 | 1. Value must be 100 characters or less 2. Conditional 3. If Payee ID Type is in [02,03], then value must be populated |
| 1388 | FTX215 | FTX.006.215 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Conditional | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | FTX00006 | VALUE-BASED-PAYMENT | X(20) | 23 | 765 | 784 | 1. Value must be 20 characters or less 2. Conditional 3. When populated, value must match MSIS Identification Number (ELG.002.019) 4. When Adjustment Indicator does not equal "1", there must be a valid record of type Enrollment Time Span where the Performance Period Start Date is equal to or greater than Enrollment Start Date and Performance Period End Date is less than or equal to Enrollment End Date |
| 1389 | FTX216 | FTX.006.216 | PERFORMANCE-PERIOD-START-DATE | Performance Period Start Date | Mandatory | The date representing the beginning of the performance period that the value-based dollar amount is rewarding or penalizing. | N/A | FTX00006 | VALUE-BASED-PAYMENT | 9(8) | 24 | 785 | 792 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Performance Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1390 | FTX217 | FTX.006.217 | PERFORMANCE-PERIOD-END-DATE | Performance Period End Date | Mandatory | The date representing the end of the performance period that the value-based dollar amount is rewarding or penalizing. | N/A | FTX00006 | VALUE-BASED-PAYMENT | 9(8) | 25 | 793 | 800 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Performance Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1391 | FTX218 | FTX.006.218 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 26 | 801 | 802 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1392 | FTX221 | FTX.006.221 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00006 | VALUE-BASED-PAYMENT | X(1) | 27 | 803 | 803 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1393 | FTX220 | FTX.006.220 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00006 | VALUE-BASED-PAYMENT | X(50) | 28 | 804 | 853 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1394 | FTX219 | FTX.006.219 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00006 | VALUE-BASED-PAYMENT | X(5) | 29 | 854 | 858 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1395 | FTX222 | FTX.006.222 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(20) | 30 | 859 | 878 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1396 | FTX223 | FTX.006.223 | 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 transaction is submitted. | WAIVER-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 31 | 879 | 880 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Conditional |
| 1397 | FTX224 | FTX.006.224 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 32 | 881 | 882 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1398 | FTX225 | FTX.006.225 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 33 | 883 | 884 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share (VVL) 3. Mandatory |
| 1399 | FTX226 | FTX.006.226 | SDP-IND | State Directed Payment Indicator | Mandatory | Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. | SDP-IND | FTX00006 | VALUE-BASED-PAYMENT | X(1) | 34 | 885 | 885 | 1. Value must be 1 character 2. Value must be in State Directed Payment Indicator List (VVL) 3. Mandatory |
| 1400 | FTX227 | FTX.006.227 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 35 | 886 | 887 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1401 | FTX228 | FTX.006.228 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00006 | VALUE-BASED-PAYMENT | X(15) | 36 | 888 | 902 | 1. Value must be 15 characters or less 2. Conditional |
| 1402 | FTX229 | FTX.006.229 | VALUE-BASED-PAYMENT-MODEL-TYPE | Value Based Payment Model Type | Conditional | This is the type of value-based payment model to which the financial transaction applies. These values come from the “Alternative Payment Model (APM) Framework Final White Paper”, produced by the Healthcare Learning and Action Network. https://hcp-lan.org/work products/apm-whitepaper.pdf |
VALUE-BASED-PAYMENT-MODEL-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 37 | 903 | 904 | 1. Value must be 2 characters 2. Value must be in Value Based Payment Model Type List (VVL) 3. Conditional |
| 1403 | FTX230 | FTX.006.230 | PAYMENT-CAT-XREF | Payment Cat Xref | Conditional | Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(50) | 38 | 905 | 954 | 1. Value must be 50 characters or less 2. Conditional |
| 1404 | FTX231 | FTX.006.231 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00006 | VALUE-BASED-PAYMENT | X(2) | 39 | 955 | 956 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1405 | FTX232 | FTX.006.232 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(100) | 40 | 957 | 1056 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1406 | FTX233 | FTX.006.233 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(500) | 41 | 1057 | 1556 | 1. Value must be 500 characters or less 2. Conditional |
| 1407 | FTX234 | FTX.006.234 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00006 | VALUE-BASED-PAYMENT | X(500) | 42 | 1557 | 2056 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1408 | FTX236 | FTX.007.236 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00007" |
| 1409 | FTX237 | FTX.007.237 | 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. | STATE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1410 | FTX238 | FTX.007.238 | 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. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1411 | FTX239 | FTX.007.239 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1412 | FTX240 | FTX.007.240 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1413 | FTX242 | FTX.007.242 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1414 | FTX243 | FTX.007.243 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1415 | FTX244 | FTX.007.244 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1416 | FTX245 | FTX.007.245 | 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. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1417 | FTX246 | FTX.007.246 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1418 | FTX247 | FTX.007.247 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. |
N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1419 | FTX248 | FTX.007.248 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 1420 | FTX249 | FTX.007.249 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1421 | FTX250 | FTX.007.250 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Mandatory |
| 1422 | FTX251 | FTX.007.251 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1423 | FTX252 | FTX.007.252 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1424 | FTX253 | FTX.007.253 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1425 | FTX254 | FTX.007.254 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1426 | FTX255 | FTX.007.255 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. |
N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(30) | 19 | 533 | 562 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1427 | FTX256 | FTX.007.256 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 20 | 563 | 564 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1428 | FTX257 | FTX.007.257 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 21 | 565 | 664 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1429 | FTX258 | FTX.007.258 | CONTRACT-ID | Contract Identifier | Mandatory | Managed care plan contract ID | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 22 | 665 | 764 | 1. Value must be 100 characters or less 2. Mandatory |
| 1430 | FTX259 | FTX.007.259 | PAYMENT-PERIOD-START-DATE | Payment Period Start Date | Mandatory | The date representing the start of the time period that the payment is expected to be used by the provider. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | 9(8) | 23 | 765 | 772 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Payment Period End Date 3. Mandatory 4. Value of the CC component must be equal to "20" |
| 1431 | FTX260 | FTX.007.260 | PAYMENT-PERIOD-END-DATE | Payment Period End Date | Mandatory | The date representing the end of the time period that the payment is expected to be used by the provider. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | 9(8) | 24 | 773 | 780 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Payment Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1432 | FTX261 | FTX.007.261 | PAYMENT-PERIOD-TYPE | Payment Period Type | Mandatory | A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment. | PAYMENT-PERIOD-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 25 | 781 | 782 | 1. Value must be 2 characters 2. Value must be in Payment Period Type List (VVL) 3. Mandatory |
| 1433 | FTX262 | FTX.007.262 | PAYMENT-PERIOD-TYPE-OTHER-TEXT | Payment Period Type Other Text | Conditional | This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other". | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 26 | 783 | 882 | 1. Value must be 100 characters or less 2. Value must be populated when Payment Period Type equals "95" 3. Conditional |
| 1434 | FTX263 | FTX.007.263 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 27 | 883 | 884 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1435 | FTX266 | FTX.007.266 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(1) | 28 | 885 | 885 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1436 | FTX265 | FTX.007.265 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(50) | 29 | 886 | 935 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1437 | FTX264 | FTX.007.264 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(5) | 30 | 936 | 940 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1438 | FTX267 | FTX.007.267 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(20) | 31 | 941 | 960 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1439 | FTX268 | FTX.007.268 | 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 transaction is submitted. | WAIVER-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 32 | 961 | 962 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Conditional |
| 1440 | FTX269 | FTX.007.269 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 33 | 963 | 964 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1441 | FTX270 | FTX.007.270 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 34 | 965 | 966 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share (VVL) 3. Mandatory |
| 1442 | FTX271 | FTX.007.271 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 35 | 967 | 968 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1443 | FTX272 | FTX.007.272 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(15) | 36 | 969 | 983 | 1. Value must be 15 characters or less 2. Conditional |
| 1444 | FTX273 | FTX.007.273 | PAYMENT-CAT-XREF | Payment Cat Xref | Conditional | Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(50) | 37 | 984 | 1033 | 1. Value must be 50 characters or less 2. Conditional |
| 1445 | FTX274 | FTX.007.274 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(2) | 38 | 1034 | 1035 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1446 | FTX275 | FTX.007.275 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(100) | 39 | 1036 | 1135 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1447 | FTX276 | FTX.007.276 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(500) | 40 | 1136 | 1635 | 1. Value must be 500 characters or less 2. Conditional |
| 1448 | FTX277 | FTX.007.277 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00007 | STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM | X(500) | 41 | 1636 | 2135 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1449 | FTX279 | FTX.008.279 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00008 | COST-SETTLEMENT-PAYMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00008" |
| 1450 | FTX280 | FTX.008.280 | 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. | STATE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1451 | FTX281 | FTX.008.281 | 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. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1452 | FTX282 | FTX.008.282 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1453 | FTX283 | FTX.008.283 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1454 | FTX285 | FTX.008.285 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00008 | COST-SETTLEMENT-PAYMENT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1455 | FTX286 | FTX.008.286 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1456 | FTX287 | FTX.008.287 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1457 | FTX288 | FTX.008.288 | 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. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1458 | FTX289 | FTX.008.289 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1459 | FTX290 | FTX.008.290 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. |
N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1460 | FTX291 | FTX.008.291 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 1461 | FTX292 | FTX.008.292 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1462 | FTX293 | FTX.008.293 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Mandatory |
