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pdfT-MSIS Data Dictionary Appendices
Version: v4.0.0
v4.0.0
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Preface ......................................................................................................................................................... 3
Appendix D: Types of Service (TOS) Reference ............................................................................................ 4
Appendix E: Program Type Reference ....................................................................................................... 12
Appendix F: Eligibility Group Table ............................................................................................................ 14
Appendix P: CMS Guidance Library............................................................................................................ 32
Appendix P.01: Submitting Adjustment Claims to T-MSIS ......................................................................... 33
Appendix P.05: Populating Qualifier Fields and Their Associated Value Fields ......................................... 40
Appendix P.07: Finding Provider Roles on Standard Transactions ............................................................ 47
Appendix Q: Terms and Abbreviations ...................................................................................................... 57
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Preface
Appendices B, C, G, I, and J have been retired from the T-MSIS specifications Appendix artifact in v4.0.0 because
they were redundant to the Valid Value List (VVL) artifact. Appendices H, K, L, and P.02 have been retired from
the T-MSIS specifications Appendix artifact in v4.0.0 because they have been determined to be outdated and/or
obsolete. Appendices A, M, O, P.04, and P.06 were retired from previous versions of the T-MSIS specifications
Appendix artifact.
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Appendix D
Appendix D: Types of Service (TOS) Reference
Definitions of Types of Service
Type of Service values are predominantly defined in the Code of Federal Regulations (CFR). Clarification of the
definitions are provided below to aid in the classification of medical care and services for T-MSIS reporting
purposes. They do not modify any requirements of the Social Security Act or supersede in any way the definitions
included in the Code of Federal Regulations.
Institutional Inpatient Facility Services
1. Inpatient Hospital Services (TOS Code=001) include services referenced in the following regulatory
contexts:
Term
Description
Inpatient hospital services, other than services in an 42 CFR § 440.10
institution for mental diseases
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage.
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: Inpatient hospital services do not include nursing facility services furnished by a hospital with swing-bed
approval. However, include services provided in a psychiatric wing of a general hospital if the psychiatric wing is
not administratively separated from the general hospital.
2. Mental Health Facility Services
a. Inpatient Psychiatric Facility Services for Individuals Age 21 and Under (TOS Code=048) include services
referenced in the following regulatory contexts:
Term
Description
Inpatient psychiatric services for individuals under 42 CFR § 440.160
age 21
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent cover
42 CFR § 457.431
coverage.
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
b. Other Mental Health Facility Services (Individuals Age 65 or Older) (TOS Code= 044 and 045)
include services referenced in the following regulatory context:
Term
Description
Inpatient hospital services, nursing facility
42 CFR 440.140
services, and intermediate care facility services for
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Appendix D
Term
individuals aged 65 or older in institutions for
mental diseases
Description
3. Nursing Facilities (NF) Services (TOS Code=009 and 047) include services referenced in the following
regulatory contexts:
Term
Description
Nursing facility services for individuals aged 21 or
42 CFR § 440.40
older (other than services in an institution for mental
disease), EPSDT, and family planning services and
supplies
Nursing facility services, other than in institutions for 42 CFR § 440.155
mental diseases
NOTE: ICF Services for individuals without intellectual disabilities. This is combined with nursing facility services.
4. ICF Services for Individuals with Intellectual Disabilities (TOS Code=046) include services referenced in the
following regulatory context:
Term
Description
Intermediate care facility (ICF/IID) services
42 CFR 440.150
Institutional Outpatient Facility Services
5. Outpatient Hospital Services (TOS Code=002) include services referenced in the following regulatory
contexts:
Term
Description
Outpatient hospital services and rural health clinic
42 CFR § 440.20
services
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
Practitioner Services
6. Physicians' Services (TOS Code=012) include services referenced in the following regulatory contexts:
Term
Description
Physicians' services and medical and surgical services 42 CFR § 440.50
of a dentist.
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
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Appendix D
Secretary-approved coverage
42 CFR § 457.450
7. Dental Services (TOS Code=029) include services referenced in the following regulatory contexts:
Term
Description
Dental services
42 CFR § 440.100
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: Include services related to providing and fitting dentures as dental services. Dentures mean artificial
structures made by, or under the direction of, a dentist to replace a full or partial set of teeth. Dental services do
not include services provided as part of inpatient hospital, outpatient hospital, non-dental clinic, or laboratory
services and billed by the hospital, non-dental clinic, or laboratory or services which meet the requirements of
42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or physician under State
law).
8. Other Licensed Practitioners' Services (TOS Code=015) include services referenced in the following
regulatory contexts:
Term
Description
Medical or other remedial care provided by licensed 42 CFR § 440.60
practitioners
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: The category “Other Licensed Practitioners' Services” is different than the “Other Care” category.
Examples of other practitioners (if covered under State law) are:
• Chiropractors;
• Podiatrists;
• Psychologists; and
• Optometrists.
Other Licensed Practitioners' Services include hearing aids and eyeglasses only if they are billed directly by the
professional practitioner. If billed by a physician, they are reported as Physicians' Services. Otherwise, report
them under Other Care.
Other Licensed Practitioners' Services do not include prosthetic devices billed by physicians, laboratory or Xray services provided by other practitioners, or services of other practitioners that are included in inpatient
or outpatient hospital bills. These services are counted under the related type of service as appropriate.
Devices billed by providers not included under the listed types of service are counted under Other Care.
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Appendix D
Report Other Licensed Practitioners' Services that are billed by a hospital as inpatient or outpatient services,
as appropriate.
Speech therapists, audiologists, opticians, physical therapists, and occupational therapists are not included
within Other Licensed Practitioners' Services.
Chiropractors' services include only services that are provided by a chiropractor (who is licensed by the State)
and consist of treatment by means of manual manipulation of the spine that the chiropractor is legally
authorized by the State to perform.
9. Clinic Services (TOS Code=028) include services referenced in the following regulatory contexts:
Term
Description
Clinic services
42 CFR § 440.90
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: For reporting purposes, consider a group of physicians who share, only for mutual convenience, space,
services of support staff, etc., as physicians, rather than a clinic, even though they practice under the name of
the clinic.
Report dental clinic services as dental services.
Report any services not included above under other care. Clinic staff may include practitioners with different
specialties.
10. Laboratory and X-Ray Services (TOS Code=005, 006, 007, and 008) include services referenced in the
following regulatory contexts:
Term
Description
Other laboratory and X-ray services
42 CFR § 440.30
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: X-ray services provided by dentists are reported under dental services.
Personal Care and Home Health Services
11. Home Health Services (TOS Code=016,017, 018, 019, 020, and 021) include services referenced in the
following regulatory contexts:
Term
Description
Other laboratory and X-ray services
42 CFR § 440.70
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
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Appendix D
Existing comprehensive State-based coverage
Secretary-approved coverage
42 CFR § 457.440
42 CFR § 457.450
12. Personal Support Services
a. Personal Care Services (TOS Code=051) include services referenced in the following regulatory contexts:
Term
Description
Personal care services
42 CFR § 440.167
b. Targeted Case Management Services (TOS Code=053) include services referenced in the following
regulatory contexts:
Term
Description
Case management services
42 CFR § 440.169
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
c. Rehabilitative Services (TOS Code=043) include services referenced in the following regulatory context:
Term
Description
Diagnostic, screening, preventive, and
42 CFR 440.130
rehabilitative services
d. Physical Therapy, Occupational Therapy, and Services For Individuals with Speech, Hearing, and
Language Disorders (TOS Codes=030, 031, and 032) include services referenced in the following
regulatory contexts:
Term
Description
Physical therapy, occupational therapy, and
42 CFR § 440.110
services for individuals with speech, hearing, and
language disorders
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
e. Hospice Services (TOS Code=087) include services referenced in the following regulatory contexts:
Term
Description
Hospice care
SSA §1905(o)
Definition of child health assistance
42 CFR § 457.402
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Appendix D
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450
f.
Nurse Midwife (TOS Code=025) include services referenced in the following regulatory contexts:
Term
Description
Nurse-midwife service
42 CFR § 440.165
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
g. Nurse Practitioner (TOS Code=026) include services referenced in the following regulatory contexts:
Term
Description
Nurse practitioner services
42 CFR § 440.166
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
h. Private Duty Nursing (TOS Code=022) include services referenced in the following regulatory contexts:
Term
Description
Private duty nursing services
42 CFR § 440.80
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
i.
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Religious Non-Medical Health Care Institutions (TOS Code=058) include services referenced in the
following regulatory context:
Term
Description
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Appendix D
Any other medical care or remedial care
recognized under State law and specified by the
Secretary
42 CFR § 440.170
Other Services
13. Other Services
a. Prescribed Drugs (TOS Code=033) include services referenced in the following regulatory contexts:
Term
Description
Prescribed drugs, dentures, prosthetic devices,
42 CFR § 440.120
and eyeglasses
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent 42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
Health benefits coverage options
42 CFR § 457.410
b. Sterilizations (TOS Code=084) include services referenced in the following statutory contexts:
Term
Description
Sterilizations
42 CFR § 441, Subpart F
c. Transportation (TOS Code=056) include services referenced in the following regulatory contexts:
Term
Description
Any other medical care or remedial care
42 CFR 440.170
recognized under State law and specified by the
Secretary
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: Transportation, as defined above, is furnished only by a provider to whom a direct vendor
payment can appropriately be made. If other arrangements are made to assure transportation under
42 CFR 431.53, FFP is available as an administrative cost.
d. Other Pregnancy-related Procedures (TOS Code=086) include services referenced in the following
regulatory contexts:
Term
Description
Abortions
42 CFR Subpart E
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
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Appendix D
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450
e. Other Services – Continued (TOS Code=035, 036, 037, 062, 063, 064, 065, 066, 067, 068, 069, 073,
074, 075, 076, 077, 078, 079, 080, 081, 082, 083). These services do not meet the definitions of any
of the previously described service categories. These include, but are not limited to services
referenced in the following regulatory contexts:
Term
Description
Prescribed drugs, dentures, prosthetic devices,
42 CFR § 440.120
and eyeglasses
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
14. COVID-19 Testing includes in vitro diagnostic products for the detection of SARS–CoV–2 or the diagnosis of
the virus that causes COVID–19, and any visit for COVID–19 testing-related services for which payment may
be made under the State plan.
a. COVID-19 Testing (TOS Code=136) should be reported for any COVID-19 diagnostic product that is
administered during any portion of the emergency period, beginning March 18, 2020, to an
uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testingrelated services.
a. COVID-19 Testing-Related Services (TOS Code=137) should be reported for any COVID–19 testingrelated services provided to an uninsured individual who receives limited Medicaid coverage for
COVID-19 testing and testing-related services for which payment may be made under the State plan.
15. Medication Assisted Treatment (MAT) services and drugs for evidenced-based treatment of Opioid Use
Disorder (OUD) (TOS Code=145) include services referenced in the following regulatory context:
Term
Description
Medication-assisted treatment
SSA §1905(a)(29)
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Appendix E
Appendix E: Program Type Reference
Definitions of Program Type Reference
The following definitions describe special Medicaid/CHIP programs that are coded independently of type of
service for T-MSIS purposes. These programs tend to cover bands of services that cut across many types of service.
Program Type 01.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (See 42 CFR §
440.40(b)).
Program Type 02.
Family Planning (See 42 CFR § 440.40(c)).
Program Type 03.
Rural Health Clinics (RHC) (See 42 CFR § 440.20(b)).
Program Type 04.
Federally Qualified Health Center (FQHC) (See SSA § 1905(a)(2)).
Program Type 05.
Indian Health Services (See SSA §1911) (See 42 CFR § 431.110).
Program Type 07.
Home and Community Based Waivers (See SSA § 1915(c) and 42 CFR § 440.180).
