Redline - Data Dictionary

T-MSIS Data Dictionary - v2.4.0 to v4.0.0 Redline.pdf

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

Redline - Data Dictionary

OMB: 0938-0345

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Centers for Medicaid and CHIP Services (CMCS)

T-MSIS Data Dic,onary - Changes Between Versions 2.4.0 and 4.0.0 - Redline
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 09380345 (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.
T-MSIS Data Dic,onary – CIP File Changes Between Versions 2.4.0 and 4.0.0 .......................................................................................................................................................................................................................................................................................................................... 2
T-MSIS Data Dic,onary – CLT File Changes Between Versions 2.4.0 and 4.0.0 ...................................................................................................................................................................................................................................................................................................................... 109
T-MSIS Data Dic,onary – COT File Changes Between Versions 2.4.0 and 4.0.0 ..................................................................................................................................................................................................................................................................................................................... 196
T-MSIS Data Dic,onary – CRX File Changes Between Versions 2.4.0 and 4.0.0 ..................................................................................................................................................................................................................................................................................................................... 289
T-MSIS Data Dic,onary – ELG File Changes Between Versions 2.4.0 and 4.0.0 ..................................................................................................................................................................................................................................................................................................................... 358
T-MSIS Data Dic,onary – MCR File Changes Between Versions 2.4.0 and 4.0.0 .................................................................................................................................................................................................................................................................................................................... 460
T-MSIS Data Dic,onary – PRV File Changes Between Versions 2.4.0 and 4.0.0 ..................................................................................................................................................................................................................................................................................................................... 490
T-MSIS Data Dic,onary – TPL File Changes Between Versions 2.4.0 and 4.0.0 ...................................................................................................................................................................................................................................................................................................................... 530
T-MSIS Data Dic,onary – FTX File Changes Between Versions 2.4.0 and 4.0.0 ..................................................................................................................................................................................................................................................................................................................... 555

T-MSIS Data Dic,onary – CIP File Changes Between Versions 2.4.0 and 4.0.0

Data
Element
Number

System Data
Element
Number

Data Element

Data Element
Name Text

Data
Element
Necessity

Deﬁni,on

Valid Value List
(VVL)

File
Segment
Number

File Segment
Name

Size

Pipe
Separated
Value
Segment
Data
Element
Order

Fixed
Length
Field
Start
Posi,on

Fixed
Coding Requirements
Length
Field
Stop
Posi,on

CIP001

CIP.001.001

RECORD-ID

Record ID

Mandatory

The Record Identifier element uniquely identifies
each segment in a multi-segment entity record and is
primarily used as a "key" to maintain referential
integrity between data distributed over many
segments for a particular entity.The Record ID

RECORD-ID

CIP00001

FILE-HEADERRECORD-IP

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CIP00001"

DATADICTIONARYVERSION

CIP00001

FILE-HEADERRECORD-IP

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

SUBMISSIONTRANSACTIONTYPE

CIP00001

FILE-HEADERRECORD-IP

X(1)

1.1. Value must be 1 character

represents the type of segment being reported.
The Record ID communicates how the contents
of a given row of data should be interpreted
depending on which segment type the Record
ID represents. Each type of segment collects
diﬀerent data elements so each segment type
has a disLnct layout. The ﬁrst 3 characters
idenLfy the relevant ﬁle (e.g., ELG, PRV, CIP,
etc.). The last 5 digits are the segment idenLﬁer
padded with leading zeros (e.g., 00001, 00002,
00003, etc.).
CIP002

CIP.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

CIP003

CIP.001.003

SUBMISSIONTRANSACTIONTYPE

Submission
TransacLon
Type

Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

2. Value must be in Submission TransacLon
Type List (VVL)

2. Value must be 1 character
3.3. Mandatory

CIP004

CIP.001.004

FILE-ENCODINGSPECIFICATION

File Encoding
SpeciﬁcaLon

Mandatory

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

CIP00001

FILE-HEADERRECORD-IP

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

CIP005

CIP.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state
submission ﬁle. Use the version number specified

N/A

CIP00001

FILE-HEADERRECORD-IP

X(9)

1. Value must be 9 characters or less
2. Mandatory

A code to idenLfy the subject area to which the N/A
records in its ﬁle relate. Each T-MSIS submission
ﬁle should only contain records for one subject
area (i.e., Eligible, Third-party liability, Provider,
Managed Care Plan InformaLon, InpaLent,
Long-Term Care, Other, and Pharmacy Claim, and
Financial TransacLons).

CIP00001

FILE-HEADERRECORD-IP

X(8)

1. Value must equal 'CLAIM-IP'"CLAIM-IP"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CIP00001

The date on which the ﬁle was created.

N/A

on the title page of the data mapping document

CIP006

CIP007

CIP008

CIP.001.006

CIP.001.007

CIP.001.008

FILE-NAME

SUBMITTINGSTATE

DATE-FILECREATED

File Name

Submieng
State

Date File
Created

Mandatory

3. For TYPE-OF-SERVICE = 001, 058, 060, 084, 086,
090, 091, 092, 093, 123, 132, or 135, FILE-NAME
must be CLAIM-IP.

FILE-HEADERRECORD-IP

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory
CIP00001

FILE-HEADERRECORD-IP

9(8)

1.1. The date must be a valid calendar date in

the form "CCYYMMDD"
2. Value of the CC component must be "20"
23. Value must be 8 characters in the form
"CCYYMMDD"
3. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
4.less than current date

4. Value must be equal to or afer the value

of associated End of Time Period
5. Mandatory

CIP009

CIP.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

CIP00001

FILE-HEADERRECORD-IP

9(8)

1. Value of the CC component must be "20"
2. Value must be 8 characters in the form
"CCYYMMDD"
3.1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
4. Value must be less than current date
5.in the form "CCYYMMDD"

2. Value must be equal to or earlier than
associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"
CIP010

CIP.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

CIP00001

FILE-HEADERRECORD-IP

9(8)

1. ValueThe date must be 8 charactersa valid
calendar date in the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
4. Value must be equal to or earlier than

associated Date File Created
5

4. Value must be equal to or afer associated
Start of Time Period
6

5. Mandatory

CIP011

CIP.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

CIP00001

FILE-HEADERRECORD-IP

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
CIP012

CIP013

CIP.001.012

CIP.001.013

SSN-INDICATOR

TOT-REC-CNT

SSN Indicator

Total Record
Count

Mandatory

Indicates whether the state uses the eligible
person's social security number instead of an
MSIS IdenLﬁcaLon Number as the unique,
unchanging eligible person idenLﬁer. A state's
SSN/Non-SSN designaLon on the eligibility ﬁle
should match on the claims and third party
liability ﬁles.

