Transformed - Medicaid Statistical Information System (T-MSIS)

Centers for Medicaid and CHIP Services (CMCS)

Transformed Medicaid Statistical Information System (T-MSIS)

Record Segment Definitions and Relationships
Version: v4.0.0
2024-06-03
PRA Disclosure Statement: The Transformed Medicaid Statistical Information System (T-MSIS) is used to assist the Centers for Medicare & Medicaid
Services (CMS) with monitoring and oversight of Medicaid and CHIP programs, to enable evaluation of demonstrations under section 1115 of the
Social Security Act and to calculate quality measures and other metrics, including those reported through the new Medicaid and CHIP Scoreboard.
Section 4735 of the Balanced Budget Act of 1997 included a statutory requirement for states to submit claims data, enrollee encounter data, and
supporting information. Section 6504 of the Affordable Care Act strengthened this provision by requiring states to include data elements the
Secretary determines necessary for program integrity, program oversight, and administration. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0345 (Expires: 03/31/2026). The time required to complete this information collection is estimated to average 10 hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Table of Contents
Table of Contents ............................................................................................................................................................................ 2
T-MSIS Record Segment Descriptions .............................................................................................................................................. 3
Record Segment Relationships Figures .......................................................................................................................................... 20
Claim IP File – Record Segment Relationships ...............................................................................................................................................20
Claim LT File – Record Segment Relationships ..............................................................................................................................................21
Claim OT File – Claim Record Segment Relationships ....................................................................................................................................22
Claim RX File – Claim Record Segment Relationships ....................................................................................................................................23
Eligible File – Eligible Person Record Segment Relationships ........................................................................................................................24
Financial Transactions File – Record Segment Relationships .........................................................................................................................26
Managed Care File – Managed Care Entity Record Segment Relationships ...................................................................................................27
Provider File – Provider Record Segment Relationships ................................................................................................................................28
Third-Party Liability File – Record Segment Relationships .............................................................................................................................30

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T-MSIS Record Segment Descriptions
Table 1 contains descriptions of each T-MSIS Record Segment. Figures 1 through 9 illustrate intra-file segment relationships.
For ELG, MCR, PRV, and TPL files, the effective date of the child segment must fall completely within the set of effective-end date span of the
active parent segment(s). There shall be no dates where a child segment is active without a corresponding active parent segment.
The T-MSIS Financial Transactions file (FTX) is intended to capture any financial transactions that are not either a fee-for-service (FFS) claim, a
managed care encounter, or a type of financial transaction explicitly excluded from T-MSIS. FFS claims and managed care encounters must be
mapped and reported to the T-MSIS IP, LT, OT, or RX files as appropriate.
States are required to submit transactions for the following expenditures to T-MSIS:
• All Medicaid and CHIP based medical assistance (as defined by MBES/MACFin) expenditures and recoupments between the state, a
provider, a managed care plan, broker, and/or a beneficiary except for:
o quarterly Drug Rebates collected from Manufacturers,
o monthly Medicare Part A or Part B premium payments
o provider-level (not beneficiary/service specific) monthly, quarterly, bi-annual, or annual lump sum Disproportionate Share
Hospital (DSH), Upper Payment Limit (UPL) Supplemental, or Graduate Medical Education (GME) payments
• Non-emergency medical transportation (NEMT) broker payments, even if they were claims via MBES/MACFin as an administrative cost all other administrative costs (as defined by MBES/MACFin) are excluded from T-MSIS
• All payments and recoupments from a managed care plan to their providers and subcontractors

Table 1: T-MSIS Record Segment Definitions for File Types
File Name

Record Segment Name

Claim Inpatient File

FILE-HEADER-RECORD-IP

Record
Identifier
CIP00001

Claim Inpatient File

CLAIM-HEADER-RECORD-IP

CIP00002

Claim Inpatient File

CLAIM-LINE-RECORD-IP

CIP00003

Claim Inpatient File

CLAIM-DX-IP

CIP00004

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Record Segment Definition
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture data about an
acute care inpatient facility claim or
encounter that applies to the claim in its
totality.
A record segment to capture data about
specific goods or services rendered to a
Medicaid/CHIP enrollee during the hospital
stay.
A record segment to capture data about the
diagnosis code(s) associated with a claim.