Program Type 08.
Money Follows the Person (MFP) service package (established by Section 6071 of Deficit
Reduction Act of 2005 [Public Law 109-171] and extended by Section 2403 off the Patient
Protection and Affordable Care Act of 2010 [Public Law 111-148]).
Program Type 10.
Balancing Incentive Payments (BIP). The Balancing Incentive Program authorizes grants
to States to increase access to non-institutional long-term services and supports (LTSS) as of
October 1, 2011.
The Balancing Incentive Program will help States transform their long-term care systems by:
• Lowering costs through improved systems performance & efficiency
• Creating tools to help consumers with care planning & assessment
• Improving quality measurement & oversight
The Balancing Incentive Program also provides new ways to serve more people in home and
community-based settings, in keeping with the integration mandate of the Americans with
Disabilities Act (ADA), as required by the Olmstead decision. The Balancing Incentive Program
was created by the Affordable Care Act of 2010 (Section 10202).
Program Type 11.
Community First Choice (See SSA § 1915(k)).
Program Type 12.
Psychiatric Rehab Facility for Children. Under the authority of section 2707 of the Patient
Protection and Affordable Care Act of 2010 (Affordable Care Act), the Centers for Medicare &
Medicaid Services (CMS) is funding the Medicaid Emergency Psychiatric Demonstration, which
will be conducted by participating States. This is a 3-year Demonstration that permits
participating States to provide payment under the State Medicaid plan to certain nongovernment psychiatric hospitals for inpatient emergency psychiatric care to Medicaid recipients
aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and are
determined to be dangerous to themselves or others.
Program Type 13.
Home and Community-Based Services (HCBS) State Plan Option (See SSA § 1915(i)).
States can offer a variety of services under a State Plan Home and Community-Based Services
(HCBS) benefit. People must meet State-defined criteria based on need and typically get a
combination of acute-care medical services (like dental services, skilled nursing services) and
long-term services (like respite, case management, supported employment and environmental
modifications).
1915(i) State plan HCBS: State Options
• Target the HCBS benefit to one or more specific populations
• Establish separate additional needs-based criteria for individual HCBS
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Appendix E
•
•
Program Type 14.
•
Establish a new Medicaid eligibility group for people who get State plan HCBS
Define the HCBS included in the benefit, including State- defined and CMS-approved
“other services” applicable to the population
Option to allow any or all HCBS to be self-directed
State Plan CHIP (See 42 CRF § 457).
Program Type 15.
Psychiatric Residential Treatment Facilities Demonstration Grant Program. The
Community Alternatives to Psychiatric Residential Treatment Facilities (PRTF) Demonstration
Grant Program was authorized by Section 6063 of the Deficit Reduction Act of 2005 to provide
up to $218 million to up to 10 states to develop 5-year demonstration programs that provide
home and community-based services to children as alternatives to PRTF's. Nine states
implemented demonstration grants. These projects were designed to test the cost-effectiveness
of providing services in a child’s home or community rather than in a PRTF and whether the
services improve or maintain the child’s functioning.
Program Type 16.
SSA § 1915(j) (Self-directed personal assistance services/personal care under State
Plan or 1915(c) waiver). Self-directed personal assistance services (PAS) are personal care and
related services provided under the Medicaid State plan and/or section 1915(c) waivers the
State already has in place.
• Participation in self-directed PAS is voluntary
• Participants set their own provider qualifications and train their PAS providers
Participants determine how much they pay for a service, support or item
Program Type 17.
COVID-19 Testing Services Section 6004(a)(3) of the Families First Coronavirus
Response Act (FFCRA) added Section 1902(a)(10)(A)(ii)(XXIII) to the Social Security Act (the
Act). During any portion of the public health emergency period beginning March 18, 2020, this
provision permits states to temporarily cover uninsured individuals through an optional
Medicaid eligibility group for the limited purpose of COVID-19 testing. Such medical assistance,
as limited by clause XVIII in the text following Section 1902(a)(10)(G) of the Act, includes: in
vitro diagnostic products for the detection of SARS–CoV–2 or the diagnosis of the virus that
causes COVID–19, and any visit for COVID–19 testing-related services for which payment may
be made under the State plan. For the purposes of this eligibility group, please reference the
COVID-19 FAQs on implementation of Section 6008 of the Families First Coronavirus Response
Act and Coronavirus Aid, Relief, and Economic Security (CARES) Act for the definition of an
uninsured individual.[4] States can claim 100 percent FMAP for services provided to an
individual enrolled in the COVID-19 testing group. The 100 percent match is only available for
the testing and testing-related services provided to beneficiaries enrolled in the new COVID-19
testing group (and for related administrative expenditures).
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Appendix F
Appendix F: Eligibility Group Table
MEDICAID MANDATORY COVERAGE
Code
Eligibility Group
Short Description
Citation
01
Parents and Other
Caretaker Relatives
Parents and other
caretaker relatives of
dependent children with
household income at or
below a standard
established by the state.
42 CFR
435.110;
1902(a)(10)(A)
(i)(I); 1931(b)
and (d)
Family/Adult
Mandatory
Coverage
02
Transitional
Medical Assistance
Families with Medicaid
eligibility extended for up
to 12 months because of
earnings.
408(a)(11)(A);
1902(a)(52);
1902(e)(1)(B);
1925;
1931(c)(2)
Family/Adult
Mandatory
Coverage
03
Extended Medicaid
due to Earnings
Families with Medicaid
eligibility extended for 4
months because of
increased earnings.
42 CFR
435.112;
408(a)(11)(A);
1902 (e)(1)(A);
1931 (c)(2)
Family/Adult
Mandatory
Coverage
04
Extended Medicaid
due to Spousal
Support Collections
Families with Medicaid
eligibility extended for 4
months as the result of
the collection of spousal
support.
42 CFR
435.115;
408(a)(11)(B);
1931 (c)(1)
Family/Adult
Mandatory
Coverage
05
Pregnant Women
Women who are
pregnant or post-partum,
with household income
at or below a standard
established by the state.
42 CFR
435.116;
1902(a)(10)(A)
(i)(III) and (IV);
1902(a)(10)(A)
(ii)(I), (IV) and
(IX);
1931(b) and
(d);
Family/Adult
Mandatory
Coverage
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Type
Category
14
Appendix F
Code
Eligibility Group
Short Description
06
Deemed Newborns
Children born to women
covered under Medicaid
or a separate CHIP for
the date of the child's
birth, who are deemed
eligible for Medicaid until
the child turns age 1
42 CFR
435.117;
1902(e)(4)
and 2112€
Family/Adult
Mandatory
Coverage
07
Infants and
Children under Age
19
Infants and children
under age 19 with
household income at or
below standards
established by the state
based on age group.
42 CFR
435.118
1902(a)(10)(A)
(i)(III), (IV),
(VI) and (VII);
1902(a)(10)(A)
(ii)(IV) and
(IX); 1931(b)
and (d)
Family/Adult
Mandatory
Coverage
08
Children with Title
IV-E Adoption
Assistance, Foster
Care or
Guardianship Care
Individuals for whom an
adoption assistance
agreement is in effect or
foster care or kinship
guardianship assistance
maintenance payments
are made under Title IV-E
of the Act.
42 CFR
435.145;
473(b)(3);
1902(a)(10)(A)
(i)(I)
Family/Adult
Mandatory
Coverage
09
Former Foster Care
Children
Individuals under the age
of 26, not otherwise
mandatorily eligible, who
were in foster care and
on Medicaid either when
they turned age 18 or
aged out of foster care.
42 CFR
435.150;
1902(a)(10)(A)
(i)(IX)
Family/Adult
Mandatory
Coverage
11
Individuals
Receiving SSI
Individuals who are aged,
blind or disabled who
receive SSI.
42 CFR
435.120;
1902(a)(10)(A)
(i)(II)(aa)
ABD
Mandatory
Coverage
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Citation
Type
Category
15
Appendix F
Code
Eligibility Group
12
Aged, Blind and
Disabled Individuals
in 209(b) States
In 209(b) states, aged,
blind and disabled
individuals who meet
more restrictive criteria
than used in SSI.
42 CFR
435.121;
1902(f)
ABD
Mandatory
Coverage
13
Individuals
Receiving
Mandatory State
Supplements
Individuals receiving
mandatory State
Supplements to SSI
benefits.
42 CFR
435.130
ABD
Mandatory
Coverage
14
Individuals Who
Are Essential
Spouses
Individuals who were
eligible as essential
spouses in 1973 and who
continue be essential to
the well-being of a
recipient of cash
assistance.
42 CFR
435.131;
1905(a)
ABD
Mandatory
Coverage
15
Institutionalized
Individuals
Continuously
Eligible Since 1973
Institutionalized
individuals who were
eligible for Medicaid in
1973 as inpatients of
Title XIX medical
institutions or
intermediate care
facilities, and who
continue to meet the
1973 requirements.
42 CFR
435.132
ABD
Mandatory
Coverage
16
Blind or Disabled
Individuals Eligible
in 1973
Blind or disabled
individuals who were
eligible for Medicaid in
1973 who meet all
current requirements for
Medicaid except for the
blindness or disability
criteria.
42 CFR
435.133
ABD
Mandatory
Coverage
v4.0.0
Short Description
Citation
Type
Category
16
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
17
Individuals Who
Lost Eligibility for
SSI/SSP Due to an
Increase in OASDI
Benefits in 1972
Individuals who would be 42 CFR
eligible for SSI/SSP except 435.134
for the increase in OASDI
benefits in 1972, who
were entitled to and
receiving cash assistance
in August, 1972.
ABD
Mandatory
Coverage
18
Individuals Who
Would be Eligible
for SSI/SSP but for
OASDI COLA
increases since
April, 1977
Individuals who are
receiving OASDI and
became ineligible for
SSI/SSP after April, 1977,
who would continue to
be eligible if the cost of
living increases in OASDI
since their last month of
eligibility for
SSI/SSP/OASDI were
deducted from income.
42 CFR
435.135;
ABD
Mandatory
Coverage
19
Disabled Widows
and Widowers
Ineligible for SSI
due to Increase in
OASDI
Disabled widows and
widowers who would be
eligible for SSI /SSP,
except for the increase in
OASDI benefits due to
the elimination of the
reduction factor in P.L.
98-21, who therefore are
deemed to be SSI or SSP
recipients.
42 CFR
435.137;
1634(b)
ABD
Mandatory
Coverage
v4.0.0
17
Appendix F
Code
Eligibility Group
Short Description
20
Disabled Widows
and Widowers
Ineligible for SSI
due to Early Receipt
of Social Security
Disabled widows and
widowers who would be
eligible for SSI/SSP,
except for the early
receipt of OASDI
benefits, who are not
entitled to Medicare Part
A, who therefore are
deemed to be SSI
recipients.
42 CFR
435.138;
1634(d)
ABD
Mandatory
Coverage
21
Working Disabled
under 1619(b)
Blind or disabled
individuals who
participated in Medicaid
as SSI cash recipients or
who were considered to
be receiving SSI, who
would still qualify for SSI
except for earnings.
1619(b);
1902(a)(10)(A)
(i)(II)(bb);
1905(q)
ABD
Mandatory
Coverage
22
Disabled Adult
Children
Individuals who lose
eligibility for SSI at age 18
or older due to receipt of
or increase in Title II
OASDI child benefits.
1634(c)
ABD
Mandatory
Coverage
23
Qualified Medicare
Beneficiaries
Individuals with income
equal to or less than
100% of the FPL who are
entitled to Medicare Part
A, who qualify for
Medicare cost-sharing.
1902(a)(10)(E)
(i);
ABD
Mandatory
Coverage
v4.0.0
Citation
Type
Category
1905(p)
18
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
24
Qualified Disabled
and Working
Individuals
Working, disabled
individuals with income
equal to or less than
200% of the FPL, who are
entitled to Medicare Part
A under section 1818A,
who qualify for payment
of Medicare Part A
premiums.