| 1463 | FTX294 | FTX.008.294 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1464 | FTX295 | FTX.008.295 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1465 | FTX296 | FTX.008.296 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1466 | FTX297 | FTX.008.297 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1467 | FTX298 | FTX.008.298 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. |
N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(30) | 19 | 533 | 562 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1468 | FTX299 | FTX.008.299 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 20 | 563 | 564 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1469 | FTX300 | FTX.008.300 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(100) | 21 | 565 | 664 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1470 | FTX301 | FTX.008.301 | COST-SETTLEMENT-PERIOD-START-DATE | Cost Settlement Period Start Date | Mandatory | The date representing the beginning of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement begin date would be March 1 of that year. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | 9(8) | 22 | 665 | 672 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Cost Settlement Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1471 | FTX302 | FTX.008.302 | COST-SETTLEMENT-PERIOD-END-DATE | Cost Settlement Period End Date | Mandatory | The date representing the end of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement end date would be March 31 of that year. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | 9(8) | 23 | 673 | 680 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Cost Settlement Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1472 | FTX303 | FTX.008.303 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 24 | 681 | 682 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1473 | FTX306 | FTX.008.306 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00008 | COST-SETTLEMENT-PAYMENT | X(1) | 25 | 683 | 683 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1474 | FTX305 | FTX.008.305 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00008 | COST-SETTLEMENT-PAYMENT | X(50) | 26 | 684 | 733 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1475 | FTX304 | FTX.008.304 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00008 | COST-SETTLEMENT-PAYMENT | X(5) | 27 | 734 | 738 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1476 | FTX307 | FTX.008.307 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(20) | 28 | 739 | 758 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1477 | FTX308 | FTX.008.308 | 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 transaction is submitted. | WAIVER-TYPE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 29 | 759 | 760 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Conditional |
| 1478 | FTX309 | FTX.008.309 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 30 | 761 | 762 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1479 | FTX310 | FTX.008.310 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 31 | 763 | 764 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share (VVL) 3. Mandatory |
| 1480 | FTX311 | FTX.008.311 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 32 | 765 | 766 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1481 | FTX312 | FTX.008.312 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(15) | 33 | 767 | 781 | 1. Value must be 15 characters or less 2. Conditional |
| 1482 | FTX313 | FTX.008.313 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00008 | COST-SETTLEMENT-PAYMENT | X(2) | 34 | 782 | 783 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1483 | FTX314 | FTX.008.314 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(100) | 35 | 784 | 883 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1484 | FTX315 | FTX.008.315 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(500) | 36 | 884 | 1383 | 1. Value must be 500 characters or less 2. Conditional |
| 1485 | FTX316 | FTX.008.316 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00008 | COST-SETTLEMENT-PAYMENT | X(500) | 37 | 1384 | 1883 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1486 | FTX318 | FTX.009.318 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00009 | FQHC-WRAP-PAYMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00009" |
| 1487 | FTX319 | FTX.009.319 | 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. | STATE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1488 | FTX320 | FTX.009.320 | 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. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1489 | FTX321 | FTX.009.321 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1490 | FTX322 | FTX.009.322 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1491 | FTX324 | FTX.009.324 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00009 | FQHC-WRAP-PAYMENT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1492 | FTX325 | FTX.009.325 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1493 | FTX326 | FTX.009.326 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1494 | FTX327 | FTX.009.327 | 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. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1495 | FTX328 | FTX.009.328 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1496 | FTX329 | FTX.009.329 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. |
N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1497 | FTX330 | FTX.009.330 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 1498 | FTX331 | FTX.009.331 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1499 | FTX332 | FTX.009.332 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(30) | 14 | 299 | 328 | 1. Value must be 30 characters or less 2. Mandatory |
| 1500 | FTX333 | FTX.009.333 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 15 | 329 | 330 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1501 | FTX334 | FTX.009.334 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(100) | 16 | 331 | 430 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1502 | FTX335 | FTX.009.335 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1503 | FTX336 | FTX.009.336 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1504 | FTX337 | FTX.009.337 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. |
N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(30) | 19 | 533 | 562 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1505 | FTX338 | FTX.009.338 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 20 | 563 | 564 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1506 | FTX339 | FTX.009.339 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(100) | 21 | 565 | 664 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1507 | FTX340 | FTX.009.340 | WRAP-PERIOD-START-DATE | Wrap Period Start Date | Mandatory | The date representing the beginning of the FQHC wrap payment or recoupment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment begin date would be March 1 of that year. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | 9(8) | 22 | 665 | 672 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Coverage Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1508 | FTX341 | FTX.009.341 | WRAP-PERIOD-END-DATE | Wrap Period End Date | Mandatory | The date representing the end of the FQHC wrap payment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment end date would be March 31 of that year. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | 9(8) | 23 | 673 | 680 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Wrap Period Start Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1509 | FTX342 | FTX.009.342 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 24 | 681 | 682 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1510 | FTX345 | FTX.009.345 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00009 | FQHC-WRAP-PAYMENT | X(1) | 25 | 683 | 683 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1511 | FTX344 | FTX.009.344 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00009 | FQHC-WRAP-PAYMENT | X(50) | 26 | 684 | 733 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1512 | FTX343 | FTX.009.343 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00009 | FQHC-WRAP-PAYMENT | X(5) | 27 | 734 | 738 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1513 | FTX346 | FTX.009.346 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(20) | 28 | 739 | 758 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1514 | FTX347 | FTX.009.347 | 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 transaction is submitted. | WAIVER-TYPE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 29 | 759 | 760 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Conditional |
| 1515 | FTX348 | FTX.009.348 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 30 | 761 | 762 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1516 | FTX349 | FTX.009.349 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 31 | 763 | 764 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share (VVL) 3. Mandatory |
| 1517 | FTX350 | FTX.009.350 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 32 | 765 | 766 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1518 | FTX351 | FTX.009.351 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(15) | 33 | 767 | 781 | 1. Value must be 15 characters or less 2. Conditional |
| 1519 | FTX352 | FTX.009.352 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00009 | FQHC-WRAP-PAYMENT | X(2) | 34 | 782 | 783 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1520 | FTX353 | FTX.009.353 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(100) | 35 | 784 | 883 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1521 | FTX354 | FTX.009.354 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(500) | 36 | 884 | 1383 | 1. Value must be 500 characters or less 2. Conditional |
| 1522 | FTX355 | FTX.009.355 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00009 | FQHC-WRAP-PAYMENT | X(500) | 37 | 1384 | 1883 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1523 | FTX357 | FTX.095.357 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | FTX00095 | MISCELLANEOUS-PAYMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00095" |
| 1524 | FTX358 | FTX.095.358 | 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. | STATE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1525 | FTX359 | FTX.095.359 | 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. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1526 | FTX360 | FTX.095.360 | ICN-ORIG | Original ICN | Mandatory | A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(50) | 4 | 22 | 71 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1527 | FTX361 | FTX.095.361 | ICN-ADJ | Adjustment ICN | Conditional | A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(50) | 5 | 72 | 121 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 1528 | FTX363 | FTX.095.363 | ADJUSTMENT-IND | Adjustment Indicator | Mandatory | Indicates the type of adjustment record. | ADJUSTMENT-IND | FTX00095 | MISCELLANEOUS-PAYMENT | X(1) | 6 | 122 | 122 | 1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 1529 | FTX364 | FTX.095.364 | PAYMENT-OR-RECOUPMENT-DATE | Payment Or Recoupment Date | Mandatory | The date that the payment or recoupment was executed by the payer. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | 9(8) | 7 | 123 | 130 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to "20" |
| 1530 | FTX365 | FTX.095.365 | PAYMENT-OR-RECOUPMENT-AMOUNT | Payment Or Recoupment Amount | Mandatory | The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | S9(11)V99 | 8 | 131 | 143 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Mandatory |
| 1531 | FTX366 | FTX.095.366 | 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. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | 9(8) | 9 | 144 | 151 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 1532 | FTX367 | FTX.095.367 | CHECK-NUM | Check Number | Conditional | The check or electronic funds transfer number. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(15) | 10 | 152 | 166 | 1. Value must be 15 characters or less 2. When populated. value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 1533 | FTX368 | FTX.095.368 | PAYER-ID | Payer ID | Mandatory | This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. |
N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(30) | 11 | 167 | 196 | 1. Value must be 30 characters or less 2. Mandatory |
| 1534 | FTX369 | FTX.095.369 | PAYER-ID-TYPE | Payer ID Type | Mandatory | This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. | PAYER-ID-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 12 | 197 | 198 | 1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 1535 | FTX370 | FTX.095.370 | PAYER-ID-TYPE-OTHER-TEXT | Payer ID Type Other Text | Conditional | This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 13 | 199 | 298 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1536 | FTX371 | FTX.095.371 | PAYER-MCR-PLAN-TYPE | Payer MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 14 | 299 | 300 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payer ID Type equals "02", then value must be populated 4. If Payer ID Type does not equal "02", then value must not be populated 5. Conditional |
| 1537 | FTX372 | FTX.095.372 | PAYER-MCR-PLAN-TYPE-OTHER-TEXT | Payer MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 15 | 301 | 400 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1538 | FTX373 | FTX.095.373 | PAYEE-ID | Payee Identifier | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(30) | 16 | 401 | 430 | 1. Value must be 30 characters or less 2. Mandatory |