FLF Record
Segment Length
2,400

2,400

2,400

2,400

File Name

Record Segment Name

Claim Long-term Care File

FILE-HEADER-RECORD-LT

Record
Identifier
CLT00001

Claim Long-term Care File

CLAIM-HEADER-RECORD-LT

CLT00002

Claim Long-term Care File

CLAIM-LINE-RECORD-LT

CLT00003

Claim Long-term Care File

CLAIM-DX-LT

CLT00004

Claim Other File

FILE-HEADER-RECORD-OT

COT00001

Claim Other File

CLAIM-HEADER-RECORD-OT

COT00002

Claim Other File

CLAIM-LINE-RECORD-OT

COT00003

Claim Other File

CLAIM-DX-OT

COT00004

Claim Prescription File

FILE-HEADER-RECORD-RX

CRX00001

Claim Prescription File

CLAIM-HEADER-RECORD-RX

CRX00002

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Record Segment Definition
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture data about an
inpatient long-term care facility claim or
encounter that applies to the claim in its
totality.
A record segment to capture data about
specific goods or services rendered to a
Medicaid/CHIP enrollee during a long-term
care stay.
A record segment to capture data about the
diagnosis code(s) associated with a claim.
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture data about
another type of claim or encounter (besides
IP, LT, and RX) that applies to the claim in
its totality.
A record segment to capture data about
specific goods or services rendered to a
Medicaid/CHIP enrollee during an
outpatient visit.
A record segment to capture data about the
diagnosis code(s) associated with a claim.
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture data about a
pharmacy claim or encounter that applies to
the claim in its totality.

FLF Record
Segment Length
2,200

2,200

2,200

2,200
2,100

2,100

2,100

2,100
1,600

1,600

File Name
Claim Prescription File

CLAIM-LINE-RECORD-RX

Record
Identifier
CRX00003

Claim Prescription File

CLAIM-DX-RX

CRX00004

Eligible File

FILE-HEADER-RECORDELIGIBILITY

ELG00001

Eligible File

PRIMARY-DEMOGRAPHICSELIGIBILITY

ELG00002

Eligible File

VARIABLE-DEMOGRAPHICSELIGIBILITY

ELG00003

Eligible File

ELIGIBLE-CONTACTINFORMATION
ELIGIBILITY-DETERMINANTS

ELG00004

HEALTH-HOME-SPAPARTICIPATIONINFORMATION
HEALTH-HOME-SPAPROVIDERS

ELG00006

HEALTH-HOME-CHRONICCONDITIONS

ELG00008

Eligible File

Eligible File
Eligible File

Eligible File

Record Segment Name

ELG00005

ELG00007

-5-

Record Segment Definition
A record segment to capture data about
specific prescription goods or services
rendered to a Medicaid/CHIP enrollee.
A record segment to capture data about the
diagnosis code(s) associated with a claim.
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture basic
demographic information about the
individual.
A record segment to capture additional
demographic information that is more prone
to periodic changes than primary
demographics.
A record segment to capture addresses and
phone numbers of the individual.
A record segment to capture factors that
influence an individual’s eligibility for basic
Medicaid/CHIP, as well as the various
waivers and demonstrations.
A record segment to capture the eligible
person's participation in the state's health
home initiative.
A record segment to capture the identity of
the health home entity in which the eligible
person is enrolled, as well as the identity of
the provider with primary responsibility for
coordinating the delivery of health home
services.
A record segment to capture an eligible
person's chronic conditions that qualified
him/her for participation in the health home
initiative.