1902(a)(10)(E)
(ii);
1905(p)(3)(A)(
i); 1905(s)
ABD
Mandatory
Coverage
25
Specified Low
Income Medicare
Beneficiaries
Individuals with income
between 100% and 120%
of the FPL who are
entitled to Medicare Part
A, who qualify for
payment of Medicare
Part B premiums.
1902(a)(10)(E)
(iii);
1905(p)(3)(A)(
ii)
ABD
Mandatory
Coverage
26
Qualifying
Individuals
Individuals with income
between 120% and 135%
of the FPL who are
entitled to Medicare Part
A, who qualify for
payment of Medicare
Part B premiums.
1902(a)(10)(E)
(iv);
1905(p)(3)(A)(
ii)
ABD
Mandatory
Coverage
MEDICAID OPTIONS FOR COVERAGE
Code
27
v4.0.0
Eligibility Group
Optional Coverage
of Parents and
Other Caretaker
Relatives
Short Description
Citation
Individuals qualifying as
parents or caretaker
relatives who are not
mandatorily eligible and
who have income at or
below a standard
established by the State.
42 CFR
435.220;
1902(a)(10)(A)
(ii)(I)
Type
Family/Adult
Category
Options for
Coverage
19
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
28
Reasonable
Classifications of
Individuals under
Age 21
Individuals under age 21
who are not mandatorily
eligible and who have
income at or below a
standard established by
the State.
42 CFR
435.222;
1902(a)(10)(A)
(ii)(I) and (IV)
Family/Adult
Options for
Coverage
29
Children with NonIV-E Adoption
Assistance
Children with special
needs for whom there is
a non-IV-E adoption
assistance agreement in
effect with a state, who
either were eligible for
Medicaid or had income
at or below a standard
established by the state.
42 CFR
435.227;
1902(a)(10)(A)
(ii)(VIII);
Family/Adult
Options for
Coverage
30
Independent Foster
Care Adolescents
Individuals under an age
specified by the State,
less than age 21, who
were in State-sponsored
foster care on their 18th
birthday and who meet
the income standard
established by the State.
42 CFR
435.226;
1902(a)(10)(A)
(ii)(XVII)
Family/Adult
Options for
Coverage
31
Optional Targeted
Low Income
Children
Uninsured children who
meet the definition of
optional targeted low
income children at 42
CFR 435.4, who have
household income at or
below a standard
established by the State.
42 CFR
435.229 and
435.4;
1902(a)(10)(A)
(ii)(XIV);
1905(u)(2)(B)
Family/Adult
Options for
Coverage
32
Individuals Electing
COBRA
Continuation
Coverage
Individuals choosing to
continue COBRA benefits
with income equal to or
less than 100% of the
FPL.
1902(a)(10)(F)
; 1902(u)(1)
Family/Adult
Options for
Coverage
v4.0.0
20
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
33
Individuals above
133% FPL under
Age 65
Individuals under 65, not
otherwise mandatorily or
optionally eligible, with
income above 133% FPL
and at or below a
standard established by
the State.
CFR 435.218;
1902(hh);
1902(a)(10)(A)
(ii)(XX)
Family/Adult
Options for
Coverage
34
Certain Individuals
Needing Treatment
for Breast or
Cervical Cancer
Individuals under the age
of 65 who have been
screened for breast or
cervical cancer and need
treatment.
42 CFR
435.213;
1902(a)(10)(A)
(ii)(XVIII);
1902(aa)
Family/Adult
Options for
Coverage
35
Individuals Eligible
for Family Planning
Services
Individuals who are not
pregnant, with income
equal to or below the
highest standard for
pregnant women, as
specified by the State,
limited to family planning
and related services.
42 CFR
435.214;
1902(a)(10)(A)
(ii)(XXI)
Family/Adult
Options for
Coverage
36
Individuals with
Tuberculosis
Individuals infected with
tuberculosis whose
income does not exceed
established standards,
limited to tuberculosisrelated services.
42 CFR
435.215;
1902(a)(10)(A)
(ii)(XII);
1902(z)
Family/Adult
Options for
Coverage
37
Aged, Blind or
Disabled Individuals
Eligible for but Not
Receiving Cash
Assistance
Individuals who meet the
requirements of SSI or
Optional State
Supplement, but who do
not receive cash.
42 CFR
435.210 &
230;
1902(a)(10)(A)
(ii)(I);
ABD
Options for
Coverage
v4.0.0
21
Appendix F
Code
Eligibility Group
Short Description
Citation
38
Individuals Eligible
for Cash Assistance
except for
Institutionalization
Individuals who meet the
requirements of AFDC,
SSI or Optional State
Supplement, and would
be eligible if they were
not living in a medical
institution.
42 CFR
435.211;
1902(a)(10)(A)
(ii)(IV);
ABD
Options for
Coverage
39
Individuals
Receiving Home
and Community
Based Services
under Institutional
Rules
Individuals who would be
eligible for Medicaid
under the State Plan if in
a medical institution,
who would live in an
institution if they did not
receive home and
community based
services.
42 CFR
435.217;
1902(a)(10)(A)
(ii)(VI)
ABD
Options for
Coverage
40
Optional State
Supplement
Recipients - 1634
States, and SSI
Criteria States with
1616 Agreements
Individuals in 1634 States
and in SSI Criteria States
with agreements under
1616, who receive a state
supplementary payment
(but not SSI).
42 CFR
435.232;
1902(a)(10)(A)
(ii)(IV)
ABD
Options for
Coverage
41
Optional State
Supplement
Recipients - 209(b)
States, and SSI
Criteria States
without 1616
Agreements
Individuals in 209(b)
States and in SSI Criteria
States without
agreements under 1616,
who receive a state
supplementary payment
(but not SSI).
42 CFR
435.234;
1902(a)(10)(A)
(ii)(XI)
ABD
Options for
Coverage
42
Institutionalized
Individuals Eligible
under a Special
Income Level
Individuals who are in
institutions for at least 30
consecutive days who are
eligible under a special
income level.
42 CFR
435.236;
1902(a)(10)(A)
(ii)(V)
ABD
Options for
Coverage
v4.0.0
Type
Category
22
Appendix F
Code
Eligibility Group
Short Description
43
Individuals
participating in a
PACE Program
under Institutional
Rules
Individuals who would be
eligible for Medicaid
under the State Plan if in
a medical institution,
who would require
institutionalization if they
did not participate in the
PACE program.
1934
ABD
Options for
Coverage
44
Individuals
Receiving Hospice
Care
Individuals who would be
eligible for Medicaid
under the State Plan if
they were in a medical
institution, who are
terminally ill, and who
will receive hospice care.
1902(a)(10)(A)
(ii)(VII);
1905(o)
ABD
Options for
Coverage
45
Qualified Disabled
Children under Age
19
Certain children under 19
living at home, who are
disabled and would be
eligible if they were living
in a medical institution.
1902(e)(3)
ABD
Options for
Coverage
46
Poverty Level Aged
or Disabled
Individuals who are aged
or disabled with income
equal to or less than a
percentage of the FPL,
established by the state
(no higher than 100%).
1902(a)(10)(A)
(ii)(X);
1902(m)(1)
ABD
Options for
Coverage
47
Work Incentives
Eligibility Group
Individuals with a
disability with income
below 250% of the FPL,
who would qualify for SSI
except for earned
income.
1902(a)(10)(A)
(ii)(XIII)
ABD
Options for
Coverage
v4.0.0
Citation
Type
Category
23
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
48
Ticket to Work
Basic Group
Individuals with earned
income between ages 16
and 64 with a disability,
with income and
resources equal to or
below a standard
specified by the State.
1902(a)(10)(A)
(ii)(XV)
ABD
Options for
Coverage
49
Ticket to Work
Medical
Improvements
Group
Individuals with earned
1902(a)(10)(A)
income between ages 16 (ii)(XVI)
and 64 who are no longer
disabled but still have a
medical impairment, with
income and resources
equal to or below a
standard specified by the
State.
ABD
Options for
Coverage
50
Family Opportunity
Act Children with
Disabilities
Children under 19 who
1902(a)(10)(A)
are disabled, with income (ii)(XIX);
equal to or less than a
1902(cc)(1)
standard specified by the
State (no higher than
300% of the FPL).
ABD
Options for
Coverage
51
Individuals Eligible
for Home and
Community-Based
Services
Individuals with income
equal to or below 150%
of the FPL, who qualify
for home and community
based services without a
determination that they
would otherwise live in
an institution.
ABD
Options for
Coverage
v4.0.0
1902(a)(10)(A)
(ii)(XXII);
1915(i)
24
Appendix F
Code
52
*721
Eligibility Group
Short Description
Citation
Type
Category
Individuals Eligible
for Home and
Community-Based
Services - Special
Income Level
Individuals with income
equal to or below 300%
of the SSI federal benefit
rate, who meet the
eligibility requirements
for a waiver approved for
the State under 1915(c),
(d) or (e), or 1115.
1902(a)(10)(A)
(ii)(XXII);
1915(i)
ABD
Options for
Coverage
Adult Group Individuals at or
below 133% FPL
Age 19 through 64 newly eligible for all
states
Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.
42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)
Family/Adult
Mandatory
Coverage
1
ACA Medicaid expansion for childless adults (represented in T-MSIS by ELIGIBILITY-GROUP valid values "72" through "75")
are still technically characterized as mandatory eligibility groups by Subsection 1902(a)(10)(A) of the Social Security Act
(SSA) despite the U.S. Supreme Court ruling (National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012))
which ruled that states could not be required to offer such coverage. Therefore, some states may not report any of the
Medicaid expansion groups to T-MSIS if these groups are not applicable to a particular state.
v4.0.0
25
Appendix F
Code
Eligibility Group
Short Description
Citation
*732
Adult Group Individuals at or
below 133% FPL
Age 19 through 64not newly eligible
for non 1905z(3)
states
Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.
42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)
1905z(3)
Family/Adult
Mandatory
Coverage
*741
Adult Group Individuals at or
below 133% FPL
Age 19 through 64
– not newly eligible
parent/ caretakerrelative(s) in
1905z(3) states
Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.
42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)
Family/Adult
Mandatory
Coverage
Adult Group Individuals at or
below 133% FPL
Age 19 through 64not newly eligible
non-parent/
caretakerrelative(s) in
1905z(3) states
Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.
42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)
Family/Adult
Mandatory
Coverage
*751
Type
Category
1905z(3)
1905z(3)
2
ACA Medicaid expansion for childless adults (represented in T-MSIS by ELIGIBILITY-GROUP valid values "72" through "75")
are still technically characterized as mandatory eligibility groups by Subsection 1902(a)(10)(A) of the Social Security Act
(SSA) despite the U.S. Supreme Court ruling (National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012))
which ruled that states could not be required to offer such coverage. Therefore, some states may not report any of the
Medicaid expansion groups to T-MSIS if these groups are not applicable to a particular state.
v4.0.0
26
Appendix F
Code
76
Eligibility Group
Uninsured
Individual eligible
for COVID-19
testing
Short Description
Uninsured individuals
who are eligible for
medical assistance for
COVID-19 diagnostic
products and any visit
described as a COVID–19
testing-related service
for which payment may
be made under the State
plan during any portion
of the public health
emergency period,
beginning March 18,
2020.
Citation
1902(a)(10)
(A)(ii)(XXIII)
Type
Family/Adult
Category
Optional
MEDICAID MEDICALLY NEEDY
Code
Eligibility Group
Short Description
Citation
Type
Category
53
Medically Needy
Pregnant Women
Women who are
pregnant, who would
qualify as categorically
needy, except for
income.