SSN-INDICATOR

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

CIP00001

FILE-HEADERRECORD-IP

X(1)

1.1. Value must be 1 character

2. Value must be in SSN Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

CIP00001

FILE-HEADERRECORD-IP

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory
CIP014

CIP.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CIP00001

FILE-HEADERRECORD-IP

X(500)

582

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

CIP016

CIP.002.016

RECORD-ID

Record ID

Mandatory

RECORD-ID

CIP00002

CLAIMHEADERRECORD-IP

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CIP00002"

STATE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

1.1. Value must be 2 characters

CIP.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (CIP.001.007)
CIP018

CIP019

CIP.002.018

CIP.002.019

RECORDNUMBER

ICN-ORIG

Record Number

Original ICN

Mandatory

A sequenLal number assigned by the submiaer
to idenLfy each record segment row in the
submission ﬁle. The Record Number, in
conjuncLon with the Record IdenLﬁer, uniquely
idenLﬁes a single record within the submission
ﬁle.

N/A

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4. Mandatory

CIP00002

CLAIMHEADERRECORD-IP

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

CIP020

CIP.002.020

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(50)

121

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. If associated Adjustment Indicator value is
equals "0,", then value must not be
populated
4. CondiLonal
5. If associated Adjustment Indicator value
equals "4", then value must be populated

CIP021

CIP.002.021

SUBMITTER-ID

Submiaer ID

Mandatory

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(12)

122

133

1. Value must be 12 characters or less
2. Mandatory

CIP022

CIP.002.022

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

A state-assigned unique idenLﬁcaLon number
used to idenLfy a Medicaid/CHIP enrolled
individual (except on service tracking payments). .
Value may be an SSN, temporary SSN or Stateassigned eligible individual idenLﬁer. MSIS
IdenLﬁcaLon Numbers are a unique "key" value
used to maintain referenLal integrity of data
distributed over mulLples ﬁles, segments and
reporLng periods. See T-MSIS Guidance
Document, "CMS Guidance: ReporLng Shared
MSIS IdenLﬁcaLon Numbers" for informaLon on
reporLng the MSIS IdenLﬁcaLon Numbers ID for
pregnant women, unborn children, mothers,
and their deemed newborns younger than 1
year of age who share the same MSIS
IdenLﬁcaLon Number.
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47572reporLng-shared-msisidenLﬁcaLon-numbers-eligibility/

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(20)

134

153

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. When Type of Claim not in (4, D, X, Z, U, V, Y,
W),1. Value must be 20 characters or less

2. Mandatory
3. Value must match MSIS IdenLﬁcaLon
Number (ELG.021.251) and the Admission
Date (CIP.002.094) must be between
Enrollment EﬀecLve Date (ELG.021.253) and
Enrollment End Date (ELG.021.254)
6. When Type of Claim (CIP.002.100) equals 4, D
or X (lump sum payment) value must begin with
an '&'

CIP023

CIP.002.023

CROSSOVERINDICATOR

Crossover
Indicator

Conditional

Mandatory

An indicator specifying whether the claim is a
crossover claim where a porLon is paid by
Medicare.

CROSSOVERINDICATOR

CIP00002

CLAIMHEADERRECORD-IP

X(1)

154

1.1. Value must be 1 character

2. Value must be in Crossover Indicator List
(VVL)
23. If Crossover Indicator value isequals "1",
then associated Dual Eligible Code
(ELG.005.085) value must be in "[01", ",02",
",04", ",08", ",09", or ",10"] for the same Lme
period (by date of service)
3. Value must be 1 character
4. Conditional
5. If the TYPE-OF-CLAIM value is in ["1", "3", "A",
"C"], then value is mandatory and must be
reported.4. Mandatory

CIP024

CIP025

CIP026

CIP.002.024

CIP.002.025

CIP.002.026

TYPE-OFHOSPITAL

1115ADEMONSTRATIO
N-IND

ADJUSTMENTIND

Type of Hospital

1115A
DemonstraLon
Indicator

Adjustment
Indicator

Mandatory

This code denotes the type of hospital on the
claim (servicing facility).

TYPE-OFHOSPITAL

CondiLonal Indicates thatIn the claims ﬁles this data element
indicates whether the claim or encounter was
covered under the authority of an 1115(A)1115A
demonstraLon. 1115(A) is a Center for Medicare
and Medicaid InnovationIn the Eligibility ﬁle, this
data element indicates whether the individual
parLcipates in an 1115A demonstraLon.

1115ADEMONSTRATI
ON-IND

Mandatory

ADJUSTMENTIND

Indicates the type of adjustment record.

CIP00002

CLAIMHEADERRECORD-IP

X(2)

CLAIMHEADERRECORD-IP

X(1)

155

156

1.1. Value must be 2 characters

2. Value must be in Type of Hospital List (VVL)
2. Value must be 2 characters
3.3. Mandatory

157

1.1. Value must be 1 character

2. Value must be in 1115A DemonstraLon
Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal
4. When value equals '"0'", is invalid or not

populated, then the associated 1115A
DemonstraLon Indicator (ELG.018.2233) must
equal '"0'", is invalid or not populated
CIP00002

CLAIMHEADERRECORD-IP

X(1)

158

1.1. Value must be 1 character

2. Value must be in Adjustment Indicator List
(VVL)
2. If associated Type of Claim value is in [ 1, 3, 5,
A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]
3. If associated Type of Claim value is '4, D, X',
then. Value must be in [ 5, 6 0,1,4]
4. Value must be 1 character
5. Mandatory

5. If value equals "0", then associated

Adjustment ICN must not be populated
6. Value must equal "1", when associated
Claim Status equals "686"

CIP027

CIP.002.027

ADJUSTMENTREASON-CODE

Adjustment
Reason Code

CondiLonal Claim adjustment reason codes communicate
why a claim was paid diﬀerently than it was
billed. If the amount paid is different from the

ADJUSTMENTREASON-CODE

CIP00002

CLAIMHEADERRECORD-IP

X(3)

159

161

1.1. Value must be 3 characters or less

2. Value must be in Adjustment Reason Code
List (VVL)

amount billed you need an adjustment reason code.

2. Value must be 3 characters or less
3.3. CondiLonal
4. Value must not be populated when
associated Adjustment Indicator equals "0"the

total paid amount is diﬀerent from the total
billed amount
CIP028

CIP.002.028

ADMISSIONTYPE

Admission Type

Mandatory

The basic types of admission for InpaLent
hospital stays and a code indicaLng the priority
of this admission.

ADMISSIONTYPE

CIP00002

CLAIMHEADERRECORD-IP

X(1)

162

1.1. Value must be 1 character

2. Value must be in Admission Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

CIP029

CIP.002.029

DRGDESCRIPTION

DRG DescripLon CondiLonal DescripLon of the associated state-speciﬁc DRG
code. If using standard MS-DRG classiﬁcaLon
system, a DRG Description is not required.leave
blank.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(20)

163

182

1. Value must be 20 characters or less
2. CondiLonal

CIP030

CIP.002.030

ADMITTINGDIAGNOSIS-CODE

Admitting
Diagnosis Code

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

183

189

Conditional

ICD-9 or ICD-10 diagnosis codes used as a tool to
group and identify diseases, disorders, symptoms,
poisonings, adverse effects of drugs and chemicals,
injuries and other reasons for patient encounters.
Diagnosis codes should be passed through to T-MSIS
exactly as they were submitted by the provider on
their claim (with the exception of removing the
decimal). For example: 210.5 is coded as "2105".