FLF Record
Segment Length
1,600
1,600
1,000

1,000
1,000

1,000
1,000

1,000
1,000

1,000

File Name
Eligible File

LOCK-IN-INFORMATION

Record
Identifier
ELG00009

Eligible File

MFP-INFORMATION

ELG00010

Eligible File

STATE-PLAN-OPTIONPARTICIPATION

ELG00011

Eligible File

WAIVER-PARTICIPATION

ELG00012

Eligible File

LTSS-PARTICIPATION

ELG00013

Eligible File

MANAGED-CAREPARTICIPATION

ELG00014

Eligible File

ETHNICITY-INFORMATION

ELG00015

Eligible File

RACE-INFORMATION

ELG00016

Eligible File

DISABILITY-INFORMATION

ELG00017

Eligible File

1115A-DEMONSTRATIONINFORMATION
HCBS-CHRONICCONDITIONS-NON-HEALTHHOME

ELG00018

ENROLLMENT-TIME-SPANSEGMENT

ELG00021

Eligible File

Eligible File

Record Segment Name

ELG00020

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Record Segment Definition
A record segment to capture the provider,
or providers, to whom the eligible person is
restricted, as well as the time periods during
which the lock-in provisions are in force.
A record segment to capture information
about an eligible person's participation in
the Money Follows the Person
demonstration program.
A record segment to capture the identity of
the State Plan Options in which an eligible
person is enrolled.
A record segment to capture the identity of
the waivers in which an eligible person is
enrolled.
A record segment to capture the level of
care an eligible person receives at various
points in time while in a long-term care
facility.
A record segment to capture information
about an eligible person's enrollment in a
managed care plan.
A record segment to capture information
about an eligible person's ethnicity.
A record segment to capture information
about an eligible person's race.
A record segment to capture information
about an eligible person's disabilities.
A record segment to capture an eligible
person's 1115A participation.
A record segment to capture an eligible
person's chronic conditions for which an
eligible person is receiving home and
community-based care.
A record segment to capture the eligible
person's type of enrollment and time spans
of enrollment.

FLF Record
Segment Length
1,000

1,000

1,000
1,000
1,000

1,000
1,000
1,000
1,000
1,000
1,000

1,000

File Name

Record Segment Name

Eligible File

ELG-IDENTIFIERS

Record
Identifier
ELG00022

Eligible File

SOGI

ELG00023

Financial Transaction File

FILE-HEADER-RECORD-FTX

FTX00001

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Record Segment Definition
A record segment to capture the identifiers
assigned to a beneficiary by various
entities.
A record segment to capture the sexual
orientation and gender identity of the
individual. For more information, see the
CMCS Information Bulletin (CIB) dated
November 9, 2023 with subject “Guidance
on Adding Sexual Orientation and Gender
Identity Questions to State Medicaid and
CHIP Applications for Health Coverage.”
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.

FLF Record
Segment Length
1,000
1,000

2,500

File Name
Financial Transaction File

Record Segment Name
INDIVIDUAL-CAPITATIONPMPM

Record
Identifier
FTX00002

Record Segment Definition
A record segment to capture individual
capitation payments and sub-capitation
payments. Per 42 CFR § 438.2, capitation
payment means a payment the State makes
periodically to a contractor on behalf of
each beneficiary enrolled under a contract
and based on the actuarially sound
capitation rate for the provision of services
under the State plan. The State makes the
payment regardless of whether the
beneficiary receives services during the
period covered by the payment. Subcapitation payments refer to a payment a
Medicaid/CHIP managed care plan makes
periodically to a sub-capitated entity or subcapitated network provider.1 Capitation and
sub-capitation payments do not include
either partial or whole premium assistance
payments for employer-sponsored
insurance, marketplace qualified health
plans, or other private commercial
insurance at the market rate. See also CMS
Technical Instructions: Reporting Subcapitation Payments and Encounters
Associated with Sub-capitation Payments
from Managed Care Plans for more
information.

FLF Record
Segment Length
2,500

https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-technical-instructions-reporting-sub-capitation-payments-and-encounters-associated-with-sub-capitationpayments-from-managed-care-plans/
1

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File Name
Financial Transaction File

Record Segment Name
INDIVIDUAL-HEALTHINSURANCE-PREMIUMPAYMENT

Record
Identifier
FTX00003

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Record Segment Definition
A record segment to capture individual
health insurance premium payments made
by Medicaid or CHIP. Partial or full payment
of a Medicaid or CHIP beneficiary’s portion
of employer-sponsored health insurance,
qualified health plan, or other private
commercial insurance premium payment for
an individual. The payment may have been
made directly to the insurance carrier or
reimbursed directly to the policy owner.
Premium assistance payments may not be
recouped from a beneficiary or policy
holder. For Medicaid, individual health
insurance premium payments have been
covered under the authority of SSA 1905(a),
1906A, or an 1115 demonstration waiver.
For Medicaid, individual health insurance
premium payments are typically reported to
the MBES CMS-64 form category 18E. For
CHIP, individual health insurance premium
assistance payments have been covered
under the authority of SSA 2105(c)(3) or an
1115 demonstration waiver. For CHIP
individual health insurance premium
assistance payments have typically been
reported to the CBES CMS-21 form
category 1.A and 1.C which can represent
either CHIP health insurance premium
assistance payments or CHIP capitation
payments - only the CHIP health insurance
premium assistance payments made should
be reported in a FTX00003 segment.