| 1539 | FTX374 | FTX.095.374 | PAYEE-ID-TYPE | Payee Identifier Type | Mandatory | This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. | PAYEE-ID-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 17 | 431 | 432 | 1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 1540 | FTX375 | FTX.095.375 | PAYEE-ID-TYPE-OTHER-TEXT | Payee ID Type Other Text | Conditional | This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 18 | 433 | 532 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1541 | FTX376 | FTX.095.376 | PAYEE-MCR-PLAN-TYPE | Payee MCR Plan Type | Conditional | This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. | MANAGED-CARE-PLAN-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 19 | 533 | 534 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. If Payee ID Type is in [02,03], then value must be populated 4. If Payee ID Type is not [02,03], then value must not be populated 5. Conditional |
| 1542 | FTX377 | FTX.095.377 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT | Payee MCR Plan Type Other Text | Conditional | This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 20 | 535 | 634 | 1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
| 1543 | FTX378 | FTX.095.378 | PAYEE-TAX-ID | Payee Tax ID | Mandatory | This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. |
N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(30) | 21 | 635 | 664 | 1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 1544 | FTX379 | FTX.095.379 | PAYEE-TAX-ID-TYPE | Payee Tax ID Type | Mandatory | This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. | PAYEE-TAX-ID-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 22 | 665 | 666 | 1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 1545 | FTX380 | FTX.095.380 | PAYEE-TAX-ID-TYPE-OTHER-TEXT | Payee Tax ID Type Other Text | Conditional | This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 23 | 667 | 766 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 1546 | FTX381 | FTX.095.381 | CONTRACT-ID | Contract Identifier | Conditional | Managed care plan contract ID | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 24 | 767 | 866 | 1. Value must be 100 characters or less 2. Conditional |
| 1547 | FTX382 | FTX.095.382 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier Identification Number | Conditional | The state-assigned identification number of the Third Party Liability (TPL) Entity. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(12) | 25 | 867 | 878 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1548 | FTX383 | FTX.095.383 | MSIS-IDENTIFICATION-NUM | MSIS Identification Number | Conditional | A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(20) | 26 | 879 | 898 | 1. Value must be 20 characters or less 2. Conditional 3. When populated, value must match MSIS Identification Number (ELG.002.019) 4. When Adjustment Indicator does not equal "1", there must be a valid record of type Enrollment Time Span where the Payment Period Start Date is equal to or greater than Enrollment Start Date and Period End Date is less than or equal to Enrollment End Date |
| 1549 | FTX384 | FTX.095.384 | PAYMENT-PERIOD-START-DATE | Payment Period Start Date | Mandatory | The date representing the start of the time period that the payment is expected to be used by the provider. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | 9(8) | 27 | 899 | 906 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Payment Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 1550 | FTX385 | FTX.095.385 | PAYMENT-PERIOD-END-DATE | Payment Period End Date | Mandatory | The date representing the end of the time period that the payment is expected to be used by the provider. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | 9(8) | 28 | 907 | 914 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value must be after or the same as the associated Payment Period Start Date 4. Value of the CC component must be equal to "20" |
| 1551 | FTX386 | FTX.095.386 | PAYMENT-PERIOD-TYPE | Payment Period Type | Mandatory | A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment. | PAYMENT-PERIOD-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 29 | 915 | 916 | 1. Value must be 2 characters 2. Value must be in Payment Period Type List (VVL) 3. Mandatory |
| 1552 | FTX387 | FTX.095.387 | PAYMENT-PERIOD-TYPE-OTHER-TEXT | Payment Period Type Other Text | Conditional | This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 30 | 917 | 1016 | 1. Value must be 100 characters or less 2. Value must be populated when Payment Period Type equals "95" 3. Conditional |
| 1553 | FTX388 | FTX.095.388 | TRANSACTION-TYPE | Transaction Type | Conditional | This is a code that classifies the type of financial transaction when the financial transaction does not fit into any other financial transaction segment type (e.g., FTX00002, FTX00003, FTX00004, etc.). | TRANSACTION-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 31 | 1017 | 1018 | 1. Value must be 2 characters 2. Value must be in Transaction Type List (VVL) 3. Conditional |
| 1554 | FTX389 | FTX.095.389 | TRANSACTION-TYPE-OTHER-TEXT | Transaction Type Other Text | Conditional | This is a description of the type of financial transaction when the TRANSACTION-TYPE is "Other". | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 32 | 1019 | 1118 | 1. Value must be 100 characters or less 2. Value must be populated when Payee Identifier Type equals "95" 3. Conditional |
| 1555 | FTX390 | FTX.095.390 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | Category for Federal Reimbursement | Mandatory | A code to indicate the Federal funding source for the payment. | CATEGORY-FOR-FEDERAL-REIMBURSEMENT | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 33 | 1119 | 1120 | 1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 1556 | FTX393 | FTX.095.393 | MBESCBES-FORM-GROUP | MBESCBES Form Group | Mandatory | Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). | MBESCBES-FORM-GROUP | FTX00095 | MISCELLANEOUS-PAYMENT | X(1) | 34 | 1121 | 1121 | 1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Mandatory |
| 1557 | FTX392 | FTX.095.392 | MBESCBES-FORM | MBESCBES Form | Mandatory | The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is. | MBESCBES-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3 | FTX00095 | MISCELLANEOUS-PAYMENT | X(50) | 35 | 1122 | 1171 | 1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 1558 | FTX391 | FTX.095.391 | MBESCBES-CATEGORY-OF-SERVICE | MBESCBES Category of Service | Mandatory | A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation. | 21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM |
FTX00095 | MISCELLANEOUS-PAYMENT | X(5) | 36 | 1172 | 1176 | 1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 1559 | FTX394 | FTX.095.394 | WAIVER-ID | Waiver ID | Conditional | Field specifying the waiver or demonstration which authorized payment. 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 "core" part of the waiver IDs, without including suffixes for renewals or amendments. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(20) | 37 | 1177 | 1196 | 1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 1560 | FTX395 | FTX.095.395 | 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 transaction is submitted. | WAIVER-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 38 | 1197 | 1198 | 1. Value must be 2 characters 2. Value must be in Waiver Type List (VVL) 3. Value must have a corresponding value in Waiver ID 4. Conditional |
| 1561 | FTX396 | FTX.095.396 | FUNDING-CODE | Funding Code | Mandatory | A code to indicate the source of non-federal share funds. | FUNDING-CODE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 39 | 1199 | 1200 | 1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 1562 | FTX397 | FTX.095.397 | FUNDING-SOURCE-NONFEDERAL-SHARE | Funding Source Nonfederal Share | Mandatory | 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. | FUNDING-SOURCE-NONFEDERAL-SHARE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 40 | 1201 | 1202 | 1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share (VVL) 3. Mandatory |
| 1563 | FTX398 | FTX.095.398 | SDP-IND | State Directed Payment Indicator | Mandatory | Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. | SDP-IND | FTX00095 | MISCELLANEOUS-PAYMENT | X(1) | 41 | 1203 | 1203 | 1. Value must be 1 character 2. Value must be in State Directed Payment Indicator List (VVL) 3. Mandatory |
| 1564 | FTX399 | FTX.095.399 | SOURCE-LOCATION | Source Location | Mandatory | The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. | SOURCE-LOCATION | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 42 | 1204 | 1205 | 1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 1565 | FTX400 | FTX.095.400 | SPA-NUMBER | SPA Number | Conditional | State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally = an Situational entry for specific SPA types |
N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(15) | 43 | 1206 | 1220 | 1. Value must be 15 characters or less 2. Conditional |
| 1566 | FTX401 | FTX.095.401 | PAYMENT-CAT-XREF | Payment Cat Xref | Conditional | Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(50) | 44 | 1221 | 1270 | 1. Value must be 50 characters or less 2. Conditional |
| 1567 | FTX402 | FTX.095.402 | EXPENDITURE-AUTHORITY-TYPE | Expenditure Authority Type | Mandatory | Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. | EXPENDITURE-AUTHORITY-TYPE | FTX00095 | MISCELLANEOUS-PAYMENT | X(2) | 45 | 1271 | 1272 | 1. Value must be 2 characters 2. Value must be in Expenditure Authority Type List (VVL) 3. Mandatory |
| 1568 | FTX403 | FTX.095.403 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT | Expenditure Authority Type Other Text | Conditional | This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(100) | 46 | 1273 | 1372 | 1. Value must be 100 characters or less 2. If Expenditure Authority Type equals "95", then value must be populated 3. Conditional |
| 1569 | FTX404 | FTX.095.404 | MEMO | Memo | Conditional | This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(500) | 47 | 1373 | 1872 | 1. Value must be 500 characters or less 2. Conditional |
| 1570 | FTX405 | FTX.095.405 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | FTX00095 | MISCELLANEOUS-PAYMENT | X(500) | 48 | 1873 | 2372 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1571 | MCR001 | MCR.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00001" |
| 1572 | 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. | DATA-DICTIONARY-VERSION | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 1573 | 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. | SUBMISSION-TRANSACTION-TYPE | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 1574 | MCR004 | MCR.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 1575 | 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. | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 1576 | MCR006 | MCR.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(8) | 6 | 32 | 39 | 1. Value must equal "MNGDCARE" 2. Mandatory |
| 1577 | 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. | STATE | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same for all records |
| 1578 | MCR008 | MCR.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 1579 | 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. | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 1580 | 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. | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 1581 | 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. | FILE-STATUS-INDICATOR | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 1582 | 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. | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | 9(11) | 12 | 67 | 77 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 1583 | MCR113 | MCR.001.113 | FILE-SUBMISSION-METHOD | File Submission Method | Mandatory | The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. | FILE-SUBMISSION-METHOD | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(2) | 13 | 78 | 79 | 1. Value must be 2 characters 2. Value must be in File Submission Method List (VVL) 3. Mandatory |
| 1584 | 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, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(4) | 14 | 80 | 83 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 1585 | MCR014 | MCR.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00001 | FILE-HEADER-RECORD-MANAGED-CARE | X(500) | 15 | 84 | 583 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1586 | MCR016 | MCR.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00002 | MANAGED-CARE-MAIN | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00002" |
| 1587 | 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. | STATE | MCR00002 | MANAGED-CARE-MAIN | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1588 | 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. | N/A | MCR00002 | MANAGED-CARE-MAIN | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1589 | MCR019 | MCR.002.019 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00002 | MANAGED-CARE-MAIN | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1590 | MCR020 | MCR.002.020 | MANAGED-CARE-CONTRACT-EFF-DATE | Managed Care Contract Effective Date | Mandatory | The start date of the managed care contract period with the state. | N/A | MCR00002 | MANAGED-CARE-MAIN | 9(8) | 5 | 34 | 41 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value must occur before Managed Care Contract End Date (MCR.002.021) |