6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
CIP031

CIP.002.031

ADMITTINGDIAGNOSIS-CODEFLAG

Admitting
Diagnosis Code
Flag

Mandatory

A flag that identifies the coding system used for the
Admitting Diagnosis Code.

ADMITTINGDIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

190

1. Value must be in Diagnosis Code Flag(VVL)
2. Value must be 1 character
3. Mandatory

CIP032

CIP.002.032

DIAGNOSISCODE-1

Diagnosis Code 1

Conditional

The primary/principal ICD-9/10-CM diagnosis code
as reported on the claim.

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

191

197

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. If Type of Claim (CIP.002.100) in ("1", "3", "A",
"C", "U", "W") then value must be populated.

CIP033

CIP.002.033

DIAGNOSISCODE-FLAG-1

Diagnosis Code
Flag 1

Conditional

Flag used to identify if associated Diagnosis Code
field is reported with ICD-9 or ICD-10 code. Each
Diagnosis Code Flag is associated with one, and only
one, Diagnosis Code in a given file segment record.
For example, Diagnosis Code n is associated with
Diagnosis Code Flag n, where n can be any integer
greater than or equal to 1.

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

198

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP034

CIP.002.034

DIAGNOSIS-POAFLAG-1

Diagnosis POA
Flag 1

Conditional

A code to identify conditions that are present at the
time the order for inpatient admission occurs;
conditions that develop during an outpatient
encounter, including emergency department,
observation, or outpatient surgery.

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

199

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

200

206

POA indicator is used to identify certain preventable
conditions that are: (a) high cost or high volume or
both, (b) result in the assignment of a case to a
Diagnosis Related Group (DRG)* that has a higher
payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through
the application of evidence-based guidelines.
*States that do not use the grouper methodology
may use CMS-approved methodology that is
prospective in nature.
Each Diagnosis Code Flag is associated with one, and
only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP035

CIP.002.035

DIAGNOSISCODE-2

Diagnosis Code 2

Conditional

10. Value must not be populated when Diagnosis
Code 1 (CIP.002.032) is not populated
CIP036

CIP.002.036

DIAGNOSISCODE-FLAG-2

Diagnosis Code
Flag 2

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

207

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP037

CIP.002.037

DIAGNOSIS-POAFLAG-2

Diagnosis POA
Flag 2

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

208

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

209

215

POA indicator is used to identify certain preventable
conditions that are: (a) high cost or high volume or
both, (b) result in the assignment of a case to a
Diagnosis Related Group (DRG)* that has a higher
payment when present as a secondary diagnosis, and
(c) could reasonablyhave been prevented through
the application of evidence-based guidelines.
*States that do not use the grouper methodology
may use CMS-approved methodology that is
prospective in nature.
Each Diagnosis Code Flag is associated with one, and
only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP038

CIP.002.038

DIAGNOSISCODE-3

Diagnosis Code 3

Conditional

codes should be passed through to T-MSIS exactly as
they were submitted by the provider on their claim
(with the exception of removing the decimal). For
example: 210.5 is coded as "2105".

(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 2 (CIP.002.035) is not populated

CIP039

CIP.002.039

DIAGNOSISCODE-FLAG-3

Diagnosis Code
Flag 3

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

216

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP040

CIP.002.040

DIAGNOSIS-POAFLAG-3

Diagnosis POA
Flag 3

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

217

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP041

CIP.002.041

DIAGNOSISCODE-4

Diagnosis Code 4

Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

218

224

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 3 (CIP.002.038) is not populated

CIP042

CIP.002.042

DIAGNOSISCODE-FLAG-4

Diagnosis Code
Flag 4

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

225

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP043

CIP.002.043

DIAGNOSIS-POAFLAG-4

Diagnosis POA
Flag 4

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

226

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

POA indicator is used to identify certain preventable
conditions that are: (a) high cost or high volume or

both, (b) result in the assignment of a case to a
Diagnosis Related Group (DRG)* that has a higher
payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through
the application of evidence-based guidelines.
*States that do not use the grouper methodology
may use CMS-approved methodology that is
prospective in nature.
Each Diagnosis Code Flag is associated with one, and
only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP044

CIP.002.044

DIAGNOSISCODE-5

Diagnosis Code 5

Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

227

233

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 4 (CIP.002.041) is not populated

CIP045

CIP.002.045

DIAGNOSISCODE-FLAG-5

Diagnosis Code
Flag 5

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

234

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional

Diagnosis Code Flag n, where n can be any integer
greater than or equal to 1.
CIP046

CIP.002.046

DIAGNOSIS-POAFLAG-5

Diagnosis POA
Flag 5

Conditional

4. Value should not be populated, if the
associated diagnosis code is not populated
DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

235

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

236

242

CIP.002.047

DIAGNOSISCODE-6

Diagnosis Code 6

Conditional

8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 5 (CIP.002.044) is not populated
CIP048

CIP.002.048

DIAGNOSISCODE-FLAG-6

Diagnosis Code
Flag 6

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

243

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP049

CIP.002.049

DIAGNOSIS-POAFLAG-6

Diagnosis POA
Flag 6

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

244

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

245

251

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"

CIP.002.050

DIAGNOSISCODE-7

Diagnosis Code 7

Conditional

ICD-9 or ICD-10 diagnosis codes used as a tool to
group and identify diseases, disorders, symptoms,
poisonings, adverse effects of drugs and chemicals,

injuries and other reasons for patient encounters.
Diagnosis codes should be passed through to T-MSIS
exactly as they were submitted by the provider on
their claim (with the exception of removing the
decimal). For example: 210.5 is coded as "2105".

(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 6 (CIP.002.047) is not populated

CIP051

CIP.002.051

DIAGNOSISCODE-FLAG-7

Diagnosis Code
Flag 7

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

252

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP052

CIP.002.052

DIAGNOSIS-POAFLAG-7

Diagnosis POA
Flag 7

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

253

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

prospective in nature.
Each Diagnosis Code Flag is associated with one, and
only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP053

CIP.002.053

DIAGNOSISCODE-8

Diagnosis Code 8

Conditional

ICD-9 or ICD-10 diagnosis codes used as a tool to
group and identify diseases, disorders, symptoms,
poisonings,

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

254

260

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 7 (CIP.002.050) is not populated

adverse effects of drugs and chemicals, injuries and
other reasons for patient encounters. Diagnosis
codes should be passed through to T-MSIS exactly as
they were submitted by the provider on their claim
(with the exception of removing the decimal). For
example: 210.5 is coded as "2105".