42 CFR
435.301(b)(1)(
i) and (iv);
1902(a)(10)(C)
(ii)(II)
Family/Adult
Medically
Needy
54
Medically Needy
Children under Age
18
Children under 18 who
would qualify as
categorically needy,
except for income.
42 CFR
435.301(b)(1)(
ii);
1902(a)(10)(C)
(ii)(II)
Family/Adult
Medically
Needy
55
Medically Needy
Children Age 18
through 20
Children over 18 and
under an age established
by the State (less than
age 21), who would
qualify as categorically
needy, except for
income.
42 CFR
435.308;
1902(a)(10)(C)
(ii)(II)
Family/Adult
Medically
Needy
v4.0.0
27
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
56
Medically Needy
Parents and Other
Caretakers
Parents and other
caretaker relatives of
dependent children,
eligible as categorically
needy except for income.
42 CFR
435.310
Family/Adult
Medically
Needy
59
Medically Needy
Aged, Blind or
Disabled
Individuals who are age
65 or older, blind or
disabled, who are not
eligible as categorically
needy, who meet income
and resource standards
specified by the State, or
who meet the income
standard using medical
and remedial care
expenses to offset excess
income.
42 CFR
435.320,
435.322,
435.324, and
435.330;
1902(a)(10)(C)
ABD
Medically
Needy
60
Medically Needy
Blind or Disabled
Individuals Eligible
in 1973
Blind or disabled
individuals who were
eligible for Medicaid as
Medically Needy in 1973
who meet all current
requirements for
Medicaid except for the
blindness or disability
criteria.
42 CFR
435.340
ABD
Medically
Needy
CHIP COVERAGE
Code
61
v4.0.0
Eligibility Group
Targeted LowIncome Children
Short Description
Citation
Uninsured children under
age 19 who do not have
access to public
employee coverage and
whose household income
is within standards
established by the state.
42 CFR
457.310;
2102(b)(1)(B)(
v)
Type
Children
Category
Optional
28
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
62
Deemed Newborn
Children born to targeted
low-income pregnant
women who are deemed
eligible for CHIP or
Medicaid for one year.
2112(e)
Children
Optional
63
Children Ineligible
for Medicaid Due
to Loss of Income
Disregards
Children determined to
be ineligible for Medicaid
as a result of the
elimination of income
disregards under the
MAGI income
methodology.
42 CFR
457.340(d)
Section
2101(f) of the
ACA
Children
Mandatory
CHIP ADDITIONAL OPTIONS FOR COVERAGE
Code
Eligibility Group
Short Description
Citation
Type
Category
64
Coverage from
Conception to
Birth
Uninsured children from
conception to birth who
do not have access to
public employee
coverage and whose
household income is
within standards
established by the state.
42 CFR
457.310
2102(b)(1)(B)(
v)
Children
Option for
Coverage
65
Children with
Access to Public
Employee
Coverage
Uninsured children under
age 19 having access to
public employee
coverage and whose
household income is
within standards
established by the state.
2110(b)(2)(B)
and (b)(6)
Children
Option for
Coverage
v4.0.0
29
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
66
Children Eligible
for Dental Only
Supplemental
Coverage
Children who are
otherwise eligible for
CHIP but for the fact that
they are enrolled in a
group health plan or
health insurance offered
through an employer.
Coverage is limited to
dental services.
2110(b)(5)
Children
Option for
Coverage
67
Targeted LowIncome Pregnant
Women
Uninsured pregnant
women who do not have
access to public
employee coverage and
whose household income
is within standards
established by the state.
2112
Pregnant
Women
Option for
Coverage
68
Pregnant Women
with Access to
Public Employee
Coverage
Uninsured pregnant
women having access to
public employee
coverage and whose
household income is
within standards
established by the state.
2110(b)(2)(B)
and (b)(6)
Pregnant
Women
Option for
Coverage
1115 EXPANSION ELIGIBILITY GROUPS
v4.0.0
30
Appendix F
Code
Eligibility Group
Short Description
Citation
Type
Category
69
Individuals with
Mental Health
Conditions
(expansion group)
Individuals with mental
health conditions who do
not qualify for Medicaid
due to the severity or
duration of their
disability or due to other
eligibility factors; and/or
those who are otherwise
eligible but require
benefits or services that
are not comparable to
those provided to other
Medicaid beneficiaries.
1115
expansion
N/A
N/A
70
Family Planning
Participants
(expansion group)
Individuals of child
bearing age who require
family planning services
and supplies and for
which the state does not
choose to, or cannot
provide, optional
eligibility coverage under
the Individuals Eligible
for Family Planning
Services eligibility group
(1902(a)(10)(A)(ii)(XXI)).
1115
expansion
N/A
N/A
71
Other expansion
group
Individuals who do not
qualify for Medicaid or
CHIP under a mandatory
eligibility or coverage
group and for whom the
state chooses to provide
eligibility and/or benefits
in a manner not
permitted by title XIX or
XXI of the Social Security
Act.
1115
expansion
N/A
N/A
v4.0.0
31
Appendix P
Appendix P: CMS Guidance Library
v4.0.0
32
Appendix P.01
Appendix P.01: Submitting Adjustment Claims to T-MSIS
Brief Issue Description
There are two ways original claims, and their subsequent adjustments can be linked into a claim family – either
through all adjustments linking back to the original claim or each subsequent adjustment linking back to the
prior claim (i.e., “daisy chain”). Identifying the members of a claim family is necessary to evaluate the changes to
a claim that occur throughout its life.
Background Discussion
Before delving into CMS’ guidance on how to populate the ICN-ORIG and ICN-ADJ fields, some background
discussion is needed on terminology and concepts.
What claim transactions should be submitted to T-MSIS?
Every “final adjudicated version of the claim/encounter” should be submitted to T-MSIS.
A “final adjudicated version of the claim/encounter” is a claim that has completed the adjudication process and
the paid/denied process. The claim and each claim line will have one of the finalized claim status categories
listed in Table 1, below. The actual disposition of the claim can be either “paid” or “denied.”
Table 1: Finalized Claim Status Categories
Code Finalized Claim Status Category Description
F0
Finalized-The encounter has completed the adjudication cycle and no more action will
be taken. (Used on encounter records)
F1
Finalized/Payment-The claim/line has been paid.
F2
Finalized/Denial-The claim/line has been denied.
F3
Finalized/Revised - Adjudication information has been changed.
Both original claims (or encounters) and adjusted claims (or encounters) can be a “final adjudicated version of
the claim/encounter.” Whenever a claim/encounter flows through the adjudication and payment processes (if
applicable) and falls into one of the claim status categories in Table 1, the state should send the claim/encounter
to T-MSIS.
If a claim flows through the adjudication and payment processes and falls into one of the finalized claim status
categories multiple times within a single T-MSIS reporting period, CMS expects each of these final adjudicated
versions of the claim/encounter to be submitted to T-MSIS, not just the one effective on the last day of the
reporting period.
If the claim has not been through the final adjudication process or is “pending” (or in “suspense”), the claim
should not be sent to T-MSIS until disposition has been settled to one of the finalized claim status categories.
Table 2 provides examples and CMS’ expectations.
v4.0.0
33
Appendix P.01
Table 2: Scenarios for When to Submit Claims
Claim Submission Scenario
CMS’ Expectation
Adjudicated and paid in the same
reporting month
CMS expects the claim to be sent to T-MSIS in the reporting month.
Adjudicated in one reporting
period, but paid in another
reporting month
CMS expects the claim to be sent to T-MSIS in the month that the claim was paid.
Adjudicated and paid in one
reporting month, and then readjudicated and paid in a
subsequent month
The claim should be reported in the month it is paid, regardless of whether it is an
original claim or an adjustment. Therefore, in this scenario, CMS expects the original to
be reported in month one and the adjustment to be reported in the subsequent
month.
Adjudicated and paid, and then readjudicated and paid in the same
reporting month
In this scenario, if a claim flows through the adjudication and payment processes and
falls into one of the claim status categories in Table 1 multiple times within a single TMSIS reporting period, CMS expects each of these final adjudicated versions of the
claim/encounter to be submitted to T-MSIS, not just the one effective on the last day
of the reporting period.
Re-adjudicated and paid multiple
times in the same reporting month
In this scenario, if a claim flows through the adjudication and payment processes and
falls into one of the claim status categories in Table 1 multiple times within a single TMSIS reporting period, CMS expects each of these final adjudicated versions of the
claim/encounter to be submitted to T-MSIS, not just the one effective on the last day
of the reporting period.
What is a claim family?
A “claim family” (a.k.a. “adjustment set”) is defined as a set of post-adjudication claim transactions in paid or
denied status that relate to the same provider/enrollee/services/dates of service. This grouping of the original
claim and all its subsequent adjustment and/or void claims shows the progression of changes that have occurred
since it was first submitted.
Are gross adjustments considered claims/encounters?
While the gross adjustment adjudication indicator codes (values “5” and “6” in Table 3) are reported to T-MSIS
in the CLAIM-OT file, they are not technically “claims” or “encounters.” Each of these transactions does not
relate to a specific service-provider/enrollee episode of care. Instead, these transactions represent payments
made by the state for services rendered to multiple enrollees (as in the case of a provider providing screening
services for a group of enrollees), DSH payments, or a recoupment of funds previously dispensed in a debit gross
adjustment. Therefore, the concept of “claims family” does not apply. Each of these transactions stands on its
own and does not constitute a subsequent transaction being a replacement of the earlier transaction.
Refer to T-MSIS Coding Blog entry “Reporting Adjustment Indicator (ADJUSTMENT-IND) for Financial
Transactions (Claims)” for additional detailed information.
What alternatives are there for tying the members of a claim family together?
The Original ICN Approach
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Appendix P.01
Under this approach, the state assigns an ICN to the initial final adjudicated version of the claim/encounter and
records this identifier in the ICN-ORIG field. If adjustment claims subsequently are created, the ICN assigned to
the initial final adjudicated version of the claim/encounter is carried forward on every subsequent adjustment
claim. Table 3 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated
when the original ICN approach is used.
Table 3: ICN-ORIG/ICN-ADJ Relationships Under the Original ICN Approach
Event
ADJUDICATIONDATE
ICNORIG
ICNADJ
ADJUSTMENT
-IND
On 5/1/2014, the state completes the adjudication process on
the initial version of the claim
5/1/2014
1
-
0
On 7/15/2014, the state completes a claim re-adjudication /
adjustment
7/15/2014
1
2
4
On 8/12/2014, the state completes a 2nd claim re-adjudication /
adjustment
8/12/2014
1
3
4
On 9/5/2014, the state completes a 3rd claim re-adjudication /
adjustment
9/5/2014
1
4
4
The Daisy-Chain ICN Approach
Under this approach, the state records the ICN of the previous final adjudicated version of the claim/encounter
in the ICN-ORIG field of the adjustment claim record. If additional adjustment claims are subsequently created,
the ICN-ORIG on the new adjustment claim only points back one generation. Table 4 illustrates how the ICNORIG and ICN-ADJ values on the members of a claim family are populated when the daisy-chain ICN approach is
used.
Table 4: ICN-ORIG/ICN-ADJ Relationships Under the Daisy-Chain ICN Approach
Event
ADJUDICATIONDATE
ICNORIG
ICNADJ
ADJUSTMENT
-IND
On 6/1/2014, the state completes the adjudication process on
the initial version of the claim
6/1/2014
11
-
0
On 8/15/2014, the state completes a claim readjudication/adjustment
8/15/2014
11
12
4
On 9/12/2014, the state completes a 2nd claim readjudication/adjustment
9/12/2014
12
13
4
On 10/5/2014, the state completes a 3rd claim readjudication/adjustment
10/5/2014
13
14
4
How are ICN-ORIG and ICN-ADJ fields impacted when voids are submitted?