FLF Record
Segment Length
2,500

File Name
Financial Transaction File

Record Segment Name
GROUP-INSURANCEPREMIUM-PAYMENT

Record
Identifier
FTX00004

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Record Segment Definition
A record segment to capture group
insurance premium payments made by
Medicaid or CHIP. Partial or full payment of
a Medicaid or CHIP beneficiary’s portion of
employer-sponsored health insurance,
qualified health plan, or other private
commercial insurance premium payment for
group coverage. The payment may have
been made directly to the insurance carrier
or reimbursed directly to the policy owner.
Premium assistance payments may not be
recouped from a beneficiary or policy
holder. For Medicaid, group health
insurance premium payments have been
covered under the authority of SSA 1905(a),
1906, 1906A, or an 1115 demonstration
waiver. For Medicaid, group health
insurance premium payments have typically
been reported to the MBES CMS-64 form
category 18C or 18E. For CHIP, group
health insurance premium assistance
payments have been covered under the
authority of SSA 2105(c)(3) or an 1115
demonstration waiver. For CHIP group
health insurance premium payments have
typically been reported to the CBES CMS21 form category 1.A and 1.C which can
represent either CHIP health insurance
premium assistance payments or CHIP
capitation payments - only the CHIP health
insurance premium assistance payments
made should be reported in a FTX00003
segment.

FLF Record
Segment Length
2,500

File Name
Financial Transaction File

Record Segment Name
COST-SHARING-OFFSET

Record
Identifier
FTX00005

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Record Segment Definition
A record segment to capture cost sharing
offsets. Cost sharing offsets are any cost
sharing (e.g., Medicaid or CHIP beneficiary
premiums) collected by either the state
Medicaid or CHIP agencies (or their
representatives) directly from beneficiaries.
This type of cost-sharing does not go to a
health care provider for services rendered.
The federal regulation for these offsets can
be found at 42 CFR 447.55 (or 1916) and
42 CFR 457.510. For CHIP these are
reported to the CBES CMS-21 form
category 1.B and 1.D.

FLF Record
Segment Length
2,500

File Name
Financial Transaction File

2

Record Segment Name
VALUE-BASED-PAYMENT

Record
Identifier
FTX00006

https://www.medicaid.gov/sites/default/files/2020-09/smd20004.pdf

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Record Segment Definition
A record segment to capture value-based
payments. Value-based payments or
recoupments are made under value-based
payment (VBP) agreements, including
Medicaid Shared Savings Payments. A
value-based payment may be made by a
state Medicaid or CHIP agency to a fee-forservice (FFS) provider or by a managed
care plan or sub-capitated entity to a
managed care provider. Payments made
from managed care plans (MCOs, PIHPs, or
PAHPs) to providers under value-based
payment (VBP) agreements can either be
directed as part of the managed care plan’s
contract by the state as a state directed
payment (SDP) under 42 CFR 438.6(c) or
offered independently of the managed care
plan’s contract with the state. A value-based
payment may also be made by a managed
care plan to a provider or a sub-capitated
entity. Value-based payments captured by
this T-MSIS record segment do not include
incentive payments as defined by 42 CFR
438.6(a) or (b), which are incentive or
withholds paid by the state to the managed
care plan for the managed care plan’s
performance. Value-based payments are
not subject to UPL.2

FLF Record
Segment Length
2,500

3
4

File Name

Record Segment Name

Financial Transaction File

STATE-DIRECTED-PAYMENTSEPARATE-PAYMENT-TERM

Record
Identifier
FTX00007

Record Segment Definition
A record segment to capture State Directed
Payment Separate Payment Term
payments. All state directed payments,
which are contractual obligations where
states direct Medicaid managed care plans’
expenditures for services under the
contract, must be incorporated into all
applicable managed care contract(s) and
described in all applicable rate
certification(s) as noted in 42 C.F.R. §
438.7(b)(6).3 As part of the Medicaid
Managed Care Rate Development Guide,
CMS provided guidance on two ways that
states could incorporate state directed
payments – either through adjustments to
the base capitation rates as an adjustment
to the rate or through a separate payment
term.4 This segment is meant to capture
payments made from the State to the
Medicaid managed care plan (MCO, PIHP,
or PAHP) for SDPs incorporated through
separate payment terms. These payments
are aggregate payments (not beneficiary or
service specific.) This field should not
capture payments made from the managed
care plan to providers in compliance with an
SDP contractual obligation.

https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd21001.pdf
https://www.medicaid.gov/medicaid/managed-care/guidance/rate-review-and-rate-guides/index.html

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FLF Record
Segment Length
2,500