CIP054

CIP.002.054

DIAGNOSISCODE-FLAG-8

Diagnosis Code
Flag 8

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

261

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP055

CIP.002.055

DIAGNOSIS-POAFLAG-8

Diagnosis POA
Flag 8

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

262

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

CIP.002.056

DIAGNOSISCODE-9

Diagnosis Code 9

Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

263

269

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 8 (CIP.002.053) is not populated

CIP057

CIP.002.057

DIAGNOSISCODE-FLAG-9

Diagnosis Code
Flag 9

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

270

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP058

CIP.002.058

DIAGNOSIS-POAFLAG-9

Diagnosis POA
Flag 9

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

271

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

272

278

CIP.002.059

DIAGNOSISCODE-10

Diagnosis Code
10

Conditional

5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 9 (CIP.002.056) is not populated
CIP060

CIP.002.060

DIAGNOSISCODE-FLAG-10

Diagnosis Code
Flag 10

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

279

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP061

CIP.002.061

DIAGNOSIS-POAFLAG-10

Diagnosis POA
Flag 10

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

280

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP062

CIP.002.062

DIAGNOSISCODE-11

Diagnosis Code
11

Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

281

287

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 10 (CIP.002.059) is not populated

CIP063

CIP.002.063

DIAGNOSISCODE-FLAG-11

Diagnosis Code
Flag 11

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

288

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CIP064

CIP.002.064

DIAGNOSIS-POAFLAG-11

Diagnosis POA
Flag 11

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

289

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through
the application of evidence-based guidelines.
*States that do not use the grouper methodology
may use CMS-approved methodology that is
prospective in nature.
Each Diagnosis Code Flag is associated with one, and
only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CIP065

CIP.002.065

DIAGNOSISCODE-12

Diagnosis Code
12

Conditional

DIAGNOSISCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(7)

290

296

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 11 (CIP.002.062) is not populated

CIP066

CIP.002.066

DIAGNOSISCODE-FLAG-12

Diagnosis Code
Flag 12

Conditional

DIAGNOSISCODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

297

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

Diagnosis Code Flag n, where n can be any integer
greater than or equal to 1.
CIP067

CIP.002.067

DIAGNOSIS-POAFLAG-12

Diagnosis POA
Flag 12

Conditional

DIAGNOSISPOA-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

298

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(4)

5315

299183

302186

1. Value must be 4 characters or less
2. CondiLonal

CIP068

CIP.002.068

DIAGNOSISRELATED-GROUP

Diagnosis
Related Group

CondiLonal A code represenLng the Diagnosis Related
Group (DRG) that is applicable for the inpaLent
services being rendered. This ﬁeld is required on
FFS claims and encounters records in which
diagnosis related groups are used to determine
paid amounts.

CIP069

CIP.002.069

DIAGNOSISRELATEDGROUP-IND

Diagnosis
Related Group
Indicator

CondiLonal An indicator idenLfying the grouping algorithm
used to assign Diagnosis Related Group (DRG)
values. Values are generated by combining two
types of informaLon: PosiLon 1-2, State/Group
generaLng DRG: If state speciﬁc system, ﬁll with
two digit US postal code representaLon for
state. If CMS Grouper, ﬁll with 'HG'. If any other
system, ﬁll with 'XX'. PosiLon 3-4, ﬁll with the
number that represents the DRG version used
(01-98). For example, 'HG15' would represent
CMS Grouper version 15. If version is unknown,
ﬁll with '99'.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(4)

5416

303187

306190

1. Value must be 4 characters or less
2. The right-most 2 posiLons must be found
in [01-99]
3. CondiLonal
4. Value must be populated, when associated
Diagnosis Related Group (CIP.002.068) is
populated

CIP070

CIP.002.070

PROCEDURECODE-1

Procedure Code
1

CondiLonal A procedure code based on ICD-9 and ICD-10
used by the state to idenLfy the procedures
performed during the hospital stay referenced
by this claim. The principal procedure and
related info should be recorded in ProcedureCODE-1, PROCEDURE-CODE- Code1, Procedure
Code Date-1, and Procedure-CODE-FLAG- Code
Flag 1. The principal procedure is performed for
deﬁniLve treatment rather than for diagnosLc
or exploratory purposes. It is closely related to
either the principal diagnosis or to
complicaLons that arise during other
treatments. Use Procedure-CODE- Code 2
through Procedure-CODE- Code 6 (and related
data elements) to record secondary, terLary,
etc. procedures.

PROCEDURECODE

CIP00002

CLAIMHEADERRECORD-IP

X(8)

5517

307191

314198

1.1. Value must be 8 characters or less

PROCEDURECODE-MOD-1

Procedure Code
Modifier 1

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

CIP071

CIP.002.071

[No longer essential - Both data element and
associated requirement(s); preserved for file
submission integrity. See Data Dictionary v2.3 for

2. When populated, there must be a
corresponding Procedure Code Flag
23. If associated Procedure Code Flag List
(VVL) value indicates an ICD-9-CM encoding
'"02'", then value must be a valid ICD-9-CM
procedure code
34. If associated Procedure Code Flag List
(VVL) value indicates an ICD-10-CM encoding
'"07'", then value must be a valid ICD-10-CM
procedure code
45. If associated Procedure Code Flag List
(VVL) value indicates an "Other" encoding '1087',"10-87", then State must provide T-MSIS
system with State-speciﬁc procedure code
list, and value must be a valid State-speciﬁc
procedure code
56. Value must be 8 characters or less
6. in Procedure Code List (VVL)
7. CondiLonal
56

315

316

1. Not Applicable

specific definition and coding requirement
description(s).]

CIP072

CIP.002.072

PROCEDURECODE-FLAG-1

Procedure Code
Flag 1

CondiLonal A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

PROCEDURECODE-FLAG

CIP00002

CLAIMHEADERRECORD-IP

X(2)

5718

317199

318200

1.1. Value must be 2 characters

2. Value must be in Procedure Code Flag List
(VVL)
3. CondiLonal
4. When populated, there must be a
corresponding Procedure Code
2. Value must be in Procedure Code Flag List (VVL)
3. Value must be 2 characters
4.5. If Procedure Code 1 (CIP.002.070) is

populated, Procedure Code Flag 1
(CIP.002.072) must be '"02'" (ICD-9 CM) or
'"07'" (ICD-10 - CM PCS).
5. Conditional)
CIP073

CIP.002.073

PROCEDURECODE-DATE-1

Procedure Code
Date 1

CondiLonal The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

5819

319201

326208

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only in the form "CCYYMMDD"
2. Value must be on the leap year, never April
31st or Sept 31st)
3. Value must be before associated
EndingDischarge Date of Service value
43. Value must be provided with an

associated Procedure Code value
54. Value must be on or afer associated
Beginning Date of Service value
65. Value must be on or before associated
Eligible Date of Death value
76. Value must be not be populated when
associated Procedure Code is not populated
87. CondiLonal

CIP074

CIP.002.074

PROCEDURECODE-2

Procedure Code
2

CondiLonal A procedure code based on ICD-9 and ICD-10
used by the state to idenLfy the procedures
performed during the hospital stay referenced
by this claim. The principal procedure and
related info should be recorded in Procedure
Code 1, Procedure-CODE-DATE- Code 1, and
Procedure-CODE-FLAG- Code Flag 1. The principal
procedure is performed for deﬁniLve treatment
rather than for diagnosLc or exploratory
purposes. It is closely related to either the
principal diagnosis or to complicaLons that arise
during other treatments. Use Procedure-CODECode 2 through Procedure-CODE- Code 6 (and
related data elements) to record secondary,
terLary, etc. procedures.