| 1591 | 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. | N/A | MCR00002 | MANAGED-CARE-MAIN | 9(8) | 6 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory |
| 1592 | 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 should be as it appears on the contract. | N/A | MCR00002 | MANAGED-CARE-MAIN | X(55) | 7 | 50 | 104 | 1. Value must be 55 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 1593 | MCR023 | MCR.002.023 | MANAGED-CARE-PROGRAM | Managed Care Program | Mandatory | The state program through which a managed care plan is approved to operate. | MANAGED-CARE-PROGRAM | MCR00002 | MANAGED-CARE-MAIN | X(1) | 8 | 105 | 105 | 1. Value must be 1 character 2. Value must be in Managed Care Program List (VVL) 3. Mandatory |
| 1594 | 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. Assign plan type value "15" for plans that primarily cover non-emergency medical transportation (NEMT). 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" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/ |
MANAGED-CARE-PLAN-TYPE | MCR00002 | MANAGED-CARE-MAIN | X(2) | 9 | 106 | 107 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. Mandatory |
| 1595 | MCR025 | MCR.002.025 | REIMBURSEMENT-ARRANGEMENT | Reimbursement Arrangement | Mandatory | A code indicating the how the managed care entity is reimbursed. | REIMBURSEMENT-ARRANGEMENT | MCR00002 | MANAGED-CARE-MAIN | X(2) | 10 | 108 | 109 | 1. Value must be 2 characters 2. Value must be in Reimbursement Arrangement List (VVL) 3. Mandatory |
| 1596 | MCR026 | MCR.002.026 | MANAGED-CARE-PROFIT-STATUS | Managed Care Profit Status | Mandatory | A code denoting the profit status of managed care entity. | MANAGED-CARE-PROFIT-STATUS | MCR00002 | MANAGED-CARE-MAIN | X(2) | 11 | 110 | 111 | 1. Value must be 2 characters 2. Value must be in Managed Care Profit Status List (VVL) 3. Mandatory |
| 1597 | 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 and micropolitan, metropolitan and non-CBSA area) classify the 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 metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009. See the hyperlink below for further information. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf | CORE-BASED-STATISTICAL-AREA-CODE | MCR00002 | MANAGED-CARE-MAIN | X(1) | 12 | 112 | 112 | 1. Value must be 1 character 2. Value must be in Core Based Statistical Area Code List (VVL) 3. Mandatory |
| 1598 | 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. | N/A | MCR00002 | MANAGED-CARE-MAIN | 9(3) | 13 | 113 | 115 | 1. Value must be between 000 and 100 inclusively 2. Mandatory |
| 1599 | 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. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareservicearea-in-the-managed-care-file-managed-care/ |
MANAGED-CARE-SERVICE-AREA | MCR00002 | MANAGED-CARE-MAIN | X(1) | 14 | 116 | 116 | 1. Value must be 1 character 2. Value must be in Managed Care Service Area List (VVL) 3. Mandatory 4. When value equals "2", the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
| 1600 | 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. | N/A | MCR00002 | MANAGED-CARE-MAIN | 9(8) | 15 | 117 | 124 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1601 | 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. | N/A | MCR00002 | MANAGED-CARE-MAIN | 9(8) | 16 | 125 | 132 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1602 | MCR032 | MCR.002.032 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00002 | MANAGED-CARE-MAIN | X(500) | 17 | 133 | 632 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1603 | MCR034 | MCR.003.034 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00003" |
| 1604 | 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. | STATE | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1605 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1606 | MCR037 | MCR.003.037 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1607 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(15) | 5 | 34 | 48 | 1. Value must be 15 characters or less 2. Value must not contain a pipe symbol 3. Each managed care entity's locations must have a unique identifier 4. Value must be populated if associated Managed Care Address Type (MCR.003.041) equals 3 (Managed care entity's service location address) 5. Mandatory |
| 1608 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | 9(8) | 6 | 49 | 56 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1609 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | 9(8) | 7 | 57 | 64 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1610 | 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 Managed Care Main segment. | MANAGED-CARE-ADDR-TYPE | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(1) | 8 | 65 | 65 | 1. Value must be 1 character 2. Value must be in Managed Care Address Type List (VVL) 3. Mandatory |
| 1611 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(60) | 9 | 66 | 125 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory |
| 1612 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(60) | 10 | 126 | 185 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s) 3. There must be an Address Line 1 in order to have an Address Line 2 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 1613 | 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. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(60) | 11 | 186 | 245 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s) 3. If Address Line 2 is not populated, then value should not be populated 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 1614 | 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.). | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(28) | 12 | 246 | 273 | 1. Value must be 28 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1615 | 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. | STATE | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(2) | 13 | 274 | 275 | 1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1616 | 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.) | ZIP-CODE | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(9) | 14 | 276 | 284 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 1617 | 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. | COUNTY | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(3) | 15 | 285 | 287 | 1. Value must be 3 characters 2. Value must be in US County Code List (VVL) 3. Mandatory |
| 1618 | MCR049 | MCR.003.049 | MANAGED-CARE-TELEPHONE | Managed Care Phone Number | Situational | Phone number for a given entity (e.g. person, organization, agency). | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(10) | 16 | 288 | 297 | 1. Value must be 10-digit number 2. Situational |
| 1619 | MCR050 | MCR.003.050 | MANAGED-CARE-EMAIL | Managed Care Email | Situational | The email address of the managed care entity listed on the contract with the state. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(60) | 17 | 298 | 357 | 1. Must contain the "@" symbol 2. May contain uppercase and lowercase Latin letters A to Z and a to z 3. May contain digits 0-9 4. Must contain a dot "." that is not the first or last character and provided that it does not appear consecutively 5. Value must be 60 characters or less 6. Situational |
| 1620 | MCR051 | MCR.003.051 | MANAGED-CARE-FAX-NUMBER | Managed Care Fax Number | Conditional | A fax number, including area code, as listed on the contract with the state. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(10) | 18 | 358 | 367 | 1. Value must be 10-digit number 2. Conditional |
| 1621 | MCR052 | MCR.003.052 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00003 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO | X(500) | 19 | 368 | 867 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1622 | MCR054 | MCR.004.054 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00004 | MANAGED-CARE-SERVICE-AREA | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00004" |
| 1623 | 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. | STATE | MCR00004 | MANAGED-CARE-SERVICE-AREA | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1624 | 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. | N/A | MCR00004 | MANAGED-CARE-SERVICE-AREA | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1625 | MCR057 | MCR.004.057 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00004 | MANAGED-CARE-SERVICE-AREA | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1626 | 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. Put each zip code, city, county, region, or other area descriptor on a separate record. Use 5 digit zip codes when service area definition is zip code based. Use ANSI codes when service area is defined by counties or cities. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareservicearea-in-the-managed-care-file-managed-care/ |
MANAGED-CARE-SERVICE-AREA-NAME | MCR00004 | MANAGED-CARE-SERVICE-AREA | X(30) | 5 | 34 | 63 | 1. Value must be 30 characters or less 2. Value must be in Managed Care Service Area Name List (VVL) 3. If associated Managed Care Service Area (MCR.002.029) is in [2,3,4,5,6], then value is mandatory and must be provided 4. Value must not contain a pipe or asterisk symbol 5. Conditional 6. If associated Managed Care Service Area (MCR.002.029) equals "5" (zip code), then value must be a 5-digit zip code 7. If associated Managed Care Service Area (MCR.002.029) equals "2" (county code), then value must be a 3-digit number |
| 1627 | 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. | N/A | MCR00004 | MANAGED-CARE-SERVICE-AREA | 9(8) | 6 | 64 | 71 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1628 | 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. | N/A | MCR00004 | MANAGED-CARE-SERVICE-AREA | 9(8) | 7 | 72 | 79 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1629 | MCR061 | MCR.004.061 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00004 | MANAGED-CARE-SERVICE-AREA | X(500) | 8 | 80 | 579 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1630 | MCR063 | MCR.005.063 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00005" |
| 1631 | 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. | STATE | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1632 | 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. | N/A | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1633 | MCR066 | MCR.005.066 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1634 | 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. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/ |
OPERATING-AUTHORITY | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | X(2) | 5 | 34 | 35 | 1. Value must be 2 characters 2. Value must be in Operating Authority List (VVL) 3. Mandatory |
| 1635 | 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. | N/A | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | X(20) | 6 | 36 | 55 | 1. Value must be 20 characters or less 2. Mandatory |
| 1636 | 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. | N/A | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | 9(8) | 7 | 56 | 63 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1637 | 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. | N/A | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | 9(8) | 8 | 64 | 71 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1638 | MCR071 | MCR.005.071 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00005 | MANAGED-CARE-OPERATING-AUTHORITY | X(500) | 9 | 72 | 571 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1639 | MCR073 | MCR.006.073 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00006" |
| 1640 | 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. | STATE | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1641 | 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. | N/A | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1642 | MCR076 | MCR.006.076 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1643 | 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. | ELIGIBILITY-GROUP | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | 9(2) | 5 | 34 | 35 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Pop List (VVL) 3. Mandatory |
| 1644 | 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. | N/A | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | 9(8) | 6 | 36 | 43 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1645 | 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. | N/A | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | 9(8) | 7 | 44 | 51 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1646 | MCR080 | MCR.006.080 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00006 | MANAGED-CARE-PLAN-POPULATION-ENROLLED | X(500) | 8 | 52 | 551 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1647 | MCR082 | MCR.007.082 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00007" |