File Name
Financial Transaction File

Record Segment Name
COST-SETTLEMENTPAYMENT

Record
Identifier
FTX00008

Record Segment Definition
A record segment to capture cost
settlement payments. A cost settlement
payment is an aggregate monthly, quarterly,
bi-annual, or annual reconciliation of interim
payments to the final cost amount for an
otherwise fee-for-service (FFS) provider
paid under a reconciled cost methodology
as part of the base reimbursement
methodology for services. If costs are
reconciled on a claim-by-claim basis, then
the reconciliation may be reflected as
adjustments to each original fee-for-service
claim rather than here as an aggregate cost
settlement. If cost settlement payment is
made in aggregate (not beneficiary or
service specific) at the provider-level, then it
would be reported to this segment. Upper
payment limit (UPL) regulations apply to
cost settlements made to providers who are
subject to the UPL (e.g., hospitals,
outpatient hospital settings, nursing
facilities, clinics, intermediate care facilities5,
and psychiatric residential treatment
facilities6). UPL regulations may not apply to
some types of cost settlements, such as
those for school-based services7, Federally
Qualified Health Clinics (FQHC), or rural
health clinics8. Cost settlement for FFS
FQHCs are reported to this type of
transaction, rather than the FQHC Wrap
Payments transaction type which is only for
FQHCs paid by managed care plans.

https://www.macpac.gov/subtopic/supplemental-payments/
https://www.medicaid.gov/medicaid/finance/payment-limit-demonstrations/upper-payment-limitfaqs/index.html?search_api_fulltext=ID%3A92241&sort_by=field_faq_date&sort_order=DESC
6
https://www.medicaid.gov/faq/how-psychiatric-residential-treatment-facility-prtf-upper-payment-limit-upl-different-other-institutional-upls/index.html
5

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FLF Record
Segment Length
2,500

File Name
Financial Transaction File

Record Segment Name
FQHC-WRAP-PAYMENT

Record
Identifier
FTX00009

Record Segment Definition
A record segment to capture FQHC wrap
payments. An FQHC wrap payment is an
additional payment to Federally Qualified
Health Centers (FQHC) or rural health
clinics (RHC) for the difference between
what is paid pursuant to a contract between
the center or clinic and a managed care
entity and the prospective payment system
(PPS) rate if the rate paid under the
contract does not match the PPS rate for
the same service. FQHC payments are not
subject to an upper payment limit. They are
separate FQHC payments that the state is
obligated to make under the statute.
Sometimes these FQHC wrap payments are
paid by the state directly to the provider.
Sometimes they are paid by the state to the
managed care plan to be distributed to the
FQHC provider(s). Either approach should
be reported to this segment. If the FQHC
wrap payment is paid by the state directly to
the provider and combined with the
provider’s fee-for-service (FFS) cost
settlement, then the entire payment should
be mapped to the Cost Settlement
transaction only.

https://www.medicaid.gov/medicaid/finance/payment-limit-demonstrations/upper-payment-limitfaqs/index.html?search_api_fulltext=ID%3A92416&sort_by=field_faq_date&sort_order=DESC
7
https://www.medicaid.gov/federal-policy-guidance/downloads/sbscib081820222.pdf
8
https://www.medicaid.gov/medicaid/downloads/upl-guidance-clinic-service-2nd-update-4-9-2015.pdf

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FLF Record
Segment Length
2,500

File Name

Record Segment Name

Record
Identifier
FTX00095

Financial Transaction File

MISCELLANEOUS-PAYMENT

Managed Care Plan
Information File

FILE-HEADER-RECORDMANAGED-CARE

MCR00001

Managed Care Plan
Information File

MANAGED-CARE-MAIN

MCR00002

Managed Care Plan
Information File

MANAGED-CARE-LOCATIONAND-CONTACT-INFO

MCR00003

Managed Care Plan
Information File

MANAGED-CARE-SERVICEAREA

MCR00004

Managed Care Plan
Information File

MANAGED-CAREOPERATING-AUTHORITY

MCR00005

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Record Segment Definition
A record segment to capture any other
miscellaneous payment transaction that is
not explicitly excluded from T-MSIS
reporting or does not meet the definition of
and was therefore not mapped to any other
specific transaction type must be reported
to this financial transaction segment type.
CMS will periodically review the
transactions mapped to this segment type
and assess the need to create new specific
financial transaction types. Financial
transactions excluded from T-MSIS are
administrative costs defined by CMS-64.10
categories of service, other than for NEMT,
and certain types of provider-level medical
assistance payments that are tracked at the
provider level by other CMS systems.
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture basic,
generally static information about a
managed care entity.
A record segment to capture addresses,
phone numbers, fax numbers, and email
addresses of the managed care
organization.
A record segment to capture the zip codes,
counties, or other geographic descriptors
that define the managed care entity’s
service area.
A record segment to capture information
about the operating authority, waivers, and
demonstrations under which a managed
care entity is contracted with the state.