PROCEDURECODE

CIP00002

N/A

PROCEDURECODE-FLAG

CIP075

CIP.002.075

PROCEDURECODE-MOD-2

Procedure Code
Modifier 2

Not
Applicable

[No longer essential - Both data element and
associated requirement(s); preserved for file
submission integrity. See Data Dictionary v2.3 for
specific definition and coding requirement
description(s).]

CIP076

CIP.002.076

PROCEDURECODE-FLAG-2

Procedure Code
Flag 2

CondiLonal A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

CLAIMHEADERRECORD-IP

X(8)

5920

327209

334216

1.1. Value must be 8 characters or less

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

335

336

1. Not Applicable

CIP00002

CLAIMHEADERRECORD-IP

X(2)

6121

337217

338218

1. When populated, thereValue must be a
corresponding Procedure Code2 characters
2. Value must be in Procedure Code Flag List
(VVL)
3. Value must be 2 characters
4. CondiLonal
4. When populated, there must be a
corresponding Procedure Code

CIP077

CIP.002.077

PROCEDURECODE-DATE-2

Procedure Code
Date 2

CondiLonal The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

6222

339219

346226

CIP.002.078

PROCEDURECODE-3

Procedure Code
3

CondiLonal A procedure code based on ICD-9 and ICD-10
used by the state to idenLfy the procedures
performed during the hospital stay referenced
by this claim. The principal procedure and
related info should be recorded in ProcedureCODE- Code 1, Procedure-CODE-DATE- Code Date
1, and Procedure-CODE-FLAG- Code Flag 1. The
principal procedure is performed for deﬁniLve
treatment rather than for diagnosLc or
exploratory purposes. It is closely related to
either the principal diagnosis or to
complicaLons that arise during other
treatments. Use Procedure-CODE- Code 2
through Procedure-CODE- Code 6 (and related
data elements) to record secondary, terLary,
etc. procedures.

PROCEDURECODE

CIP00002

CLAIMHEADERRECORD-IP

X(8)

6323

347227

2354

1.1. Value must be 8 characters or less

6. in Procedure Code List (VVL)

7. CondiLonal

CIP079

CIP.002.079

PROCEDURECODE-MOD-3

Procedure Code
Modifier 3

Not
Applicable

CIP080

CIP.002.080

PROCEDURECODE-FLAG-3

Procedure Code
Flag 3

CondiLonal A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

355

356

1. Not Applicable

PROCEDURECODE-FLAG

CIP00002

CLAIMHEADERRECORD-IP

X(2)

6524

2357

358236

CIP081

CIP.002.081

PROCEDURECODE-DATE-3

Procedure Code
Date 3

CondiLonal The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

6625

359237

366244

CIP.002.082

PROCEDURECODE-4

Procedure Code
4

CondiLonal A procedure code based on ICD-9 and ICD-10
used by the state to idenLfy the procedures
performed during the hospital stay referenced
by this claim. The principal procedure and
related info should be recorded in ProcedureCODE- Code 1, Procedure-CODE-DATE- Code Date
1, and Procedure-CODE-FLAG- Code Flag 1. The
principal procedure is performed for deﬁniLve
treatment rather than for diagnosLc or
exploratory purposes. It is closely related to
either the principal diagnosis or to
complicaLons that arise during other
treatments. Use Procedure-CODE- Code 2
through Procedure-CODE- Code 6 (and related
data elements) to record secondary, terLary,
etc. procedures.

PROCEDURECODE

CIP00002

CLAIMHEADERRECORD-IP

X(8)

6726

367245

374252

1.1. Value must be 8 characters or less

6. in Procedure Code List (VVL)

7. CondiLonal

CIP083

CIP.002.083

PROCEDURECODE-MOD-4

Procedure Code
Modifier 4

Not
Applicable

CIP084

CIP.002.084

PROCEDURECODE-FLAG-4

Procedure Code
Flag 4

CondiLonal A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

375

376

1. Not Applicable

PROCEDURECODE-FLAG

CIP00002

CLAIMHEADERRECORD-IP

X(2)

6927

377253

378254

CIP085

CIP.002.085

PROCEDURECODE-DATE-4

Procedure Code
Date 4

CondiLonal The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

7028

379255

386262

CIP.002.086

PROCEDURECODE-5

Procedure Code
5

CondiLonal A procedure code based on ICD-9 and ICD-10
used by the state to idenLfy the procedures
performed during the hospital stay referenced
by this claim. The principal procedure and
related info should be recorded in ProcedureCODE- Code 1, Procedure-CODE-DATE- Code Date
1, and Procedure-CODE-FLAG- Code Flag 1. The
principal procedure is performed for deﬁniLve
treatment rather than for diagnosLc or
exploratory purposes. It is closely related to
either the principal diagnosis or to
complicaLons that arise during other
treatments. Use Procedure-CODE- Code 2
through Procedure-CODE- Code 6 (and related
data elements) to record secondary, terLary,
etc. procedures.

PROCEDURECODE

CIP00002

CLAIMHEADERRECORD-IP

X(8)

7129

387263

394270

1.1. Value must be 8 characters or less

6. in Procedure Code List (VVL)

7. CondiLonal

CIP087

CIP.002.087

PROCEDURECODE-MOD-5

Procedure Code
Modifier 5

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

395

396

1. Not Applicable

CIP088

CIP.002.088

PROCEDURECODE-FLAG-5

Procedure Code
Flag 5

Not
ApplicableC

A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

PROCEDURECODE-FLAG

CIP00002

CLAIMHEADERRECORD-IP

X(2)

7330

397271

398272

1.1. Value must be 2 characters

ondiLonal

CIP089

CIP.002.089

PROCEDURECODE-DATE-5

Procedure Code
Date 5

CondiLonal The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

7431

399273

406280

CIP.002.090

PROCEDURECODE-6

Procedure Code
6

CondiLonal A procedure code based on ICD-9 and ICD-10
used by the state to idenLfy the procedures
performed during the hospital stay referenced
by this claim. The principal procedure and
related info should be recorded in Procedure
Code 1, Procedure-CODE-DATE- Code Date 1, and
Procedure-CODE-FLAG- Code Flag 1. The principal
procedure is performed for deﬁniLve treatment
rather than for diagnosLc or exploratory
purposes. It is closely related to either the
principal diagnosis or to complicaLons that arise
during other treatments. Use Procedure-CODECode 2 through Procedure-CODE- Code 6 (and
related data elements) to record secondary,
terLary, etc. procedures.