| 1648 | 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. | STATE | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1649 | 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. | N/A | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1650 | MCR085 | MCR.007.085 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1651 | MCR086 | MCR.007.086 | ACCREDITATION-ORGANIZATION | Accreditation Organization | Mandatory | Identify the accreditation awarded to the managed care entity. | ACCREDITATION-ORGANIZATION | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | X(2) | 5 | 34 | 35 | 1. Value must be 2 characters 2. Value must be in Accreditation Organization List (VVL) 3. Mandatory |
| 1652 | MCR087 | MCR.007.087 | DATE-ACCREDITATION-ACHIEVED | Date Accreditation Achieved | Mandatory | The date the organization achieved accreditation. | N/A | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | 9(8) | 6 | 36 | 43 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1653 | MCR088 | MCR.007.088 | DATE-ACCREDITATION-END | Date Accreditation End | Mandatory | The date when organization's accreditation ends. | N/A | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | 9(8) | 7 | 44 | 51 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1654 | MCR089 | MCR.007.089 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00007 | MANAGED-CARE-ACCREDITATION-ORGANIZATION | X(500) | 8 | 52 | 551 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1655 | MCR114 | MCR.010.114 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | MCR00010 | MANAGED-CARE-ID | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00010" |
| 1656 | MCR115 | MCR.010.115 | 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. | STATE | MCR00010 | MANAGED-CARE-ID | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 1657 | MCR116 | MCR.010.116 | 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. | N/A | MCR00010 | MANAGED-CARE-ID | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1658 | MCR117 | MCR.010.117 | STATE-PLAN-ID-NUM | State Plan ID Number | Mandatory | The ID number a state issues to a managed care entity | N/A | MCR00010 | MANAGED-CARE-ID | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1659 | MCR118 | MCR.010.118 | MANAGED-CARE-PLAN-OTHER-ID-TYPE | Managed Care Plan Other ID Type | Mandatory | A code to identify the kind of managed care identifier that is captured in the Managed Care Identifier data element. The state should submit updates to T-MSIS whenever an identifier is retired or issued. | MANAGED-CARE-PLAN-OTHER-ID-TYPE | MCR00010 | MANAGED-CARE-ID | X(2) | 5 | 34 | 35 | 1. Value must be 2 characters 2. Value must be in Managed Care Plan Other ID Type List (VVL) 3. Mandatory |
| 1660 | MCR119 | MCR.010.119 | MANAGED-CARE-PLAN-OTHER-ID | Managed Care Plan Other ID | Mandatory | A data element to capture the various IDs used to identify a managed care plan. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Identifier Type data element. | N/A | MCR00010 | MANAGED-CARE-ID | X(30) | 6 | 36 | 65 | 1. Value must be 30 characters 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 1661 | MCR120 | MCR.010.120 | MANAGED-CARE-ID-EFF-DATE | Managed Care ID Effective Date | Mandatory | The date the organization achieved accreditation. | N/A | MCR00010 | MANAGED-CARE-ID | 9(8) | 7 | 66 | 73 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1662 | MCR121 | MCR.010.121 | MANAGED-CARE-ID-END-DATE | Managed Care ID End Date | Mandatory | The date when organization's accreditation ends. | N/A | MCR00010 | MANAGED-CARE-ID | 9(8) | 8 | 74 | 81 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1663 | MCR122 | MCR.010.122 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | MCR00010 | MANAGED-CARE-ID | X(500) | 9 | 82 | 581 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1664 | PRV001 | PRV.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00001" |
| 1665 | 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. | DATA-DICTIONARY-VERSION | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 1666 | 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. | SUBMISSION-TRANSACTION-TYPE | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 1667 | PRV004 | PRV.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 1668 | 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. | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 1669 | PRV006 | PRV.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(8) | 6 | 32 | 39 | 1. Value must equal "PROVIDER" 2. Mandatory |
| 1670 | 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. | STATE | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same for all records |
| 1671 | PRV008 | PRV.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 1672 | 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. | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 1673 | 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. | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 1674 | 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. | FILE-STATUS-INDICATOR | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 1675 | 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. | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | 9(11) | 12 | 67 | 77 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 1676 | PRV139 | PRV.001.139 | FILE-SUBMISSION-METHOD | File Submission Method | Mandatory | The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. | FILE-SUBMISSION-METHOD | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(2) | 13 | 78 | 79 | 1. Value must be 2 characters 2. Value must be in File Submission Method List (VVL) 3. Mandatory |
| 1677 | 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, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(4) | 14 | 80 | 83 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 1678 | PRV014 | PRV.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00001 | FILE-HEADER-RECORD-PROVIDER | X(500) | 15 | 84 | 583 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1679 | PRV016 | PRV.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00002 | PROV-ATTRIBUTES-MAIN | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00002" |
| 1680 | 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. | STATE | PRV00002 | PROV-ATTRIBUTES-MAIN | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1681 | 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. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1682 | 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. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1683 | 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. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | 9(8) | 5 | 52 | 59 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1684 | 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. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | 9(8) | 6 | 60 | 67 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1685 | 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 legal name. DBA is an abbreviation for "doing business as." Registering a DBA is required to operate a business under a name that differs from the company's legal name. If DBA name is the same as the legal name, do not populate DBA name. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(100) | 7 | 68 | 167 | 1. Value must be 100 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Conditional |
| 1686 | 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 can have a legal name. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(100) | 8 | 168 | 267 | 1. Value must be 100 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 1687 | 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. Provider Organization Name should be same as provider last name when provider is an individual. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(60) | 9 | 268 | 327 | 1. Value must be 60 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Conditional |
| 1688 | PRV025 | PRV.002.025 | PROV-TAX-NAME | Provider Tax Name | Mandatory | The name that the provider entity uses on IRS filings. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(100) | 10 | 328 | 427 | 1. Value must be 100 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 1689 | 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. | FACILITY-GROUP-INDIVIDUAL-CODE | PRV00002 | PROV-ATTRIBUTES-MAIN | X(2) | 11 | 428 | 429 | 1. Value must be in Facility Group Individual Code List (VVL) 2. Value must be 2 characters 3. Mandatory 4. (Individual) If value equals "03", then Provider First Name (PRV.002.028) must be populated 5. (Individual) NPPES Entity Type Code associate with this NPI must equal "1" (Individual) 6. (Individual) If value equals "03", then Provider Last Name (PRV.002.030) must be populated 7. (Individual) If value equals "03", then Provider Sex (PRV.002.031) must be populated 8. (Individual) If value equals "03", then Provider Date of Birth (PRV.002.034) must be populated 9. (Organization) If value equals "01" or "02", then Provider Date of Death (PRV.002.035) must not be populated 10. (Organization) If value does not equal "03", then Provider Middle Initial (PRV.002.029) must not be populated 11. (Organization) NPPES Entity Type Code associate with this NPI must equal "2" (Organization) |
| 1690 | PRV027 | PRV.002.027 | TEACHING-IND | Teaching Indicator | Conditional | A code indicating if the provider's organization is a teaching facility. | TEACHING-IND | PRV00002 | PROV-ATTRIBUTES-MAIN | X(1) | 12 | 430 | 430 | 1. Value must be 1 character 2. Value must be in Teaching Indicator List (VVL) 3. Value must be "0" when Facility Group Individual Code (PRV.002.026) equals '02' or '03' 4. Conditional |
| 1691 | 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). | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(30) | 13 | 431 | 460 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1692 | 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). | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(1) | 14 | 461 | 461 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1693 | 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). | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(30) | 15 | 462 | 491 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1694 | PRV031 | PRV.002.031 | SEX | Sex | Conditional | Either individual's biological sex or their self-identified sex. | SEX | PRV00002 | PROV-ATTRIBUTES-MAIN | X(1) | 16 | 492 | 492 | 1. Value must be 1 character 2. Value must be in Sex List (VVL) 3. Conditional |
| 1695 | 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. | OWNERSHIP-CODE | PRV00002 | PROV-ATTRIBUTES-MAIN | X(2) | 17 | 493 | 494 | 1. Value must be 2 characters 2. Value must be in Ownership Code List (VVL) 3. Conditional 4. Value is mandatory when associated Facility Group Individual Code (PRV.002.026) is in [01,02] (organization) |
| 1696 | PRV033 | PRV.002.033 | PROV-PROFIT-STATUS | Provider Profit Status | Mandatory | A code denoting the profit status of the provider. | PROV-PROFIT-STATUS | PRV00002 | PROV-ATTRIBUTES-MAIN | X(2) | 18 | 495 | 496 | 1. Value must be 2 characters 2. Value must be in Provider Profit Status List (VVL) 3. Mandatory |
| 1697 | PRV034 | PRV.002.034 | DATE-OF-BIRTH | Date of Birth | Conditional | An individual's date of birth. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | 9(8) | 19 | 497 | 504 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be less than or equal to associated End of Time Period (PRV.001.010) 3. Conditional 4. The difference between current value and Start of Time Period (PRV.001.009) must be between 18 and 85 years |
| 1698 | PRV035 | PRV.002.035 | DATE-OF-DEATH | Date of Death | Conditional | The date an individual died on. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | 9(8) | 20 | 505 | 512 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. If populated, value must be on or after individual's Date of Birth 4. Value must be less than or equal to associated End of Time Period (PRV.001.010) 5. There can only be one value on all records when the value is populated 6. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater |
| 1699 | PRV036 | PRV.002.036 | ACCEPTING-NEW-PATIENTS-IND | Accepting New Patients Indicator | Mandatory | An indicator to identify providers who are accepting new patients. | ACCEPTING-NEW-PATIENTS-IND | PRV00002 | PROV-ATTRIBUTES-MAIN | X(1) | 21 | 513 | 513 | 1. Value must be 1 character 2. Value must be in Accepting New Patients Indicator List (VVL) 3. Mandatory |
| 1700 | PRV140 | PRV.002.140 | ATYPICAL-PROV-IND | Atypical Provider Indicator | Mandatory | An indicator to identify whether the provider is an atypical provider and therefore not eligible for an NPI. | ATYPICAL-PROV-IND | PRV00002 | PROV-ATTRIBUTES-MAIN | X(1) | 22 | 514 | 514 | 1. Value must be 1 character 2. Value must be in Atypical Provider Indicator code list (VVL) 3. Mandatory |
| 1701 | PRV037 | PRV.002.037 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00002 | PROV-ATTRIBUTES-MAIN | X(500) | 23 | 515 | 1014 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1702 | PRV039 | PRV.003.039 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00003" |
| 1703 | 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. | STATE | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1704 | 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. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1705 | 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. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1706 | PRV043 | PRV.003.043 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(5) | 5 | 52 | 56 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1707 | PRV044 | PRV.003.044 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE | Provider Location and Contact Info Effective Date | Mandatory | The first calendar day on which all of the other data elements in the same segment were effective. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | 9(8) | 6 | 57 | 64 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,19,99] |