FLF Record
Segment Length
2,500

1,000

1,000
1,000

1,000

1,000

File Name

Record Segment Name

Record
Identifier
MCR00006

Managed Care Plan
Information File

MANAGED-CARE-PLANPOPULATION-ENROLLED

Managed Care Plan
Information File

MANAGED- CAREACCREDITATIONORGANIZATION
MANAGED-CARE-PLAN-ID

MCR00007

Provider File

FILE-HEADER-RECORDPROVIDER

PRV00001

Provider File

PROV-ATTRIBUTES-MAIN

PRV00002

Managed Care Plan
Information File

MCR00010

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Record Segment Definition
A record segment to capture the identity of
the Medicaid/CHIP eligibility groups that the
managed care entity is authorized to enroll.
A record segment to capture information
concerning the accreditations that the
managed care entity has.
A record segment to capture information
concerning the ID(s) associated with a
managed care plan.
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture basic,
generally static information about each
provider.
A provider is an individual person (medical
or non-medical), a group of individuals, or
an organization (e.g., institution, facility,
agency, hospital, nursing facility, home
health agency, school, or transportation
organization) that delivers or facilitates
health-related treatments, health care
services, or living supports.

FLF Record
Segment Length
1,000

1,000
1,000
1,100

1,100

File Name

Record Segment Name

Record
Identifier
PRV00003

Provider File

PROV-LOCATION-ANDCONTACT-INFO

Provider File

PROV-LICENSING-INFO

PRV00004

Provider File

PROV-IDENTIFIERS

PRV00005

Provider File

PROV-TAXONOMYCLASSIFICATION

PRV00006

Provider File

PROV-MEDICAIDENROLLMENT

PRV00007

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Record Segment Definition
A record segment to capture addresses,
phone numbers, and email addresses of the
provider.
Each PROV-LOCATION-AND-CONTACTINFO record segment represents the set of
contact information for a single provider
location.
The state can enter as many sets of contact
information (i.e., multiple PROVLOCATION-AND-CONTACT-INFO record
segments) as it considers necessary. The
value selected for the ADDR-TYPE field
describes the type of contact information on
that specific record (e.g., provider service
location, provider billing address, etc.). The
PROV-LOCATION-ID differentiates one
PROV-LOCATION-AND-CONTACT-INFO
record segment from another when the
ADDR-TYPE value on both records is the
same.
A record segment to capture licensing and
accreditation information relevant to the
provider.
A record segment to capture the identifiers
assigned to the provider entity by various
governmental, professional, and payer
entities.
A record segment to classify the provider
into areas of specialty, as well as the
authorized categories of service for which
the provider entity has been authorized by
the state to render to Medicaid/CHIP
eligibles.
A record segment to capture the provider’s
periods of participation in the state's
Medicaid/CHIP programs, and the reason
for a change in enrollment status.

FLF Record
Segment Length
1,100

1,100

1,100

1,100

1,100

File Name

Record Segment Name

Record
Identifier
PRV00008

Provider File

PROV-AFFILIATED-GROUPS

Provider File

PROV-AFFILIATEDPROGRAMS

PRV00009

Provider File

PROV-BED-TYPE-INFO

PRV00010

Third-party Liability File

FILE-HEADER-RECORD-TPL

TPL00001

Third-party Liability File

TPL-MEDICAID-ELIGIBLEPERSON-MAIN

TPL00002

Third-party Liability File

TPL-MEDICAID-ELIGIBLEPERSON-HEALTHINSURANCE-COVERAGE-INFO

TPL00003

Third-party Liability File

TPL-MEDICAID-ELIGIBLEPERSON-HEALTHINSURANCE-COVERAGECATEGORIES

TPL00004

Third-party Liability File

TPL-MEDICAID-ELIGIBLEOTHER-THIRD-PARTYCOVERAGE-INFORMATION

TPL00005

Third-party Liability File

TPL-ENTITY-CONTACTINFORMATION

TPL00006

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Record Segment Definition
A record segment to capture a provider’s
relationship(s) with other provider(s).
A record segment to capture the
Medicaid/CHIP health plans, waivers, health
home entities, etc. that the provider entity is
associated with.
A record segment to capture the number of
beds available for various categories of bed
at provider entities that are facilities.
A record segment containing metadata
necessary to identify the file itself, when it
was created and the number of records it
contains.
A record segment to capture basic,
generally static information to identify
Medicaid/CHIP enrollees for whom third
party funds may be available to offset some
or all their Medicaid/CHIP costs.
A record segment to capture insurance
policy information needed to facilitate
pursuit of the third-party liability.
A record segment to capture TPL insurance
coverage information to support the
applicability assessment of the third-party
insurance coverage to the Medicaid/CHIP
costs incurred on behalf of the
Medicaid/CHIP enrollee.
A record segment to flag Medicaid/CHIP
enrollees who potentially have noninsurance sources of funds that could be
used to offset Medicaid/CHIP expenditures.
A record segment to capture addresses and
phone numbers of the entity providing TPL
insurance coverage.