PROCEDURECODE

CIP00002

CLAIMHEADERRECORD-IP

X(8)

7532

407281

414288

1.1. Value must be 8 characters or less

6. in Procedure Code List (VVL)

7. CondiLonal

CIP091

CIP.002.091

PROCEDURECODE-MOD-6

Procedure Code
Modifier 6

Not
Applicable

CIP092

CIP.002.092

PROCEDURECODE-FLAG-6

Procedure Code
Flag 6

CondiLonal A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

PROCEDURECODE-MOD

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

415

416

1. Not Applicable

PROCEDURECODE-FLAG

CIP00002

CLAIMHEADERRECORD-IP

X(2)

7733

417289

418290

CIP093

CIP.002.093

PROCEDURECODE-DATE-6

Procedure Code
Date 6

Not
ApplicableC

ondiLonal

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

7834

419291

426298

CIP.002.094

ADMISSIONDATE

Admission Date

Mandatory

The date on which the recipient was admiaed to
a hospital.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

7935

427299

434306

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be less than or equal to
associated Discharge Date value in the claim
header.
4

3. Value must be greater than or equal to
associated eligible Date of Birth value.
5

4. Value must be less than or equal to
associated eligible Date of Death value.
6

5. Mandatory
76. Value must be between Enrollment
EﬀecLve Date (ELG.021.253) and Enrollment
End Date (ELG.021.254)

8. (capitated payment) when associated Type of
Claim (CIP.002.100) is not '2','B' or 'V' and Type of
Service (CIP.002.257) is not '119, '120', '121',
122'7. Value must be before AdjudicaLon

Date (CIP.003.286)

CIP095

CIP.002.095

ADMISSIONHOUR

Admission Hour

CondiLonal The hour of admission to a hospital.

HOUR

CIP00002

CLAIMHEADERRECORD-IP

X(2)

8036

435307

436308

1.1. Value must be 2 characters

2. Value must be in Hour List (VVL)
2. Value must be 2 characters

3. CondiLonal

CIP096

CIP.002.096

DISCHARGEDATE

Discharge Date

CondiLonal The date on which the recipient was discharged
from a hospital.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

8137

437309

444316

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be less than or equal to
associated AdjudicaLon Date value.
43. Value must be greater than or equal to
associated Admission Date value.
54. Value must be greater than or equal to
associated eligible Date of Birth value.
65. Value must be less than or equal to
associated eligible Date of Death value.
76. CondiLonal
87. If associated Adjustment Indicator
(CIP.002.026) does not equal "1" (Non-denied
claims) and PaLent Status (CIP.002.199) is not
equal to "30" value must be populated.
8. When populated, Discharge Hour
(CIP.002.097) must be populated
CIP097

CIP.002.097

DISCHARGEHOUR

Discharge Hour

CondiLonal The hour of discharge from a hospital.

HOUR

CIP00002

CLAIMHEADERRECORD-IP

X(2)

8238

445317

446318

1.1. Value must be 2 characters

2. Value must be in Hour List (VVL)
2. Value must be 2 characters
3.3. CondiLonal

4. When populated, Discharge Date
(CIP.002.096) must be populated
CIP098

CIP.002.098

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

8339

447319

454326

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in associated T-MSIS File
Header Record

4. (CIP.001.010)

3. Mandatory
54. Value should be on or afer associated
Admission Date value

CIP099

CIP.002.099

MEDICAID-PAIDDATE

Medicaid Paid
Date

Mandatory

The date Medicaid paid this claim or
adjustment. For Encounter Records (Type of
Claim = 3, C, W), the date the managed care
organizaLon paid the provider for the claim or
adjustment.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

8440

455327

462334

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Total Medicaid
Paid Amount
43. Mandatory
CIP100

CIP101

CIP.002.100

CIP.002.101

TYPE-OF-CLAIM

TYPE-OF-BILL

Type of Claim

Type of Bill

Mandatory

A code to indicate what type of payment is
covered in this claim. For sub-capitated
encounters from a sub-capitated enLty or subcapitated network provider, report TYPE-OFCLAIM = "3" for a Medicaid sub-capitated
encounter record or “C” for an S-CHIP subcapitated encounter record.

TYPE-OF-CLAIM

A data element corresponding with UB-04 form
locator FL4 that classiﬁes the claim as to the
type of facility (2nd digit), type of care (3rd digit)
and the billing record's sequence in the episode
of care (4th digit). (Note that the 1st digit is
always zero.)

TYPE-OF-BILL

CIP00002

CLAIMHEADERRECORD-IP

X(1)

CLAIMHEADERRECORD-IP

X(4)

8541

463335

1.1. Value must be 1 character

2. Value must be in Type of Claim List (VVL)
2. Value must be 1 character
3.3. Mandatory
4. When value equals 'Z', claim denied indicator
must equal '0'

8642

464336

467339

1.1. Value must be 4 characters

2. Value must be in Type of Bill List (VVL)
2. Value must be 4 characters
3.3. First character must be a '0'"0"

4. Mandatory

CIP102

CIP.002.102

CLAIM-STATUS

Claim Status

CondiLonal The health care claim status codes convey the
status of an enLre claim. status codes from the
277 transacLon set. Only report the claim status
for the ﬁnal, adjudicated claim.

CLAIM-STATUS

CIP00002

CLAIMHEADERRECORD-IP

X(3)

8743

468340

470342

1.1. Value must be 3 characters or less

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. If value in [ 26, 87, 542,585,654 ],], then
Claim Denied Indicator must be '0'"0" and

Claim Status Category must be "F2"
CIP103

CIP.002.103

CLAIM-STATUSCATEGORY

Claim Status
Category

Mandatory

The general category of the claim status
(accepted, rejected, pended, ﬁnalized,
addiLonal informaLon requested, etc.), which is
then further detailed in the companion data
element claim-STATUS status.

CLAIM-STATUSCATEGORY

CIP00002

CLAIMHEADERRECORD-IP

X(3)

8844

471343

473345

1.1. Value must be 3 characters or less

2. Value must be in Claim Status Category List
(VVL)
23. (Denied Claim) if associated Claim Denied
Indicator indicates the claim was denied,
then value must be "F2"
34. (Denied Claim) if associated Type of Claim
equals Z or associated Claim Status is in [ 26, 87,
542, 8585,654], then value must be "F2"
4. Value must be 3 characters or less

5. Mandatory

CIP104

CIP.002.104

SOURCELOCATION

Source LocaLon

Mandatory

The field denotes the claims payment system from
which the claim was extracted.The ﬁeld denotes

the claims payment system from which the
claim was extracted.