| 1708 | PRV045 | PRV.003.045 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE | Provider Location and Contact Info End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | 9(8) | 7 | 65 | 72 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1709 | PRV046 | PRV.003.046 | PROV-ADDR-TYPE | Provider Address Type | Mandatory | The type of address and contact information for the provider submitted in the record segment. | PROV-ADDR-TYPE | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(1) | 8 | 73 | 73 | 1. Value must be 1 character 2. Value must be in Provider Address Type List (VVL) 3. Mandatory |
| 1710 | 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.). | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(60) | 9 | 74 | 133 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory |
| 1711 | 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.). | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(60) | 10 | 134 | 193 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s) 3. There must be an Address Line 1 in order to have an Address Line 2 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 1712 | 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.). | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(60) | 11 | 194 | 253 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s) 3. If Address Line 2 is not populated, then value should not be populated 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 1713 | 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.). | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(28) | 12 | 254 | 281 | 1. Value must be 28 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1714 | 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.) | STATE | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(2) | 13 | 282 | 283 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 1715 | 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.) | ZIP-CODE | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(9) | 14 | 284 | 292 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 1716 | PRV053 | PRV.003.053 | ADDR-TELEPHONE | Provider Phone Number | Situational | Phone number for a given entity (e.g. person, organization, agency). | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(10) | 15 | 293 | 302 | 1. Value must be 10-digit number 2. Situational |
| 1717 | PRV054 | PRV.003.054 | ADDR-EMAIL | Provider Address Email | Situational | The email address of the provider for the location being captured on this record | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(60) | 16 | 303 | 362 | 1. Must contain the "@" symbol 2. May contain uppercase and lowercase Latin letters A to Z and a to z 3. May contain digits 0-9 4. Must contain a dot "." that is not the first or last character and provided that it does not appear consecutively 5. Value must be 60 characters or less 6. Situational |
| 1718 | PRV055 | PRV.003.055 | ADDR-FAX-NUM | Provider Address Fax | Situational | The fax number of the provider for the location being captured on this record. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(10) | 17 | 363 | 372 | 1. Value must be 10-digit number 2. Situational |
| 1719 | 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.) | ADDR-BORDER-STATE-IND | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(1) | 18 | 373 | 373 | 1. Value must be 1 character 2. Value must be in Address Border State Indicator List (VVL) 3. Mandatory |
| 1720 | PRV057 | PRV.003.057 | ADDR-COUNTY | Provider County Code | Mandatory | Standard ANSI code used to identify a specific U.S. County. | COUNTY | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(3) | 19 | 374 | 376 | 1. Value must be 3 characters 2. Value must be in US County Code List (VVL) 3. Mandatory |
| 1721 | PRV058 | PRV.003.058 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00003 | PROV-LOCATION-AND-CONTACT-INFO | X(500) | 20 | 377 | 876 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1722 | PRV060 | PRV.004.060 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00004 | PROV-LICENSING-INFO | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00004" |
| 1723 | 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. | STATE | PRV00004 | PROV-LICENSING-INFO | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1724 | 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. | N/A | PRV00004 | PROV-LICENSING-INFO | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1725 | 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. | N/A | PRV00004 | PROV-LICENSING-INFO | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1726 | PRV064 | PRV.004.064 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | PRV00004 | PROV-LICENSING-INFO | X(5) | 5 | 52 | 56 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1727 | 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. | N/A | PRV00004 | PROV-LICENSING-INFO | 9(8) | 6 | 57 | 64 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1728 | 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. | N/A | PRV00004 | PROV-LICENSING-INFO | 9(8) | 7 | 65 | 72 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1729 | 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. | LICENSE-TYPE | PRV00004 | PROV-LICENSING-INFO | X(1) | 8 | 73 | 73 | 1. Value must be 1 character 2. Value must be in License Type List (VVL) 3. Mandatory |
| 1730 | 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. -If associated License Type is equal to 1 and issuing authority is a State, then value must be ANSI State abbreviation code.- If associated License Type is equal to 1 and issuing authority is a county, then value must be a 5-digit, concatenated code consisting of the ANSI state code plus the ANSI county code. A list of codes can be found here: https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/home/?cid=nrcs143_013697 If associated License Type is equal to 1 and issuing authority is a municipality, then enter a text string with the name of the municipality. If associated License Type is equal to 3, then enter the text string identifying the professional society issuing the accreditation. If associated License Type is equal to 4, then value must be the text string identifying the CLIA accreditation body's name. |
N/A | PRV00004 | PROV-LICENSING-INFO | X(60) | 9 | 74 | 133 | 1. Value must be 60 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Mandatory 4. If associated License Type equals "2", then value must equal "DEA" |
| 1731 | 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. | N/A | PRV00004 | PROV-LICENSING-INFO | X(20) | 10 | 134 | 153 | 1. Value must be 20 characters or less 2. Value must not contain a pipe and asterisk symbol 3. Mandatory |
| 1732 | PRV070 | PRV.004.070 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00004 | PROV-LICENSING-INFO | X(500) | 11 | 154 | 653 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1733 | PRV072 | PRV.005.072 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00005 | PROV-IDENTIFIERS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00005" |
| 1734 | 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. | STATE | PRV00005 | PROV-IDENTIFIERS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1735 | 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. | N/A | PRV00005 | PROV-IDENTIFIERS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1736 | 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. | N/A | PRV00005 | PROV-IDENTIFIERS | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1737 | PRV076 | PRV.005.076 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | PRV00005 | PROV-IDENTIFIERS | X(5) | 5 | 52 | 56 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1738 | 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 submit updates to T-MSIS whenever an identifier is retired or issued. see Provider Identifier Type List (VVL.146) | PROV-IDENTIFIER-TYPE | PRV00005 | PROV-IDENTIFIERS | X(1) | 6 | 57 | 57 | 1. Value must be 1 character 2. Value must be in Provider Identifier Type List (VVL) 3. Mandatory 4. When value equals "2", the associated Provider Identifier (PRV.005.081) must be a valid NPI |
| 1739 | 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 Provider Identifier (PRV.005.081) data element. For (State Tax ID), if associated Provider Identifier Type (PRV.005.077) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (PRV.005.077) value is equal to 8, then value must be the name of the entity that issued the identifier. | N/A | PRV00005 | PROV-IDENTIFIERS | X(18) | 7 | 58 | 75 | 1. Value must be 18 characters or less 2. Value must not contain a pipe or asterisk symbol 3. (State-specific Medicaid Provider) if associated Provider Identifier Type (PRV.005.077) value equals "1", then value must equal (PRV.005.073) Submitting State 4. (NPI) if associated Provider Identifier Type (PRV.005.077) value equals "2", then value must equal "NPI" 5. (Medicare) if associated Provider Identifier Type (PRV.005.077) value equals "3", then value must equal "CMS" 6. (NCPDP) if associated Provider Identifier Type (PRV.005.077) value equals "4", then value must equal "NCPDP" 7. (Federal Tax ID) if associated Provider Identifier Type (PRV.005.077) value equals "5", then value must equal "IRS" 8. (SSN) if associated Provider Identifier Type (PRV.005.077) value equals "7", then value must be equal to "SSA" 9. Mandatory |
| 1740 | 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. | N/A | PRV00005 | PROV-IDENTIFIERS | 9(8) | 8 | 76 | 83 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1741 | PRV080 | PRV.005.080 | PROV-IDENTIFIER-END-DATE | Provider Identifier End Date | Mandatory | The last calendar day on which all of the other data elements in the same segment were effective. | N/A | PRV00005 | PROV-IDENTIFIERS | 9(8) | 9 | 84 | 91 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1742 | 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. | N/A | PRV00005 | PROV-IDENTIFIERS | X(30) | 10 | 92 | 121 | 1. Value must be 30 characters or less 2. Mandatory 3. Value must not contain a pipe or asterisk symbol 4. Value must have an associated Provider Identifier Type (PRV.005.077) 5. One record must have a Provider Identifier Type (PRV.005.077) equal to "1" |
| 1743 | PRV082 | PRV.005.082 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00005 | PROV-IDENTIFIERS | X(500) | 11 | 122 | 621 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1744 | PRV084 | PRV.006.084 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00006" |
| 1745 | 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. | STATE | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1746 | 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. | N/A | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1747 | 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. | N/A | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1748 | 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". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-technical-instructions-provider-classification-requirements-in-tmsis/ A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
PROV-CLASSIFICATION-TYPE | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | X(1) | 5 | 52 | 52 | 1. Value must be 1 character 2. Value must be in Provider Classification Type List (VVL) 3. Mandatory |
| 1749 | 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. | PROV-CLASSIFICATION-CODE-TYPE-4, PROV-TAXONOMY, PROV-TYPE, PROV-SPECIALTY | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | X(20) | 6 | 53 | 72 | 1. Value must be 20 characters or less 2. If associated Provider Classification Type equals "1", value must be in Provider Taxonomy List (VVL) 3. If associated Provider Classification Type equals "2", value must be in Provider Specialty List (VVL) 4. If associated Provider Classification Type equals "3", value must be in Provider Type Code List (VVL) 5. If associated Provider Classification Type equals "4", value must be in Provider Authorized Category of Service Code List (VVL) 6. Mandatory |
| 1750 | 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. | N/A | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | 9(8) | 7 | 73 | 80 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1751 | 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. | N/A | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | 9(8) | 8 | 81 | 88 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1752 | PRV092 | PRV.006.092 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00006 | PROV-TAXONOMY-CLASSIFICATION | X(500) | 9 | 89 | 588 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1753 | PRV094 | PRV.007.094 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00007" |