FLF Record
Segment Length
1,100
1,100

1,100
900

900

900

900

900

900

Record Segment Relationships Figures
Claim IP File – Record Segment Relationships
Figure 1: Claim IP File – Claim Record Segment Relationships

Description of Figure 1:
Each claim record in the T-MSIS inpatient claims file is composed of three types of record segments: One claim header segment, one or more
claim diagnosis segments, and one or more claim line segments. Each claim diagnosis segment and claim line segment joins to its corresponding
claim header segment on the following five data elements:
1. SUBMITTING-STATE
2. ICN-ORIG
3. ICN-ADJ
4. ADJUDICATION-DATE
5. ADJUSTMENT-IND (joins to LINE-ADJUSTMENT-IND for claim line segments)

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Claim LT File – Record Segment Relationships
Figure 2: Claim LT File – Claim Record Segment Relationships

Description of Figure 2:
Each claim record in the T-MSIS long-term care claims file is composed of three types of record segments: One claim header segment, one or
more claim diagnosis segments, and one or more claim line segments. Each claim diagnosis segment and claim line segment joins to its
corresponding claim header segment on the following five data elements:
1. SUBMITTING-STATE
2. ICN-ORIG
3. ICN-ADJ
4. ADJUDICATION-DATE
5. ADJUSTMENT-IND (joins to LINE-ADJUSTMENT-IND for claim line segments)

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Claim OT File – Claim Record Segment Relationships
Figure 3: Claim OT File – Claim Record Segment Relationships

Description of Figure 3:
Each claim record in the T-MSIS other claims file is composed of three types of record segments: One claim header segment, one or more claim
diagnosis segments, and one or more claim line segments. Each claim diagnosis segment and claim line segment joins to its corresponding claim
header segment on the following five data elements:
1. SUBMITTING-STATE
2. ICN-ORIG
3. ICN-ADJ
4. ADJUDICATION-DATE
5. ADJUSTMENT-IND (joins to LINE-ADJUSTMENT-IND for claim line segments)

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Claim RX File – Claim Record Segment Relationships
Figure 4: Claim RX File – Claim Record Segment Relationships

Description of Figure 4:
Each claim record in the T-MSIS pharmacy claims file is composed of three types of record segments: One claim header segment, one or more
claim diagnosis segments, and one or more claim line segments. Each claim diagnosis segment and claim line segment joins to its corresponding
claim header segment on the following five data elements:
1. SUBMITTING-STATE
2. ICN-ORIG
3. ICN-ADJ
4. ADJUDICATION-DATE
5. ADJUSTMENT-IND (joins to LINE-ADJUSTMENT-IND for claim line segments)

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Eligible File – Eligible Person Record Segment Relationships
Figure 5: Eligible File – Eligible Person Record Segment Relationships

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Description of Figure 5:
Each eligible person in T-MSIS has a record in the T-MSIS eligibility file. Each of these records is comprised of up to twenty-one different types of
record segments. The PRIMARY-DEMOGRAPHICS-ELIGIBILITY (ELG00002) segment is the parent segment and all other segments, except for the
HEALTH-HOME-SPA-PROVIDERS (ELG00007) segment, join to it on the following two data elements:
1. SUBMITTING-STATE
2. MSIS-IDENTIFICATION-NUM
The exception, the HEALTH-HOME-SPA-PROVIDERS (ELG00007) segment, is a child of the HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
(ELG00006) segment and joins to it on:
1. SUBMITTING-STATE
2. MSIS-IDENTIFICATION-NUM
3. HEALTH-HOME-SPA-ID
4. HEALTH-HOME-ENTITY-NAME

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Financial Transactions File – Record Segment Relationships
Figure 9: Financial Transactions File – FTX Record Segment Relationships

Description of Figure 9:
Unlike the other T-MSIS file types, the Financial Transactions file does not contain relationships among the segments. Each segment in this file
represents a different type of financial transaction, except for the “miscellaneous” segment which can represent multiple types of financial
transactions. The purpose of the “miscellaneous” segment is to represent financial transactions which are not common across states and/or
occur in relatively low volumes within most states, as well as to provide a flexible mechanism for CMS and/or states to add new financial
transactions in a much shorter time cycle than would be possible by adding an entirely new segment. The “miscellaneous” segment utilizes a
generalized set of data elements and an expandable valid value list to distinguish different types of financial transactions from one another.