SOURCELOCATION

CIP00002

CLAIMHEADERRECORD-IP

X(2)

8945

474346

3475

1.1. Value must be 2 characters

2. Value must be in Source LocaLon List (VVL)
2. Value must be 2 characters
3.3. Mandatory

For sub-capitated encounters from a subcapitated enLty that is not a sub-capitated
network provider, report a SOURCE-LOCATION =
'22' to indicate that the sub-capitated enLty
paid a provider for the service to the enrollee on
a FFS basis.
For sub-capitated encounters from a subcapitated network provider that were submiaed
to sub-capitated enLty, report a SOURCELOCATION = '23' to indicate that the subcapitated network provider provided the service
directly to the enrollee.
For sub-capitated encounters from a subcapitated network provider, report a SOURCELOCATION = “23” to indicate that the subcapitated network provider provided the service
directly to the enrollee.
CIP105

CIP.002.105

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(15)

9046

476348

490362

1. Value must be 15 characters or less
2. Value must have an associated Check
EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

CIP106

CIP.002.106

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

9147

491363

498370

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Value may be the same as associated

Remittance Date
4. in the form "CCYYMMDD"

2. Must have an associated Check Number
53. CondiLonal
CIP107

CIP.002.107

ALLOWEDCHARGE-SRC

Allowed Charge
Source

Conditional

CIP108

CIP.002.108

CLAIM-PYMTREM-CODE-1

Claim
PaymentRemiaa

CondiLonal Remiaance Advice Remark Codes are used to
convey informaLon about remiaance processing
or to provide a supplemental explanaLon for an
adjustment already described by a Claim
Adjustment Reason Code. Each Remiaance
Advice Remark Code idenLﬁes a speciﬁc
message as shown in the Remiaance Advice
Remark Code List. It is a code set used by the
health care industry to convey non-ﬁnancial
informaLon criLcal to understanding the
adjudicaLon of a health care claim for payment.
It is an external code set whose use is as
mandated by the AdministraLve SimpliﬁcaLon
provisions of the Health Insurance Portability
and Accountably Act of 1996 (P.L.104-191,
commonly referred to as HIPAA).

nce Advice
Remark Code 1

These codes indicate how each allowed charge was
determined. Claims records for an eligible individual
should not indicate Medicare as the source to
indicate how an allowed charge was determined on
the claim, if the eligible individual is not a dual
eligible

ALLOWEDCHARGE-SRC

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

499

1. Value must be in Allowed Charge Source List
(VVL)
2. Value must be 1 character
3. Conditional
4. (not a Medicare Beneficiary) if Dual Eligible
(ELG.005.085) equals '00', then value must not be
in ['1','I', 'K', 'M']

CLAIM-PYMTREM-CODE

CIP00002

CLAIMHEADERRECORD-IP

X(5)

9348

500371

504375

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

Claim Payment Remark Code 1 through Claim
Payment Remark Code 4 is populated on a
claim, all values must be unique

CIP109

CIP110

CIP.002.109

CIP.002.110

CLAIM-PYMTREM-CODE-2

CLAIM-PYMTREM-CODE-3

Claim
PaymentRemiaa

nce Advice
Remark Code 2

Claim
PaymentRemiaa

nce Advice
Remark Code 3

CLAIM-PYMTREM-CODE

CIP00002

CLAIMHEADERRECORD-IP

X(5)

9449

505376

509380

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

Claim Payment Remark Code 1 through Claim
Payment Remark Code 4 is populated on a
claim, all values must be unique
5. Value must not be populated when Claim
PaymentRemiaance Advice Remark Code 1
(CIP.002.108) is not populated

CIP00002

CLAIMHEADERRECORD-IP

X(5)

9550

510381

514385

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

CIP111

CIP112

CIP.002.111

CIP.002.112

CLAIM-PYMTREM-CODE-4

TOT-BILLED-AMT

Claim
PaymentRemiaa

nce Advice
Remark Code 4

Total Billed
Amount

CLAIM-PYMTREM-CODE

CondiLonal The total amount billed for this claim at the
claim header level as submiaed by the provider.
For encounter records, when Type of Claim
value is [ in [3, C, or W], then value must equal
amount the provider billed to the managed care
plan. Total Billed AmountFor sub-capitated
encounters from a sub-capitated enLty that is
not expected on financial transactionsa subcapitated network provider, report the total
amount that the provider billed the subcapitated enLty for the service. Report a null
value in this ﬁeld if the provider is a subcapitated network provider. For sub-capitated
encounters from a sub-capitated network
provider, if the sub-capitated network provider
directly employs the provider that renders the
service to the enrollee, report a null value in this
ﬁeld.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(5)

9651

515386

519390

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

9752

520391

532403

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Value must equal the sum of all Billed
Amount instances for the associated claim
4. CondiLonal
5. Value should not be populated when
associated Type of Claim is in [2, 4, 5, B, D E or X]
6. (individual line item payments) when

populated and Payment Level Indicator
(CIP.002.132) equals = '2'"2" value must be
greater than or equal to the sum of all claim
line Revenue Charges (CIP.003.251)
7. If associated Type of Claim value is 2, 4, 5, B, D,
or E, then value should not be populated

CIP113

CIP.002.113

TOT-ALLOWEDAMT

Total Allowed
Amount

CondiLonal The claim header level maximum amount
determined by the payer as being 'allowable'
under the provisions of the contract prior to the
determinaLon of actual payment. On FFS claims
the Allowed Amount is determined by the
state's MMIS. On managed care encounters the
Allowed Amount is determined by the managed
care organizaLon. For sub-capitated encounters
from a sub-capitated enLty that is not a subcapitated network provider, report the total
amount that the sub-capitated enLty allowed
for the service. Report a null value in this ﬁeld if
the provider is a sub-capitated network
provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

9853

533404

545416

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. When populated and Payment Level
Indicator = '2'equals "2", then value must
equal the sum of all claim line Allowed
Amount values
4. CondiLonal

CIP114

CIP.002.114

TOT-MEDICAIDPAID-AMT

Total Medicaid
Paid Amount

CondiLonal The total amount paid by Medicaid/CHIP or the
managed care plan on this claim or adjustment
at the claim header level, which is the sum of
the amounts paid by Medicaid or the managed
care plan at the detail level for the claim.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

9954

546417

558429

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Must have an associated Medicaid Paid
Date
4. If Total Medicare Coinsurance Amount and
Total Medicare DeducLble Amount is
reported it must equal Total Medicaid Paid
Amount
5. When Payment Level Indicator equals '"2'",
value must equal the sum of line level
Medicaid Paid Amounts.
6. CondiLonal
7. Value must not be populated or equal to
"0.00" when associated Claim Status is in
[542,585,654]
8. Value must not be greater than Total
Allowed Amount (CIP.002.113)

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)
V99

100

559

571

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. If associated Crossover Indicator value is '0'
(not a crossover claim), then value should not be
populated.
4. (Medicare Enrolled) if associated Dual Eligible
Code (ELG.005.085) value is in ["01", "02", "03",
"04", "05", "06", "08", "09", or "10"], then value is
mandatory and must be provided
5. Conditional
6. When populated, value must be less than or
equal to Total Billed Amount

For sub-capitated encounters from a subcapitated enLty that is not a sub-capitated
network provider, report the total amount that
the sub-capitated enLty paid the provider for
the service. Report a null value in this ﬁeld if the
provider is a sub-capitated network provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.
CIP115

CIP.002.115

TOT-COPAY-AMT

Total Copayment
Amount

Conditional

The total amount paid by Medicaid/CHIP enrollee
for each office or emergency department visit or
purchase of prescription drugs in addition to the
amount paid by Medicaid/CHIP.