The primary purpose of void transactions (ADJUSTMENT-IND = 1) is to nullify a claim/encounter from T-MSIS
when the state does not wish to replace it with an adjusted claim/encounter record. These records must have
v4.0.0
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Appendix P.01
the same claim key data element values as the claim/encounter being voided. Dollar and quantity fields should
be set to zero. The ADJUDICATION-DATE on these records should be set to the date that the state voided the
claim.
Refer to T-MSIS Coding Blog entry “Populating T-MSIS Claims File Data Elements on Void/Reversal/Cancel
Records” for additional detailed information.
Table 5 illustrates an example of how the dollar and quantity fields on the members of a claim family are
populated when the state wishes to void a claim.
Table 5: ICN-ORIG/ICN-ADJ – Impact of Voids
Event
ADJUDICATIONDATE
ICNORIG
ICNADJ
ADJUSTMENT
-IND
Dollar
Fields
Quantity
Fields
On 6/1/2014, the state completes the
adjudication process on the initial
version of the claim
6/1/2014
51
-
0
100.00
5
On 8/15/2014, the state completes a
claim re-adjudication/adjustment
8/15/2014
51
52
4
80.00
5
On 8/19/2014, the claim is voided
8/19/2014
51
52
1
0.00
0
If a state uses a process to record adjustments whereby, they void the previous version of the claim and then
follow-up with the creation of a new original transaction, and the state can identify that the void and the new
original claim are from the same adjudication set, the state should link them together into one claims family
using the ICN-ORIG. CMS recognizes that some states may not be able to link a resubmitted claim after a void to
the original claim. Table 6 illustrates how CMS is expecting the states to populate the ICN-ORIG/ICN-ADJ fields
when the state processes a void/new original when adjusting claims.
Table 6: ICN-ORIG/ICN-ADJ – Keeping the Claim Family Intact When the “Void/New Original” Scenario Occurs
Event
ADJUDICATIONICNICN- ADJUSTMENT
Dollar
DATE
ORIG
ADJ
-IND
Fields
Quantity
Fields
On 6/1/2014, the state completes the
adjudication process on the initial
version of the claim
6/1/2014
51
-
0
100.00
5
On 8/15/2014, the state completes the
adjudication process of a void and
associated new original
8/15/2014
51
-
1
0.00
0
On 8/15/2014, the state completes the
adjudication process of a void and
associated new original
8/15/2014
51
-
0
80.00
5
v4.0.0
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Appendix P.01
Event
ADJUDICATIONDATE
ICNORIG
ICNADJ
ADJUSTMENT
-IND
Dollar
Fields
Quantity
Fields
On 9/20/2014, the state completes the
adjudication process of a void and
associated new original
9/20/2014
51
-
1
0.00
0
On 9/20/2014, the state completes the
adjudication process of a void and
associated new original
9/20/2014
51
-
0
60.00
5
How Adjustment Records will be Applied by CMS
There is an inherent limitation in the way that CMS can interpret what to do with two claim transactions having
the same ICN-ORIG and ADJUDICATION-DATE when both transactions are received in a single submission file.
The processing rules that T-MSIS will follow are outlined below. It is up to each state to assure that claim
transactions are processed in the appropriate sequence. If the rules below do not result in the sequence of
transactions that the state desires, it is up to the state to submit transactions in separate files so that the desired
sequence is attained.
Rules for inserting claim transactions into the T-MSIS database
When two or more claim transactions with the same ICN-ORIG and ADJUDICATION-DATE are in the same
submission file
If two or more transactions in an incoming claim file have the same ICN-ORIG and ADJUDICATION-DATE values,
T-MSIS will evaluate the ADJUSTMENT-IND values and insert the transactions into the T-MSIS database as
follows:
1.
If more than two transactions in the incoming claim file have the same ICN-ORIG and
ADJUDICATION-DATE values, then T-MSIS will reject all the incoming transactions.
2.
If the ADJUSTMENT-IND values of both incoming transactions are the same (but not ‘5’ or ‘6’), then
T-MSIS will reject both incoming transactions.
3.
If the ADJUSTMENT-IND values of both incoming transactions are some combination of ‘5’ and ‘6’
and if there is no active existing transaction in the T-MSIS DB, then T-MSIS will insert both incoming
transactions into the T-MSIS DB (note, since neither transaction supersedes the other, the order in
which they are inserted does not matter).
4.
If the ADJUSTMENT-IND values of both incoming transactions are some combination of ‘5’ and ‘6’
and if there is an active existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘5’
or ‘6’, then T-MSIS will insert both incoming transactions into the T-MSIS DB (note, since neither
transaction supersedes the other, the order in which they are inserted does not matter).
5.
If the ADJUSTMENT-IND values of both incoming transactions is a ‘5’ or ‘6’ and if there is an active
existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘0’, ‘1’, or ‘4’, then T-MSIS
will reject both the incoming transactions.
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Appendix P.01
6.
If the ADJUSTMENT-IND value of one incoming transaction is a ‘5’ or ‘6’ and the ADJUSTMENT-IND
of the other transaction is ‘0’, ‘1’, or ‘4’ and if there is an active existing transaction in the T-MSIS DB
with an ADJUSTMENT-IND value of ‘5’ or ‘6’, then T-MSIS will insert the incoming transaction with
ADJUDICATION-IND of ‘5’ or ‘6’ and reject the incoming transaction with ADJUSTMENT-IND value ‘0’,
‘1’, or ‘4’.
7.
If the ADJUSTMENT-IND value of one incoming transaction is a ‘5’ or ‘6’ and the ADJUSTMENT-IND
of the other transaction is ‘0’, ‘1’, or ‘4’ and there is an active existing transaction in the T-MSIS DB
with an ADJUSTMENT-IND value of ‘0’, ‘1’, or ‘4’, then T-MSIS will reject the incoming transaction
with ADJUSTMENT-IND value ‘5’ or ‘6’ and evaluate the remaining incoming transaction as follows:
a. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the
active existing transaction is ‘0’, then T-MSIS will reject the incoming transaction.
b. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the
active existing transaction is ‘1’, then T-MSIS will insert the incoming transaction.
c. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the
active existing transaction is ‘4’, then T-MSIS will reject the incoming transaction.
d. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
active existing transaction is ‘0’, then T-MSIS will insert the incoming transaction.
e. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
active existing transaction is ‘1’, then T-MSIS will reject the incoming transaction.
f.
ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
active existing transaction is ‘4’, then T-MSIS will insert the incoming transaction.
g. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the
active existing transaction is ‘0’, then T-MSIS will insert the incoming transaction.
h. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the
active existing transaction is ‘1’, then T-MSIS will insert the incoming transaction.
i.
ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the
active existing transaction is ‘4’, then T-MSIS will insert the incoming transaction.
8.
If the ADJUSTMENT-IND value of one incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
other transaction is ‘0’ or ‘4’ and the ADJUSTMENT-IND of the active existing transaction in the TMSIS DB is ‘0’ or ‘4’, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND = ‘1’
first, and then insert the other transaction.
9.
If the ADJUSTMENT-IND value of one incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
other transaction is ‘0’ or ‘4’ and the ADJUSTMENT-IND of the active transaction in the T-MSIS DB is
‘1’, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND value of ‘0’ or ‘4’ first
and then insert the incoming transaction with ADJUSTMENT-IND = ‘1’.
10.
If the ADJUSTMENT-IND value of one incoming transaction is ‘0’ and the ADJUSTMENT-IND value of
the other incoming transaction is ‘4’ and there is no active existing transaction in the T-MSIS DB,
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Appendix P.01
then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND value of ‘0’ first and then
insert the incoming transaction with ADJUSTMENT-IND = ‘4’.
11.
If any other combination of ADJUSTMENT-IND values occurs, then T-MSIS will reject all the
transactions.
CMS Guidance
The state can use either the original ICN approach or the daisy-chain ICN approach to populate the ICN-ORIG
field on each member of the claims family. T-MSIS will group claim transactions into claim families as part of the
ETL process.
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Appendix P.05
Appendix P.05: Populating Qualifier Fields and Their Associated
Value Fields
Brief Issue Description
The purpose of this guidance document is to when record segments need to be created for all valid values in a
qualifier field’s valid value set and when it is appropriate to create a record segment for only one of the valid
values.
Background Discussion
Definitions
Simple Qualifier Field – is a data element that contains a code (a.k.a. “flag”) that defines/qualifies the coding
schema used when populating a set of corresponding data elements. This is necessary because there are several
different schemas that a state could use and it needs to be clear which of the schemas is actually used.
Examples of “simple qualifier fields” are the DIAGNOSIS-CODE-FLAG-1 through -12 on the CLAIM-HEADERRECORD-IP record segment (CIP00002). The valid value set for these fields is:
1 ICD-9
2 ICD-10
3 Other
The state would indicate which coding schema is being used to populate the corresponding data elements
DIAGNOSIS-CODE-1 through -12.
Complex Qualifier Field – is a data element that not only defines/qualifies the contents of its corresponding
data elements (similar to a “simple qualifier field”), but also represents a situation where the state needs to
create a record segment for each valid value that applies to the record’s subject.
An example of a “complex qualifier field is LICENSE-TYPE on the PROV-LICENSING-INFO record segment
(PRV00004). The valid value set for this field is:
1. State, county, or municipality professional or business license
2. DEA license
3. Professional society accreditation
4. CLIA accreditation
5. Other
The state would create a PROV-LICENSING-INFO record segment and populate the corresponding data elements
for each LICENSE-TYPE valid value that applies to the provider.
Corresponding Data Elements – Are data elements that contain values as defined by the qualifier field.
Fully Populated Record Segment – Means that all data elements in the record segment will be populated, not
just the qualifier field and its corresponding data elements. These additional data elements are necessary to
enable CMS to tie the record segment to its parent segment. These data elements comprise the segment’s
natural key. Generally these data elements are the ones bulleted below, but there could potentially be
additional ones, depending on the record segment. See the “Record Keys & Constraints” tab in the T-MSIS Data
Dictionary if there are questions concerning a record segment’s natural key.
v4.0.0
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Appendix P.05
•
•
•
•
RECORD-ID
SUBMITTING-STATE
RECORD-NUMBER
MSIS-IDENTIFICATION-NUM / STATE-PLAN-ID-NUM / SUBMITTING-STATE-PROV-ID
Record Subject – This is the individual/entity around which the record segments in a file are built. The
Medicaid/CHIP enrollee is the subject of Eligible Files. In Provider Files, the subject is the provider. The managed
care entity is the subject of Managed Care Files, and third party payers and their associated beneficiaries are the
subjects of TPL Files.
Overview
The complex qualifier fields are included in the T-MSIS record layouts so that a given record segment layout can
be used to capture a standard set of data elements (i.e., the corresponding data elements) for a category of data
(i.e., the complex qualifier field’s valid values list) when more than one category may be applicable to the record
subject.
The complex qualifier fields’ valid values lists are not “select one value from the valid values list and provide the
corresponding data element values (which is the case for simple qualifier fields).” A separate record segment
should be created and fully populated for every “complex qualifier field” valid value or unique combination of
“complex qualifier field” valid value and corresponding data element value (in accordance with the Record Keys
& Constraints) that applies to the record subject. Table 1 illustrates what CMS is expecting, using LICENSE-TYPE
in the PROV-LICENSING-INFO record segment (PRV00004) as an example.