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Managed Care File – Managed Care Entity Record Segment Relationships
Figure 2: Managed Care File – Managed Care Entity Record Segment Relationships

Description of Figure 7:
Each managed care entity in T-MSIS must have a record in the T-MSIS managed care file. Each managed care record is comprised of up to seven
different types of record segments. The MANAGED-CARE-MAIN (MCR00002) segment is the parent segment to five segments: MANAGED-CARELOCATION-AND-CONTACT-INFO (MCR00003), MANAGED-CARE-SERVICE-AREA (MCR00004), MANAGED-CARE-OPERATING-AUTHORITY
(MCR00005), MANAGED-CARE-PLAN-POPULATION-ENROLLED (MCR00006), MANAGED-CARE-ACCREDITATION-ORGANIZATION (MCR00007) and
MANAGED-CARE-PLAN-ID (MCR00010) all of which join to MANAGED-CARE-MAIN and to each other on the following two data elements:
1.
SUBMITTING-STATE
2.
STATE-PLAN-ID-NUM

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Provider File – Provider Record Segment Relationships
Figure 6: Provider File – Provider Record Segment Relationships

Description of Figure 6:
Each provider in T-MSIS (regardless of whether the provider is a single individual, a group of practitioners, a facility, or a group of facilities) must
have a record in the T-MSIS provider’s file. Each provider record is comprised of up to nine different types of record segments. The PROVATTRIBUTES-MAIN (PRV00002) segment is the parent segment to five segments: PROV-TAXONOMY-CLASSIFICATION (PRV00006), PROVMEDICAID-ENROLLMENT (PRV00007), PROV-AFFILIATED-GROUPS (PRV00008), PROV-AFFILIATED-PROGRAMS (PRV00009), and PROV-LOCATIONAND-CONTACT-INFO (PRV00003), all of which join to PROV-ATTRIBUTES-MAIN on the following two data elements:
1.
SUBMITTING-STATE
2.
SUBMITTING-STATE-PROV-ID

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In addition, the PROV-LOCATION-AND-CONTACT-INFO (PRV00003) segment is a parent segment to three additional subordinate segments:
PROV-IDENTIFIERS (PRV00005), PROV-LICENSING-INFO (PRV00004), PROV-BED-TYPE-INFO (PRV00010). These three segments join to the PROVLOCATION-AND-CONTACT-INFO segment on:
1.
SUBMITTING-STATE
2.
SUBMITTING-STATE-PROV-ID
3.
PROV-LOCATION-ID

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Third-Party Liability File – Record Segment Relationships
Figure 3: Third-Party Liability (TPL) File – TPL Record Segment Relationships

Description of Figure 8:
Each instance of potential third-party liability for T-MSIS eligibles must have a record in the T-MSIS TPL file. There are two sets of information
captured (called “subject areas”) in the TPL file: One set of records captures general information about non-Medicaid, non-Medicare health
insurers, while the other set of records captures information about third party sources of funds that individual Medicaid/CHIP eligibles have.
TPL Health Insurance Entity Subject Area
Two types of record segments comprise the “TPL health insurance entity subject area:” the TPL-ENTITY-CONTACT-INFORMATION (TPL00006) and
TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES (TPL00004) segments. There is a one-to-many relationship
between these segment types (one TPL-ENTITY-CONTACT-INFORMATION segment type to many TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH- 30 -

INSURANCE-COVERAGE-CATEGORIES segments). The TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES segment
joins to the TPL-ENTITY-CONTACT-INFORMATION segment on two fields:
1.
SUBMITTING-STATE
2.
INSURANCE-CARRIER-ID-NUM
Medicaid/CHIP Enrollees with TPL Funding Subject Area
Three types of segments make up the “Medicaid/CHIP Enrollees with TPL Funding Subject Area.” The TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
(TPL00002) segment type is the parent segment, with TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO (TPL00003) and
TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION (TPL00005) being the subordinate segments. The two subordinate
segments join to TPL-MEDICAID-ELIGIBLE-PERSON-MAIN (TPL00002) segment on:
1.
SUBMITTING-STATE
2.
MSIS-IDENTIFICATION-NUM

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