| 1754 | 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. | STATE | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1755 | 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. | N/A | PRV00007 | PROV-MEDICAID-ENROLLMENT | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1756 | 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. | N/A | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1757 | 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. | N/A | PRV00007 | PROV-MEDICAID-ENROLLMENT | 9(8) | 5 | 52 | 59 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1758 | 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. | N/A | PRV00007 | PROV-MEDICAID-ENROLLMENT | 9(8) | 6 | 60 | 67 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1759 | 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 Provider Medicaid Effective Date and Provider Medicaid End Date data elements. Note: The State Plan Enrollment data element identifies whether the provider is enrolled in Medicaid, CHIP, or both. | PROV-MEDICAID-ENROLLMENT-STATUS-CODE | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(2) | 7 | 68 | 69 | 1. Value must be 2 characters 2. Value must be in Provider Medicaid Enrollment Status Code List (VVL) 3. Mandatory |
| 1760 | 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. | STATE-PLAN-ENROLLMENT | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(1) | 8 | 70 | 70 | 1. Value must be 1 character 2. Value must be in State Plan Enrollment List (VVL) 3. Mandatory |
| 1761 | PRV102 | PRV.007.102 | PROV-ENROLLMENT-METHOD | Provider Enrollment Method | Mandatory | Process by which a provider was enrolled in Medicaid or CHIP. | PROV-ENROLLMENT-METHOD | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(1) | 9 | 71 | 71 | 1. Value must be 1 character 2. Value must be in Provider Enrollment Method List (VVL) 3. Mandatory |
| 1762 | 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. | N/A | PRV00007 | PROV-MEDICAID-ENROLLMENT | 9(8) | 10 | 72 | 79 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must not be earlier than associated Provider Medicaid Effective Date (PRV.007.098) value 3. Mandatory |
| 1763 | PRV104 | PRV.007.104 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00007 | PROV-MEDICAID-ENROLLMENT | X(500) | 11 | 80 | 579 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1764 | PRV106 | PRV.008.106 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00008 | PROV-AFFILIATED-GROUPS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00008" |
| 1765 | 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. | STATE | PRV00008 | PROV-AFFILIATED-GROUPS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1766 | 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. | N/A | PRV00008 | PROV-AFFILIATED-GROUPS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1767 | 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. | N/A | PRV00008 | PROV-AFFILIATED-GROUPS | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1768 | 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). | N/A | PRV00008 | PROV-AFFILIATED-GROUPS | X(30) | 5 | 52 | 81 | 1. Value must be 30 characters or less 2. Value must not contain a pipe symbol 3. Mandatory |
| 1769 | 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. | N/A | PRV00008 | PROV-AFFILIATED-GROUPS | 9(8) | 6 | 82 | 89 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1770 | 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. | N/A | PRV00008 | PROV-AFFILIATED-GROUPS | 9(8) | 7 | 90 | 97 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1771 | PRV113 | PRV.008.113 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00008 | PROV-AFFILIATED-GROUPS | X(500) | 8 | 98 | 597 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1772 | PRV115 | PRV.009.115 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00009 | PROV-AFFILIATED-PROGRAMS | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00009" |
| 1773 | 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. | STATE | PRV00009 | PROV-AFFILIATED-PROGRAMS | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1774 | 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. | N/A | PRV00009 | PROV-AFFILIATED-PROGRAMS | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1775 | 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. | N/A | PRV00009 | PROV-AFFILIATED-PROGRAMS | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1776 | PRV119 | PRV.009.119 | AFFILIATED-PROGRAM-TYPE | Affiliated Program Type | Mandatory | A code to identify the category of program that the provider is affiliated. | AFFILIATED-PROGRAM-TYPE | PRV00009 | PROV-AFFILIATED-PROGRAMS | X(1) | 5 | 52 | 52 | 1. Value must be 1 character 2. Value must be in Affiliated Program Type List (VVL) 3. Mandatory |
| 1777 | 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. | N/A | PRV00009 | PROV-AFFILIATED-PROGRAMS | X(50) | 6 | 53 | 102 | 1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1778 | 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. | N/A | PRV00009 | PROV-AFFILIATED-PROGRAMS | 9(8) | 7 | 103 | 110 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1779 | 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. | N/A | PRV00009 | PROV-AFFILIATED-PROGRAMS | 9(8) | 8 | 111 | 118 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1780 | PRV123 | PRV.009.123 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00009 | PROV-AFFILIATED-PROGRAMS | X(500) | 9 | 119 | 618 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1781 | PRV125 | PRV.010.125 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | PRV00010 | PROV-BED-TYPE-INFO | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "PRV00010" |
| 1782 | 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. | STATE | PRV00010 | PROV-BED-TYPE-INFO | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (PRV.001.007) |
| 1783 | 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. | N/A | PRV00010 | PROV-BED-TYPE-INFO | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1784 | 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. | N/A | PRV00010 | PROV-BED-TYPE-INFO | X(30) | 4 | 22 | 51 | 1. Value must be 30 characters or less 2. Mandatory |
| 1785 | PRV129 | PRV.010.129 | 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 value on a Provider Location and Contact Info (PRV.003) 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 be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. | N/A | PRV00010 | PROV-BED-TYPE-INFO | X(5) | 5 | 52 | 56 | 1. Value must be 5 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1786 | 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. | N/A | PRV00010 | PROV-BED-TYPE-INFO | 9(8) | 6 | 57 | 64 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1787 | 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. | N/A | PRV00010 | PROV-BED-TYPE-INFO | 9(8) | 7 | 65 | 72 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1788 | PRV134 | PRV.010.134 | BED-TYPE-CODE | Bed Type Code | Mandatory | A code to classify beds available at a facility. | BED-TYPE-CODE | PRV00010 | PROV-BED-TYPE-INFO | X(1) | 8 | 73 | 73 | 1. Value must be 1 character 2. Value must be in Bed Type Code List (VVL) 3. Mandatory |
| 1789 | 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. Beds should not be counted twice under different bed types. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T-MSIS Provider File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-provider-bed-information-in-the-tmsis-provider-file-provider/ |
N/A | PRV00010 | PROV-BED-TYPE-INFO | 9(5) | 9 | 74 | 78 | 1. Value must be 5 digits or less 2. Mandatory |
| 1790 | PRV136 | PRV.010.136 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | PRV00010 | PROV-BED-TYPE-INFO | X(500) | 10 | 79 | 578 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1791 | TPL001 | TPL.001.001 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | TPL00001 | FILE-HEADER-RECORD-TPL | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "TPL00001" |
| 1792 | 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. | DATA-DICTIONARY-VERSION | TPL00001 | FILE-HEADER-RECORD-TPL | X(10) | 2 | 9 | 18 | 1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 1793 | 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. | SUBMISSION-TRANSACTION-TYPE | TPL00001 | FILE-HEADER-RECORD-TPL | X(1) | 3 | 19 | 19 | 1. Value must be 1 character 2. Value must be in Subcaptitation Indicator List (VVL) 3. Mandatory |
| 1794 | TPL004 | TPL.001.004 | FILE-ENCODING-SPECIFICATION | File Encoding Specification | Mandatory | Denotes which supported file encoding standard was used to create the file. | FILE-ENCODING-SPECIFICATION | TPL00001 | FILE-HEADER-RECORD-TPL | X(3) | 4 | 20 | 22 | 1. Value must be 3 characters 2. Value must be in File Encoding Specification List (VVL) 3. Mandatory |
| 1795 | 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. | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | X(9) | 5 | 23 | 31 | 1. Value must be 9 characters or less 2. Mandatory |
| 1796 | TPL006 | TPL.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 contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | X(8) | 6 | 32 | 39 | 1. Value must equal "TPL-FILE" 2. Mandatory |
| 1797 | 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. | STATE | TPL00001 | FILE-HEADER-RECORD-TPL | X(2) | 7 | 40 | 41 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same for all records |
| 1798 | TPL008 | TPL.001.008 | DATE-FILE-CREATED | Date File Created | Mandatory | The date on which the file was created. | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | 9(8) | 8 | 42 | 49 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 1799 | 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. | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | 9(8) | 9 | 50 | 57 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be equal to or earlier than associated Date File Created 3. Value must be before associated End of Time Period 4. Mandatory 5. Value of the CC component must be "20" |
| 1800 | 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. | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | 9(8) | 10 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be equal to or earlier than associated Date File Created 4. Value must be equal to or after associated Start of Time Period 5. Mandatory |
| 1801 | 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. | FILE-STATUS-INDICATOR | TPL00001 | FILE-HEADER-RECORD-TPL | X(1) | 11 | 66 | 66 | 1. Value must be 1 character 2. For production files, value must be equal to "P" 3. Value must be in File Status Indicator List (VVL) 4. Mandatory |
| 1802 | 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 files. | SSN-INDICATOR | TPL00001 | FILE-HEADER-RECORD-TPL | X(1) | 12 | 67 | 67 | 1. Value must be 1 character 2. Value must be in SSN Indicator List (VVL) 3. Mandatory |
| 1803 | 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. | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | 9(11) | 13 | 68 | 78 | 1. Value must be 11 digits or less 2. Value must be a positive integer 3. Value must be between 0:99999999999 (inclusive) 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 1804 | TPL095 | TPL.001.095 | FILE-SUBMISSION-METHOD | File Submission Method | Mandatory | The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. | FILE-SUBMISSION-METHOD | TPL00001 | FILE-HEADER-RECORD-TPL | X(2) | 14 | 79 | 80 | 1. Value must be 2 characters 2. Value must be in File Submission Method List (VVL) 3. Mandatory |
| 1805 | 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, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | X(4) | 15 | 81 | 84 | 1. Value must be 4 characters or less 2. Value must between 1 and 9999 3. 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) 4. Value must not contain a pipe symbol 5. Mandatory |
| 1806 | TPL014 | TPL.001.014 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | TPL00001 | FILE-HEADER-RECORD-TPL | X(500) | 16 | 85 | 584 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1807 | TPL016 | TPL.002.016 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "TPL00002" |
| 1808 | 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. | STATE | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (TPL.001.007) |
| 1809 | 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. | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1810 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1811 | 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. | TPL-HEALTH-INSURANCE-COVERAGE-IND | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in TPL Health Insurance Coverage Indicator List (VVL) 4. Mandatory 5. 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 |
| 1812 | 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. | TPL-OTHER-COVERAGE-IND | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(1) | 6 | 43 | 43 | 1. Value must be 1 character 2. Value must be in TPL Other Coverage Indicator List (VVL) 3. Mandatory |
| 1813 | TPL022 | TPL.002.022 | ELIGIBLE-FIRST-NAME | Eligible First Name | Mandatory | The first name of the individual to whom the services were provided. | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(30) | 7 | 44 | 73 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1814 | 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). | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(1) | 8 | 74 | 74 | 1. Value must be 1 character 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1815 | TPL024 | TPL.002.024 | ELIGIBLE-LAST-NAME | Eligible Last Name | Mandatory | The last name of the individual to whom the services were provided. | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(30) | 9 | 75 | 104 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1816 | 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. | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | 9(8) | 10 | 105 | 112 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1817 | 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. | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | 9(8) | 11 | 113 | 120 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1818 | TPL027 | TPL.002.027 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | TPL00002 | TPL-MEDICAID-ELIGIBLE-PERSON-MAIN | X(500) | 12 | 121 | 620 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1819 | TPL029 | TPL.003.029 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "TPL00003" |