Example Scenario
The purpose of the PROV-LICENSING-INFO segment is to capture licensing and accreditation information
relevant to a provider. The valid value list for the LICENSE-TYPE data element shows the types of information
that CMS is interested in collecting in this record segment:
1. State, county, or municipality professional or business license
2. DEA license
3. Professional society accreditation
4. CLIA accreditation
5. Other
For our example, assume three of these categories are applicable to provider # P0123: (a) a professional license
issued by the state’s Board of Physicians (valid value # 1); (b.1) a board certification from the ABMS (valid value
# 3); (b.2) a board certification from the AOA (also valid value # 3); and (c) a DEA number (valid value # 2). Table
1 and 1a lists the data elements in the PRV00004 record segment, and shows the contents of each data element
in the four PRV00004 segments that would be required by this example.
Table 1: Examples of fully populated record segments supplying “complex qualifier field” corresponding data. While these data elements
aren't strictly "corresponding data elements," they are necessary to tie the segments to their parent segment.
Data Element Use
Data Element
Tie segments to parent
segment
RECORD-ID
Tie segments to parent
segment
SUBMITTING-STATE
v4.0.0
Physician
License
ABMS Board
Certification
AOA Board
Certification
DEA
Number
PRV00004
PRV00004
PRV00004
PRV00004
24
24
24
24
41
Appendix P.05
Tie segments to parent
segment
RECORD-NUMBER
4506
4507
4508
4509
Tie segments to parent
segment
SUBMITTING-STATEPROV-ID
P0123
P0123
P0123
P0123
Tie segments to parent
segment
PROV-LOCATION-ID
0
0
0
0
Table 1a: Examples of fully populated record segments supplying “complex qualifier field” corresponding data.
Data Element Use
Data Element
Physician
License
ABMS Board
Certification
AOA Board
Certification
DEA Number
Corresponding Data
Element
PROV-LICENSE-EFF-DATE
19921119
20100101
20120701
20131001
Corresponding Data
Element
PROV-LICENSE-END-DATE
20150930
20191231
20150630
20160930
"Complex Qualifier”
LICENSE-TYPE
1
3
3
2
Corresponding Data
Element
LICENSE-ISSUING-ENTITY-ID
24
American Board
of Medical
Specialties
American
Osteopathic
Association
DEA
Corresponding Data
Element
LICENSE-OR-ACCREDITATIONNUMBER
D98765
IM012345
A5546
FD1234563
NA
STATE-NOTATION
NA
NA
Data Element
NA
NA
NA
FILLER
NA
NA
NA
NA
CMS Guidance
CMS is instructing States to provide information corresponding to each of a complex qualifier field’s valid values
to the extent that the valid value is applicable to the record subject. Additionally, States should fully populate
the affected record segments.
In its first four columns, Table 2 displays the T-MSIS file name, record segment name, complex qualifier field
name and the complex qualifier field’s list of valid values for each of the complex qualifier fields in the T-MSIS
data set. The last two columns identify the corresponding data elements (along with the file segments where
they reside) that need to be populated for every applicable valid value in the “complex qualifier field’s” valid
value list.
Table 2: “Complex Qualifier fields” their valid values, and the corresponding data elements that need to be populated
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Appendix P.05
File Name
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
Corresponding
Data Elements To
Be Populated:
Record
Segment
Data Element
Name
Valid Value
and
Description
Record Segment
Corresponding Data Elements To Be
Populated:
Data Element Name
ELIGIBLE
v4.0.0
ELIGIBLECONTACTINFORMATION
(ELG00004)
ADDR-TYPE
01 - Primary home
address and
contact
information (used
for the eligibility
determination
process); 02 Primary work
address and
contact
information; 03 Secondary
residence and
contact
information; 04 Secondary work
address and
contact
information; 05 Other category of
address and
contact
information; 06 Eligible person’s
official mailing
address
ELIGIBLE-CONTACTINFORMATIONELG00004
ELIGIBLE-ADDR-LN1; ELIGIBLE-ADDR-LN2;
ELIGIBLE-ADDR-LN3; ELIGIBLE-CITY;
ELIGIBLE-STATE; ELIGIBLE-ZIP-CODE;
ELIGIBLE-COUNTY-CODE; ELIGIBLE-PHONENUM; TYPE-OF-LIVING-ARRANGEMENT;
ELIGIBLE-ADDR-EFF-DATE; ELIGIBLE-ADDREND-DATE
43
Appendix P.05
File Name
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
Corresponding
Data Elements To
Be Populated:
Record
Segment
Data Element
Name
Valid Value
and
Description
Record Segment
Corresponding Data Elements To Be
Populated:
Data Element Name
MNGDCARE
v4.0.0
MANAGED-CAREMAIN (MCR00002)
MANAGED-CARESERVICE-AREA
1 - Statewide: The
managed care
entity provides
services to
beneficiaries
throughout the
entire state; 2 County: The
managed care
entity provides
services to
beneficiaries in
specified counties;
3 - City: The
managed care
entity provides
services to
beneficiaries in
specified cities; 4 Region: The
managed care
entity provides
services to
beneficiaries in
specified regions,
not defined by
individual
counties within
the state
(“region” is statedefined); 5 - Zip
Code: The
managed care
entity program
provides services
to beneficiaries in
specified zip
codes; 6 - Other:
The managed care
entity provides
services to
beneficiaries in
"other" area(s),
not Statewide,
County, City, or
Region.
MANAGED-CARESERVICE-AREAMCR00004
MANAGED-CARE-SERVICE-AREA-NAME;
MANAGED-CARE-SERVICE-AREA-EFF-DATE;
MANAGED-CARE-SERVICE-AREA-END-DATE
44
Appendix P.05
File Name
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
Corresponding
Data Elements To
Be Populated:
Record
Segment
Data Element
Name
Valid Value
and
Description
Record Segment
Corresponding Data Elements To Be
Populated:
Data Element Name
MNGDCARE
MANAGED-CARELOCATION-ANDCONTACT-INFO
(MCR00003)
MANAGED-CAREADDR-TYPE
1 - MCO’s
corporate address
and contact
information; 2 MCO’s mailing
address; 3 MCO’s service
location address;
4 - MCO’s Billing
address and
contact
information; 5 CEO’s address and
contact
information; 6 CFO’s address and
contact
information; 7 Other
MANAGED-CARELOCATION-ANDCONTACT-INFOMCR00003
MANAGED-CARE-LOCATION-ID; MANAGEDCARE-ADDR-LN1; MANAGED-CARE-ADDRLN2; MANAGED-CARE-ADDR-LN3;
MANAGED-CARE-CITY; MANAGED-CARESTATE; MANAGED-CARE-ZIP-CODE;
MANAGED-CARE-COUNTY; MANAGED-CARETELEPHONE; MANAGED-CARE-EMAIL;
MANAGED-CARE-FAX-NUMBER; MANAGEDCARE-LOCATION-AND-CONTACT-INFO-EFFDATE
MNGDCARE
MANAGED-CAREID (MCR00010)
MANAGED-CAREPLAN-OTHER-ID-TYPE
01 – Federal Tax
ID; 02 – State Tax
ID
MANAGED-CARE-ID
(MCR00010)
MANAGED-CARE-PLAN-OTHER-ID,
MANAGED-CARE-PLAN-ID-EFF-DATE,
MANAGED-CARE-PLAN-ID-END-DATE
PROVIDER
PROV-LOCATIONAND-CONTACTINFO (PRV00003)
ADDR-TYPE
1 - Billing
Provider; 2 Provider Mailing;
3 - Provider
Practice; 4 Provider Service
Location
PROV-LOCATIONAND-CONTACT-INFOPRV00003
PROV-LOCATION-ID; ADDR-LN1; ADDR-LN2;
ADDR-LN3; ADDR-CITY; ADDR-STATE; ADDRZIP-CODE; ADDR-TELEPHONE; ADDR-EMAIL;
ADDR-FAX-NUM; ADDR-BORDER-STATE-IND;
ADDR-COUNTY; PROV-LOCATION-ANDCONTACT-INFO-EFF-DATE; PROV-LOCATIONAND-CONTACT-INFO-END-DATE
PROVIDER
PROV-LICENSINGINFO (PRV00004)
LICENSE-TYPE
1 - State, county,
or municipality
professional or
business license; 2
-DEA license; 3Professional
society
accreditation; 4 CLIA
accreditation; 5Other
PROV-LICENSINGINFO-PRV00004
LICENSE-OR-ACCREDITATION-NUMBER;
LICENSE-ISSUING-ENTITY-ID; PROV-LICENSEEFF-DATE; PROV-LICENSE-END-DATE
v4.0.0
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Appendix P.05
File Name
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
“Complex
Qualifier Field”
Information:
Corresponding
Data Elements To
Be Populated:
Record
Segment
Data Element
Name
Valid Value
and
Description
Record Segment
Corresponding Data Elements To Be
Populated:
Data Element Name
PROVIDER
PROV-IDENTIFIERS
(PRV00005)
PROV-IDENTIFIERTYPE
1 - State-specific
Medicaid Provider
ID; 2 – NPI; 3 Medicare ID; 4 NCPDP ID; 5 Federal Tax ID; 6 State Tax ID; 7 –
SSN; 8 – Other; 9 Old State Provider
ID
PROV-IDENTIFIERSPRV00005
PROV-IDENTIFIER; PROV-IDENTIFIERISSUING-ENTITY-ID; PROV-IDENTIFIER-EFFDATE; PROV-IDENTIFIER-END-DATE
PROVIDER
PROVTAXONOMYCLASSIFICATION
(PRV00006)
PROVCLASSIFICATION-TYPE
1 - Taxonomy
code; 2 - Provider
specialty code; 3 Provider type
code; 4 Authorized
category of
service code
PROV-TAXONOMYCLASSIFICATIONPRV00006
PROV-CLASSIFICATION-CODE; PROVTAXONOMY-CLASSIFICATION-EFF-DATE;
PROV-TAXONOMY-CLASSIFICATION-ENDDATE
PROVIDER
PROV-AFFILIATEDPROGRAMS
(PRV00009)
AFFILIATEDPROGRAM-TYPE
1 - Health Plan
(NHP-ID); 2 Health Plan (stateassigned health
plan ID); 3 –
Waiver; 4 - Health
Home Entity; 5 –
Other; 6 – Subcapitated Entity; 7
– Fee-for-service
(FFS)
PROV-AFFILIATEDPROGRAMSPRV00009
AFFILIATED-PROGRAM-ID; PROVAFFILIATED-PROGRAM-EFF-DATE; PROVAFFILIATED-PROGRAM-END-DATE
TPL
TPL-ENTITYCONTACTINFORMATION
(TPL00006)
TPL-ENTITY-ADDRTYPE
06 - TPL-Entity
Corporate
Location; 07 - TPLEntity Mailing; 08
- TPL-Entity
Satellite Location;
09 - TPL-Entity
Billing; 10 - TPLEntity
Correspondence;
11 - TPL-Other
TPL-ENTITYCONTACTINFORMATIONTPL00006
INSURANCE-CARRIER-ADDR-LN1;
INSURANCE-CARRIER-ADDR-LN2;
INSURANCE-CARRIER-ADDR-LN3;
INSURANCE-CARRIER-CITY; INSURANCECARRIER-STATE; INSURANCE-CARRIER-ZIPCODE; INSURANCE-CARRIER-PHONE-NUM;
INSURANCE-CARRIER-NAIC-CODE;
INSURANCE-CARRIER-NAME; NATIONALHEALTH-CARE-ENTITY-ID-TYPE; NATIONALHEALTH-CARE-ENTITY-ID; NATIONALHEALTH-CARE-ENTITY-NAME; TPL-ENTITYCONTACT-INFO-EFF-DATE; TPL-ENTITYCONTACT-INFO-END-DATE
v4.0.0
46
Appendix P.07
Appendix P.07: Finding Provider Roles on Standard
Transactions
How to use this guidance document
This guidance document is not intended to slow down or derail existing state development initiatives.
The intent is to provide clarification and standardization across the nation in key areas raised by state
partners. Should guidance introduce rework in ongoing development, please bring this to the attention
of your TA and CMS analyst to direct you to the most appropriate path that minimizes impact to your
progress.
Brief Issue Description
Some States have requested assistance with identifying where to find in the X-12 claim transaction sets
the NPIs and taxonomy codes of providers who performed various roles associated with the
claim/encounter.
Background Discussion
Definitions
Provider role – The function that a specific provider performed for a particular patient on specified
dates of service, and which are contained on fee-for-service claims or reported on encounter records.
The particular roles that CMS would like to track on T-MSIS claims are:
• Admitting (attending) provider
• Billing provider
• Dispensing provider
• Operating provider
• Prescribing provider
• Referring provider
• Servicing (rendering) provider
• Ordering provider
Provider role information needed for the T-MSIS claim files can be extracted from the standard X-12
transactions. The five tables in the “CMS Guidance” section of this document provide T-MSIS-to-X-12
crosswalks for each provider role. The five tables are:
Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12
transactions
Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12
transactions
Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations
on the X-12 transactions
v4.0.0
47
Appendix P.07
Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding
locations on the X-12 transactions
Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations
on the X-12 transactions
Table F: Provider roles on T-MSIS CLAIMRX files and their corresponding locations on the X-12
transactions
In each table, the first column identifies the provider role. The second and third columns identify the
specific T-MSIS record segments and data elements used to capture the NPI and taxonomy of the
provider performing the specified role. The fourth, fifth, sixth, and seventh columns in tables “A”
through “E” provide the X-12 transaction name, data element identifier, data element description and
loop id that map to the T-MSIS data element. The fourth, fifth, sixth, and seventh columns in table “F”
provide the segment name, field identifier, field name and definition of the applicable NCPDP D.0 data
set fields.
CMS Guidance
Use tables “A” through “F” to map the provider roles that are contained in the T-MSIS claim record
layouts to their corresponding X-12 standard transaction data elements.
If the T-MSIS data element does not exist in the X-12 transaction set (shown as “N/A” in the tables
below), 8-fill, leave blank or space-fill the T-MSIS data element when building T-MSIS claim files.
v4.0.0
48
Appendix P.07
Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12 transactions
Provider
IP-T-MSIS Data
IP-T-MSIS Record Segment
X-12
X-12
Role
Element
Transaction
Element
Identifier
X-12
Description
X-12 Loop
Conditional Rules
Admitting
(Attending)
ADMITTING-PROV-NPINUM
CLAIM-HEADER-RECORD-IPCIP00002
5010 A2 837-I
Institutional Claim
NM109
Attending
Provider Identifier
2310A
N/A
Admitting
(Attending)
ADMITTING-PROVTAXONOMY
CLAIM-HEADER-RECORD-IPCIP00002
5010 A2 837-I
Institutional Claim
PRV03
Provider
Taxonomy Code
2310A
N/A
Billing
BILLING-PROV-NPI-NUM
CLAIM-HEADER-RECORD-IPCIP00002
5010 A2 837-I
Institutional Claim
NM109
Billing Provider
Identifier
2010AA
N/A
Billing
BILLING-PROVTAXONOMY
CLAIM-HEADER-RECORD-IPCIP00002
5010 A2 837-I
Institutional Claim
PRV03
Provider
Taxonomy Code
2000A
N/A
Operating
OPERATING-PROV-NPINUM
CLAIM-LINE-RECORD-IP-CIP00003
5010 A2 837-I
Institutional Claim
NM109
Operating
Physician
Identifier
2310B or
2420A
Operating
OPERATING-PROVTAXONOMY
CLAIM-HEADER-RECORD-IPCIP00002
N/A
N/A
N/A
N/A
N/A
Referring
REFERRING-PROV-NPINUM
CLAIM-HEADER-RECORD-IPCIP00002
5010 A2 837-I
Institutional Claim
NM109
Referring Provider
Identifier
2310F
N/A
v4.0.0
49
The identifier in the 837i loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a different
identifier in loop 2420A at the line level of
the 837i. If there is a different identifier in
837i loop 2420A then the identifier from
loop 2420A should be reported as the
operating provider identifier.
Appendix P.07
Provider
Role
IP-T-MSIS Data
Element
IP-T-MSIS Record Segment
X-12
Transaction
X-12
Element
Identifier
X-12
Description
X-12 Loop
Referring
REFERRING-PROV-NPINUM
CLAIM-LINE-RECORD-IP-CIP00003
5010 A2 837-I
Institutional Claim
NM109
Referring Provider
Identifier
2420D
Servicing
(Rendering)
SERVICING-PROV-NPINUM
CLAIM-LINE-RECORD-IP-CIP00003
5010 A2 837-I
Institutional Claim
NM109
Rendering
Provider Identifier
2310D or
2420C
Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12 transactions
Provider
LT-T-MSIS Data Element
LT-T-MSIS Record Segment
X-12
X-12
Role
Transaction
Element
Identifier
X-12 Description
X-12 Loop
Conditional Rules
N/A
The identifier in the 837i loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a different
identifier in 2420C at the line level of the
837i. If there is a different identifier in
837i loop 2420C then the identifier from
loop 2420C should be reported as the
servicing/rendering provider identifier.
Conditional Rules
Admitting
(Attending)
ADMITTING-PROV-NPI-NUM
CLAIM-HEADER-RECORD-LTCLT00002
5010 A2 837-I
Institutional
Claim
NM109
Attending Provider
Identifier
2310A
N/A
Admitting
(Attending)
ADMITTING-PROVTAXONOMY
CLAIM-HEADER-RECORD-LTCLT00002
5010 A2 837-I
Institutional
Claim
PRV03
Provider Taxonomy
Code
2310A
N/A
Billing
BILLING-PROV-NPI-NUM
CLAIM-HEADER-RECORD-LTCLT00002
5010 A2 837-I
Institutional
Claim
NM109
Billing Provider
Identifier
2010AA
N/A
v4.0.0
50
Appendix P.07
Provider
Role
LT-T-MSIS Data Element
LT-T-MSIS Record Segment
X-12
Transaction
X-12
Element
Identifier
X-12 Description
X-12 Loop
Conditional Rules
Billing
BILLING-PROV-TAXONOMY
CLAIM-HEADER-RECORD-LTCLT00002
5010 A2 837-I
Institutional
Claim
PRV03
Provider Taxonomy
Code
2000A
N/A
Referring
REFERRING-PROV-NPI-NUM
CLAIM-HEADER-RECORD-LTCLT00002
5010 A2 837-I
Institutional
Claim
NM109
Referring Provider
Identifier
2310F
N/A
Referring
REFERRING-PROV-NPI-NUM
CLAIM-LINE-RECORD-LTCLT00003
5010 A2 837-I
Institutional
Claim
NM109
Referring Provider
Identifier
2420D
N/A
Servicing
(Rendering)
SERVICING-PROV-NPI-NUM
CLAIM-LINE-RECORD-LTCLT00003
5010 A2 837-I
Institutional
Claim
NM109
Rendering Provider
Identifier
2310D or
2420C
Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations on the X-12 transactions
Provider
OT (facility)-T-MSIS
OT (facility)-T-MSIS
X-12 Transaction
X-12
X-12 Description
Role
Element
Data Element
Record Segment
Identifier
Billing
v4.0.0
BILLING-PROV-NPI-NUM
CLAIM-HEADER-RECORD-OTCOT00002
5010 A2 837-I
Institutional Claim
NM109
Billing Provider Identifier
51
The identifier in the 837i loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in loop 2420C at
the line level of the 837i. If there is a
different identifier in 837i loop 2420C
then the identifier from loop 2420C
should be reported as the
servicing/rendering provider identifier.
X-12
Conditional Rules
Loop
2010AA
N/A
Appendix P.07
Provider
Role
OT (facility)-T-MSIS
OT (facility)-T-MSIS
Data Element
Record Segment
X-12 Transaction
X-12
Element
Identifier
X-12 Description
X-12
Conditional Rules
Loop
Billing
BILLING-PROVTAXONOMY
CLAIM-HEADER-RECORD-OTCOT00002
5010 A2 837-I
Institutional Claim
PRV03
Provider Taxonomy Code
2000A
N/A
Referring
REFERRING-PROV-NPINUM
CLAIM-HEADER-RECORD-OTCOT00002
5010 A2 837-I
Institutional Claim
NM109
Referring Provider
Identifier
2310F
N/A
Referring
REFERRING-PROV-NPINUM
CLAIM-LINE-RECORD-OT-COT00003
5010 A2 837-I
Institutional Claim
NM109
Referring Provider
Identifier
2420D
N/A
Servicing
(Rendering)
SERVICING-PROV-NPINUM
CLAIM-LINE-RECORD-OT-COT00003
5010 A2 837-I
Institutional Claim
NM109
Attending Provider
Identifier
2310A
The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i. If
there is a different identifier
in 837i loop 2420C then the
identifier from loop 2420C
should be reported as the
servicing/rendering provider
identifier. If 2310D and
2420C are not populated but
2310A is populated, then
apply 2310D here.
Or
Or
Rendering Provider
Identifier
v4.0.0
52
2310D
or 2420C
Appendix P.07
Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding locations on the X-12 transactions
Provider
OT (professional)-TOT (professional)-T-MSIS
X-12
X-12 Element
X-12
MSIS Data Element
Transaction
Identifier
Description
Role
Record Segment
X-12
Loop
Conditional Rules
Billing
BILLING-PROV-NPINUM
CLAIM-HEADER-RECORD-OTCOT00002
5010 A1 837-P
Professional
Claim
NM109
Billing Provider
Identifier
2010AA
N/A
Billing
BILLING-PROVTAXONOMY
CLAIM-HEADER-RECORD-OTCOT00002
5010 A1 837-P
Professional
Claim
PRV03
Provider
Taxonomy Code
2000A
N/A
Referring
REFERRING-PROV-NPINUM
CLAIM-HEADER-RECORD-OTCOT00002
5010 A1 837-P
Professional
Claim
NM109
Referring
Provider
Identifier
2310A
N/A
Referring
REFERRING-PROV-NPINUM
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-P
Professional
Claim
NM109
Referring
Provider
Identifier
2420F
N/A
Referring
REFERRING-PROV-NPINUM-2
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-P
Professional
Claim
NM109
Referring
Provider
Identifier
2420F
If there is a 2nd loop of 2420F
containing an NPI for a given claim,
apply the NPI from that second loop
here.
v4.0.0
53
Appendix P.07
Provider
Role
OT (professional)-TMSIS Data Element
OT (professional)-T-MSIS
Record Segment
X-12
Transaction
X-12 Element
Identifier
X-12
Description
X-12
Loop
Conditional Rules
Servicing
(Rendering)
SERVICING-PROV-NPINUM
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-P
Professional
Claim
NM109
Rendering
Provider
Identifier
2310B or
2420A
The identifier in the 837p loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420A at the line
level of the 837p. If there is a different
identifier in 837p loop 2420A then the
identifier from 2420A should be
reported as the servicing/rendering
provider identifier.
Servicing
(Rendering)
SERVICING-PROVTAXONOMY
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-P
Professional
Claim
PRV03
Provider
Taxonomy Code
2310B or
2420A
The taxonomy in the 837p loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a
different taxonomy in 2420A at the
line level of the 837p. If there is a
different taxonomy in 837p loop
2420A then the taxonomy from 2420A
should be reported as the
servicing/rendering provider
taxonomy.