| 1820 | 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. | STATE | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (TPL.001.007) |
| 1821 | 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. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1822 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1823 | TPL033 | TPL.003.033 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Conditional | The state-assigned identification number of the Third Party Liability (TPL) Entity. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(12) | 5 | 42 | 53 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1824 | 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. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(20) | 6 | 54 | 73 | 1. Value must be 20 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 1825 | TPL035 | TPL.003.035 | GROUP-NUM | Group Number | Conditional | The group number of the TPL health insurance policy. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(16) | 7 | 74 | 89 | 1. Value must be 16 characters or less 2. Value must not contain a pipe symbol 3. Conditional |
| 1826 | TPL036 | TPL.003.036 | MEMBER-ID | Member ID | Conditional | Member identification number as it appears on the card issued by the TPL insurance carrier. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(20) | 8 | 90 | 109 | 1. Value must be 20 characters or less 2. Value must not contain a pipe symbol 3. Conditional |
| 1827 | TPL037 | TPL.003.037 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Conditional | Code to classify the type of insurance plan providing TPL coverage. | INSURANCE-PLAN-TYPE | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(2) | 9 | 110 | 111 | 1. Value must be 2 characters or less 2. Value must be in Insurance Plan Type List (VVL) 3. Conditional 4. Value must have an associated Insurance Plan ID |
| 1828 | 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. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | S9(11)V99 | 10 | 112 | 124 | 1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional |
| 1829 | TPL044 | TPL.003.044 | POLICY-OWNER-FIRST-NAME | Policy Owner First Name | Mandatory | Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(30) | 11 | 125 | 154 | 1. Value must be 30 characters or less 2. Value must not contain a pipe symbol 3. Mandatory |
| 1830 | TPL045 | TPL.003.045 | POLICY-OWNER-LAST-NAME | Policy Owner Last Name | Mandatory | Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(30) | 12 | 155 | 184 | 1. Value must be 30 characters or less 2. Value must not contain a pipe symbol 3. Mandatory |
| 1831 | 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. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(9) | 13 | 185 | 193 | 1. Value must be 9-digit number 2. For any individual, the value must be the same over all segment effective and end dates 3. Conditional |
| 1832 | 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. | POLICY-OWNER-CODE | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(2) | 14 | 194 | 195 | 1. Value must be 2 characters 2. Value must be in Policy Owner Code List (VVL) 3. Conditional |
| 1833 | 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. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | 9(8) | 15 | 196 | 203 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1834 | 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. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | 9(8) | 16 | 204 | 211 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1835 | 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. | COVERAGE-TYPE | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(2) | 17 | 212 | 213 | 1. Value must be 2 characters 2. Value must be in Coverage Type List (VVL) 3. Mandatory |
| 1836 | TPL050 | TPL.003.050 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | TPL00003 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO | X(500) | 18 | 214 | 713 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1837 | TPL052 | TPL.004.052 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "TPL00004" |
| 1838 | 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. | STATE | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (TPL.001.007) |
| 1839 | 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. | N/A | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1840 | TPL055 | TPL.004.055 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Mandatory | The state-assigned identification number of the Third Party Liability (TPL) Entity. | N/A | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(12) | 4 | 22 | 33 | 1. Mandatory 2. Value must be 12 characters or less 3. Value must not contain a pipe or asterisk symbols |
| 1841 | 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 beneficiaries' insurance card. | N/A | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(20) | 5 | 34 | 53 | 1. Value must be 20 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1842 | TPL057 | TPL.004.057 | INSURANCE-PLAN-TYPE | Insurance Plan Type | Mandatory | Code to classify the entity providing TPL coverage. | INSURANCE-PLAN-TYPE | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(2) | 6 | 54 | 55 | 1. Value must be 2 characters or less 2. Value must be in Insurance Plan Type List (VVL) 3. Mandatory 4. Value must have an associated Insurance Plan ID |
| 1843 | TPL058 | TPL.004.058 | COVERAGE-TYPE | Coverage Type | Mandatory | Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier. | COVERAGE-TYPE | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(2) | 7 | 56 | 57 | 1. Value must be 2 characters 2. Value must be in Coverage Type List (VVL) 3. Mandatory |
| 1844 | 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. | N/A | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | 9(8) | 8 | 58 | 65 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1845 | 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. | N/A | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | 9(8) | 9 | 66 | 73 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1846 | TPL061 | TPL.004.061 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | TPL00004 | TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES | X(500) | 10 | 74 | 573 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1847 | TPL063 | TPL.005.063 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "TPL00005" |
| 1848 | 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. | STATE | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (TPL.001.007) |
| 1849 | 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. | N/A | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1850 | 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. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. 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 same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | X(20) | 4 | 22 | 41 | 1. Value must be 20 characters or less 2. Mandatory |
| 1851 | TPL067 | TPL.005.067 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Type of Other TPL | 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. | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | X(1) | 5 | 42 | 42 | 1. Value must be 1 character 2. Value must be in Type of Other Third-Party Liability List (VVL) 3. Mandatory |
| 1852 | 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. | N/A | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | 9(8) | 6 | 43 | 50 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] 5. Value must occur on or before individual's Date of Death (ELG.002.025) when populated |
| 1853 | 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. | N/A | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | 9(8) | 7 | 51 | 58 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1854 | TPL070 | TPL.005.070 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | TPL00005 | TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION | X(500) | 8 | 59 | 558 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1855 | TPL072 | TPL.006.072 | RECORD-ID | Record ID | Mandatory | The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). | RECORD-ID | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(8) | 1 | 1 | 8 | 1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "TPL00006" |
| 1856 | 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. | STATE | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(2) | 2 | 9 | 10 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (TPL.001.007) |
| 1857 | 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. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | 9(11) | 3 | 11 | 21 | 1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 1858 | TPL075 | TPL.006.075 | INSURANCE-CARRIER-ID-NUM | Insurance Carrier ID Number | Mandatory | The state-assigned identification number of the Third Party Liability (TPL) Entity. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(12) | 4 | 22 | 33 | 1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 1859 | TPL076 | TPL.006.076 | TPL-ENTITY-ADDR-TYPE | TPL Entity Address Type | Mandatory | The type of address for a TPL Entity submitted in the record segment. | TPL-ENTITY-ADDR-TYPE | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(2) | 5 | 34 | 35 | 1. Value must be 2 characters 2. Value must be in TPL Entity Address Type List (VVL) 3. Mandatory |
| 1860 | TPL077 | TPL.006.077 | INSURANCE-CARRIER-ADDR-LN1 | Insurance Carrier Address Line 1 | Situational | The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(60) | 6 | 36 | 95 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Situational 5. When populated, the associated Address Type is required |
| 1861 | 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.). | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(60) | 7 | 96 | 155 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s) 3. There must be an Address Line 1 in order to have an Address Line 2 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 1862 | 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.). | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(60) | 8 | 156 | 215 | 1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s) 3. If Address Line 2 is not populated, then value should not be populated 4. Value must not contain a pipe or asterisk symbols 5. Conditional |
| 1863 | TPL080 | TPL.006.080 | INSURANCE-CARRIER-CITY | Insurance Carrier City | Situational | The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(28) | 9 | 216 | 243 | 1. Value must be 28 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1864 | TPL081 | TPL.006.081 | INSURANCE-CARRIER-STATE | Insurance Carrier State | Situational | The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the TPL Insurance carrier. | STATE | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(2) | 10 | 244 | 245 | 1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Situational |
| 1865 | TPL082 | TPL.006.082 | INSURANCE-CARRIER-ZIP-CODE | Insurance Carrier ZIP Code | Situational | The ZIP Code for the location being captured on the TPL Entity Contact Information record. | ZIP-CODE | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(9) | 11 | 246 | 254 | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Situational |
| 1866 | TPL083 | TPL.006.083 | INSURANCE-CARRIER-PHONE-NUM | Insurance Carrier Phone Number | Situational | Phone number for a given entity (e.g. person, organization, agency). | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(10) | 12 | 255 | 264 | 1. Value must be 10-digit number 2. Situational |
| 1867 | 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. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | 9(8) | 13 | 265 | 272 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 1868 | 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. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | 9(8) | 14 | 273 | 280 | 1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
| 1869 | TPL090 | TPL.006.090 | INSURANCE-CARRIER-NAIC-CODE | Insurance Carrier NAIC Code | Situational | The National Association of Insurance Commissioners (NAIC) code of the TPL Insurance carrier. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(10) | 15 | 281 | 290 | 1. Value must be 10 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1870 | TPL091 | TPL.006.091 | INSURANCE-CARRIER-NAME | Insurance Carrier Name | Situational | The name of the TPL Insurance carrier. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(30) | 16 | 291 | 320 | 1. Value must be 30 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 1871 | TPL086 | TPL.006.086 | STATE-NOTATION | State Notation | Situational | A free text field for the submitting state to enter whatever information it chooses. | N/A | TPL00006 | TPL-ENTITY-CONTACT-INFORMATION | X(500) | 17 | 321 | 820 | 1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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