Ordering
ORDERING-PROV-NPINUM
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-P
Professional
Claim
NM109
Ordering
Provider
Identifier
2420E
Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations on the X-12 transactions
Provider
OT (dental)-T-MSIS
OT (dental)-T-MSIS
X-12
X-12
X-12
Transaction
Description
Role
Data Element
Record Segment
Element
Identifier
Billing
v4.0.0
BILLING-PROV-NPINUM
CLAIM-HEADER-RECORD-OTCOT00002
5010 A1 837-D
Dental Claim
NM109
Billing Provider
Identifier
X-12
Loop
2010AA
54
N/A
Conditional Rules
N/A
Appendix P.07
Provider
OT (dental)-T-MSIS
OT (dental)-T-MSIS
Role
Data Element
Record Segment
X-12
Transaction
X-12
Element
Identifier
X-12
Description
X-12
Loop
Conditional Rules
Billing
BILLING-PROVTAXONOMY
CLAIM-HEADER-RECORD-OTCOT00002
5010 A1 837-D
Dental Claim
PRV03
Provider
Taxonomy Code
2000A
N/A
Referring
REFERRING-PROV-NPINUM
CLAIM-HEADER-RECORD-OTCOT00002
5010 A1 837-D
Dental Claim
NM109
Referring
Provider
Identifier
2310A
N/A
Referring
REFERRING-PROVTAXONOMY
CLAIM-HEADER-RECORD-OTCOT00002
N/A
N/A
N/A
N/A
N/A
Servicing
(Rendering)
SERVICING-PROV-NPINUM
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-D
Dental Claim
NM109
Rendering
Provider
Identifier
2310B or
2420A
The identifier in 837d loop 2310B could be
applied to each line in T-MSIS except for lines
where there is a different identifier in 2420A
at the line level of the 837d. If there is a
different identifier in 837d) loop 2420A then
the identifier from 2420A should be reported
as the servicing/rendering provider identifier.
Servicing
(Rendering)
SERVICING-PROVTAXONOMY
CLAIM-LINE-RECORD-OTCOT00003
5010 A1 837-D
Dental Claim
PRV03
Provider
Taxonomy Code
2310B or
2420A
The taxonomy in the 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different taxonomy in
2420A at the line level of the 837p. If there is
a different taxonomy in 837p loop 2420A
then the taxonomy from 2420A should be
reported as the servicing/rendering provider
taxonomy.
v4.0.0
55
Appendix P.07
Table F: Provider roles on T-MSIS CLAIMRX (prescription drug) files and their corresponding locations on the X-12 transactions
Provider
RX-T-MSIS Data Element
RX-T-MSIS Record Segment
X-12 Segment
X-12
X-12 Field Name
Field
Role
Billing
BILLING-PROV-NPI-NUM
CLAIM-HEADER-RECORD-RX-CRX00002
NCPDP D.0 Transaction Header
Segment
201-B1
Service Provider ID
Dispensing
DISPENSING-PRESCRIPTIONDRUG-PROV-NPI
CLAIM-HEADER-RECORD-RX-CRX00002
NCPDP D.0 - Pharmacy
Provider Segment
444-E9
Provider ID
Prescribing
PRESCRIBING-PROV-NPINUM
CLAIM-HEADER-RECORD-RX-CRX00002
NCPDP D.0 - Prescriber
Segment
411-DB
Prescriber ID
v4.0.0
56
X-12 Definition
ID assigned to a pharmacy or provider
ID assigned to a pharmacy or provider
individual responsible for dispensing the
prescription
ID assigned to the prescriber
Appendix Q
Appendix Q: Terms and Abbreviations
Definitions
Acronym/Abbreviation
AAAHC
Description
Accreditation Association for Ambulatory Health Care, Inc.
ABD
Aged, Blind and Disabled
ACA
Affordable Care Act
ADA
American Dental Association
ADDR
Address
AFDC
Aid to Families with Dependent Children
AIDS
Acquired Immunodeficiency Syndrome
AMT
Amount
ANSI
American National Standards Institute
APC
Ambulatory payment classifications
APPL
Application
ARNP
Advanced Registered Nurse Practitioner
ASC
Ambulatory Surgical Center
ASCII
American Standard Code for Information Interchange
ATP
Ability-To-Pay
BIP
Balancing Incentive Program
BMI
Body Mass Index
BOE
Basis of Eligibility
CBSA
Core Based Statistical Area
CD
Code
CDIB
Certificate of Degree of Indian or Alaska Native Blood
CEO
Chief Executive Officer
CFO
Chief Financial Officer
CFR
Code of Federal Regulations
CHIP
Children’s Health Insurance Program
CHIPRA
Children’s Health Insurance Program Reauthorization Act
v4.0.0
57
Appendix Q
Page 2 Acronym/Abbreviation Description
CHPID
Controlling Health Plan Identifiers
CLIA
Clinical Laboratory Improvement Amendment
CMCS
Center for Medicaid, CHIP and Surveys and Certifications
CMHC
Community Mental Health Center
CMMI
Center for Medicare and Medicaid Innovation
CMS
Centers for Medicare & Medicaid Services
COBOL
Common Business Oriented Language
COBRA
Consolidated Omnibus Budget Reconciliation Act of 1986
COLA
Cost-of-Living Adjustment
CORF
Comprehensive Outpatient Rehabilitation Facility
COV
Covered
CPE
Certified Public Expenditures
CPT
Current Procedural Terminology
CRNA
Certified Registered Nurse Anesthetists
CRVS
California Relative Value Study
CWF
Common Working File
DBA
Doing Business As
DEA
Drug Enforcement Agency
DED
Deductible
DME
Durable Medical Equipment
DO
Doctor of osteopathy
DRG
Diagnosis Related Group
DSH
Disproportionate Share Hospital
DSN
Data Set Name
DTL
Detail
DUR
Drug Utilization Review
EBCDIC
Extended Binary-Coded-Decimal Interchange Code
EDI
Electronic Data Interchange
EFF
Effective
EFT
Electronic Funds Transfer; or Electronic File Transfer
EPSDT
Early and Periodic Screening, Diagnosis, and Treatment
v4.0.0
58
Appendix Q
Page 3 Acronym/Abbreviation Description
ESI
Employer Sponsored Insurance
ESRD
End Stage Renal Disease
FFP
Federal Financial Participation
FFS
Fee-for-Service
FFY
Federal Fiscal Year
FFYQ
Federal Fiscal Year Quarter
FI
Fiscal Intermediary
FL
Form Locator
FLF
Fixed Length Format
FPL
Federal Poverty Level
FQHC
Federally Qualified Health Center
GME
Graduate Medical Education
HCBS
Home and Community-Based Services
HCC RA
Hierarchical Condition Category Risk Assessment
HCFA
Health Care Financing Administration
HCPCS
Health Care Procedural Coding System
HETS
HIPAA Eligibility Transaction System
HHA
Home Health Agency
HHPPS
Home Health Prospective Payment System
Hib
Haemophilus influenza type b
HIC
Health Insurance Claim
HICN
Health Insurance Claim Number
HIFA
Health Insurance and Flexibility and Accountability
HIO
Health Insuring Organization
HIPAA
Health Insurance Portability and Accountably Act of 1996
HIV
Human immunodeficiency virus
HMO
Health Maintenance Organization
HPV
Human Papillomavirus
IBM
International Business Machines, Inc.
ICD
International Classification of Diseases
ICD-10-CM
The 10th revision of the ICD
v4.0.0
59
Appendix Q
Page 4 Acronym/Abbreviation Description
ICD-9-CM
The 9th revision of the ICD
ICF
Intermediate Care Facility
ICF-IID
Intermediate Care Facility for Individuals with Intellectual Disabilities
ICN
Item Control Number
IGT
Intergovernmental Transfers
IHS
Indian Health Service
IHS-BCC
IHS-B
IHS-BIP
IHS-B
IMD
Institution for Mental Disease
INA
Immigration and Nationality Act
IND
Indicator
IP
Inpatient
IPFPPS
Inpatient Psychiatric Facility Prospective Payment System
IPPS
Acute Inpatient Prospective Payment System
IRFPPS
Inpatient Rehabilitation Facility Prospective Payment System
LN
Line
LPN
Licensed Practical Nurse
LPR
Lawful permanent residents
LT
Long Term
LTC
Long Term Care
LTCHPPS
Long Term Care Hospital Prospective Payment System
LTCLA
Long Term Care Living Arrangement
LTSS
Long Term Services and Support
MACPro
Medicaid and CHIP Program Data System
MAGI
Modified Adjusted Gross Income
MAS
Maintenance Assistance Status
MBI
Medicare Beneficiary Identifier
M-CHIP
Medicaid Expansion CHIP
MCO
Managed Care Organization
MCR
Managed Care Record
MD
Medical Doctor
v4.0.0
60
Appendix Q
Page 5 Acronym/Abbreviation Description
MFP
Money Follows the Person
MH
Mental Health
MMA
Medicare Modernization Act
MMIS
Medicaid Management Information System
MOD
Modifiers
MRI
Magnetic resonance imaging
MS-DRG
Medicare Severity – Diagnosis Related Group
MSIS
Medicaid Statistical Information System
MSP
Medicare Secondary Payer
NAIC
National Association of Insurance Commissioners
NCPDP
National Council for Prescription Drug Programs
NDC
National Drug Code
NF
Nursing Facility
NHP-ID
National Health Plan Identifier
NPI
National Provider ID
OASDI
Old-Age, Survivors, and Disability Insurance
OEID
Other Entity Identifier
OIG
Office of Inspector General
OIS
Office of Information Services
OMB
Office of Management and Budget
OPPS
Outpatient Prospective Payment System
ORF
Other Rehabilitation Facility
OS
Operating System
OT
Other Type [of claim]
OTC
Over the counter
PACE
Program for All-Inclusive Care for the Elderly
PAHP
Prepaid Ambulatory Health Plan
PBM
Pharmacy Benefits Manager
PCCM
Primary Care Case Management
PERS
Personal Emergency Response System
PHP
Prepaid Health Plan
v4.0.0
61
Appendix Q
Page 6 Acronym/Abbreviation Description
PHS
Public Health Service Act
PIHP
Prepaid Inpatient Health Plan
PL
Public Law
POA
Present on Admission
POP
Population
PPS
Prospective Payment System
PROV
Provider
PRTF
Psychiatric Residential Treatment Facilities Demonstration Grant
Program
PRWORA
Personal Responsibility and Work Opportunity Reconciliation Act of
1996
PT/OT/ST
Physical Therapy/Occupational Therapy/Speech Therapy
QDWI
Qualified Disabled Working Individuals
QI
Qualified Individual
QIO
Quality Improvement Organization
QMB
Qualified Medicare Beneficiaries
RA
Remittance Advice
RBRVS
Resource-based relative value scale
REC
Record
RHC
Rural health clinic
RN
Registered Nurse
RRB
Railroad Retirement Board
RX
Prescription
SCHIP
State Children’s Health Insurance Program
SHPID
Sub-Health Plan Identifiers
SLMB
Specified Low-Income Medicare Beneficiaries
SNF
Skilled Nursing Facility
SNFPPS
Skilled Nursing Facility Prospective Payment System
SPA
State Plan Amendment
SSA
Social Security Administration
SSDI
Social Security Disability Insurance
SSI
Supplemental Security Income
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Appendix Q
Page 7 Acronym/Abbreviation Description
SSP
State Supplemental Program
SSN
Social Security Number
SUD
Substance Use Disorders
T-18 SNF
Title 18 Skilled Nursing Facility
TANF
Temporary Assistance for Needy Families
TB
Tuberculosis
TEFRA
Tax Equity and Fiscal Responsibility Act of 1982
TIN
Tax Identifier Number
T-MSIS
Transformed Medicaid Statistical Information System
TOT
Total
TPL
Third Party Liability
TWWIIA
Ticket to Work and Work Incentives Improvement Act
UB
Uniform Billing
URAC
Utilization Review Accreditation Commission
USC
United States Code
VA
Veterans Administration
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| File Type | application/pdf |
| File Modified | 2024-07-01 |
| File Created | 2024-07-01 |