CIP116

CIP.002.116

TOT-MEDICAREDEDUCTIBLEAMT

Total Medicare
DeducLble
Amount

CondiLonal The amount paid by Medicaid/CHIP, on this
claim at the claim header level, toward the
beneﬁciary's Medicare deducLble. If the
Medicare deducLble amount can be idenLﬁed
separately from Medicare coinsurance
payments, code that amount in this ﬁeld. If the
Medicare coinsurance and deducLble payments
cannot be separated, ﬁll this ﬁeld with the
combined payment amount, code Medicare
Combined Indicator a "1"'1' and leave Total
Medicare Coinsurance Amount unpopulated.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

10155

572430

584442

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value is
'0'equals "0" (not a crossover claim), then
value should not be populated.
4. (Medicare Enrolled) if associated Dual
Eligible Code (ELG.005.085) value is in ["[01",
",02", ",03", ",04", ",05", ",06", ",08", ",09", or
",10"],], then value is mandatory and must be
provided
5. CondiLonal
6. When populated, value must be less than
or equal to Total Billed Amount

CIP117

CIP.002.117

TOT-MEDICARECOINS-AMT

Total Medicare
Coinsurance
Amount

CondiLonal The total amount paid by the Medicaid/CHIP
agency or a managed care plan towards the
porLon of the Medicare allowed charges that
Medicare applied to coinsurance.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

10256

585443

597455

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value is
'0'equals "0" (not a crossover claim), then
value should not be populated.
4. CondiLonal
5. If associated Medicare Combined
DeducLble Indicator is '1',equals "1", then
value must not be populated
6. When populated, value must be less than
or equal to Total Billed Amount

CIP118

CIP.002.118

TOT-TPL-AMT

Total Third Party
LiabilityTPL
Amount

CondiLonal Third-party liability refers to the legal obligaLon
of third parLes, i.e., certain individuals, enLLes,
or programs, to pay all or part of the
expenditures for medical assistance furnished
under a state plan. This is the total amount
denoted at the claim header level paid by the
third party.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

10357

598456

610468

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Value must be less than associated Total
Billed Amount - (Total Medicare Coinsurance
Amount + Total Medicare DeducLble
Amount)
4. CondiLonal

CIP119

CIP.002.119

TOT-OTHERINSURANCEAMT

Total Other
Insurance
Amount

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

10458

611469

623481

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP121

CIP.002.121

OTHERINSURANCE-IND

Other Insurance
Indicator

CondiLonal The ﬁeld denotes whether the insured party is
covered under anotheran other insurance plan
other than Medicare or Medicaid.

OTHERINSURANCEIND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

10559

624482

1.1. Value must be 1 character

This data element indicates that the claim is for
a beneﬁciary for whom other third party
resource development and collecLon acLviLes
are in progress, when the liability is not another
health insurance plan for which the eligible is a
beneﬁciary.

OTHER-TPLCOLLECTION

CIP00002

CLAIMHEADERRECORD-IP

X(3)

10660

625483

627485

1. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. ConditionalMandatory

A code to categorize service tracking claims. A
"service tracking claim" is used to report lump sum
payments that cannot be attributed to a single
enrollee.

SERVICETRACKING-TYPE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

107

628

629

1. Value must be in Service Tracking Type List
(VVL)
2. (Service Tracking Claim) if associated Type of
Claim is in ['4','D', 'X'] then value is mandatory
and must be reported
3. Value must be 2 characters
4. Conditional

CIP122

CIP.002.122

OTHER-TPLCOLLECTION

Other TPL
CollecLon

Conditional

CIP123

CIP.002.123

SERVICETRACKING-TYPE

Service Tracking
Type

Conditional

Mandatory

2. Value must be in Other Insurance Indicator
List (VVL)
23. Value must be in [0,1 character
3.] or not populated
4. CondiLonal

CIP124

CIP.002.124

SERVICETRACKINGPAYMENT-AMT

Service Tracking
Payment Amount

Conditional

CIP125

CIP.002.125

FIXED-PAYMENTIND

Fixed Payment
Indicator

CIP126

CIP.002.126

FUNDING-CODE

Funding Code

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)
V99

108

630

642

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. If associated Type of Claim value is in [4, D, or
X], then value is mandatory and must be provided
4. Conditional
5. When populated, Service Tracking Type must
be populated
6. When populated, Total Medicaid Amount must
not be populated

CondiLonal This indicator indicates that the reimbursement
amount included on the claim is for a ﬁxed
payment. Fixed payments are made by the state
to insurers or providers for premiums or eligible
coverage, not for a parLcular service. For
example, some states have Primary Care Case
Management programs where the state pays
providers a monthly paLent management fee of
$3.50 for each eligible parLcipant under their
care. This fee is considered a ﬁxed payment. It is
very important for states to correctly idenLfy
ﬁxed payments. Fixed payments do not have a
deﬁned "medical record"'medical record'
associated with the payment; therefore, ﬁxed
payments are not subject to medical record
request and medical record review.

FIXEDPAYMENT-IND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

10961

643486

1.1. Value must be 1 character

MandatoryC

FUNDINGCODE

ondiLonal

On service tracking claims, the payment amount is
the lump sum that cannot be attributed to any one
beneficiary paid to the provider.

A code to indicate the source of non-federal
share funds.

2. Value must be in Fixed Payment Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

11062

644487

645488

1.1. Value must be 1 character

2. Value must be in Funding Code List (VVL)
2.3. If Type of Claim is not in [3,C,W], then
value must be 1 character
3. Mandatorypopulated
4. CondiLonal

CIP127

CIP128

CIP.002.127

CIP.002.128

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Non-Federal
Share

Not
ApplicableC

MEDICARECOMB-DED-IND

Medicare
Combined
DeducLble
Indicator

CondiLonal Code indicaLng that the amount paid by
Medicaid/CHIP on this claim toward the
recipient's Medicare deducLble was combined
with their coinsurance amount because the
amounts could not be separated.

ondiLonal

A code to indicate the type of non-federal share
used by the state to ﬁnance its expenditure to
the provider. In the event of two sources, states
are to report the porLon which represents the
largest proporLon not funded by the Federal
government.

FUNDINGSOURCENONFEDERALSHARE

CIP00002

MEDICARECOMB-DEDIND

CIP00002

CLAIMHEADERRECORD-IP

X(2)

CLAIMHEADERRECORD-IP

X(1)

11163

646489

647490

1.1. Value must be 2 characters

2. Value must be in Funding Source NonFederal Share List (VVL)
2.3. If Type of Claim is in [3,C,W], then value
must be 2 characters
3. Requiredpopulated
4. CondiLonal
11264

648491

1.1. Value must be 1 character

2. Value must be in Medicare Combined
DeducLble Indicator List (VVL)
2. Value must be 1 character
3.3. If value equals '"1'", then Total Medicare
Coinsurance amount ismust not be
populated.
4. Value must equal '0' if associated Type of Claim
is '3', 'C' or 'W'If value equals "0", then

Crossover Indicator must equals "0"
5. If value equals "1", then Crossover
Indicator must equals "1"
6. CondiLonal
CIP129

CIP.002.129

PROGRAM-TYPE

Program Type

Mandatory

A code to indicate special Medicaid program
under which the service was provided.

PROGRAMTYPE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

11365

6492

650493

1.1. Value must be 2 characters

2. Value must be in Program Type List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. (Community First Choice) If value equals
'"11'", then State Plan OpLon Type
(ELG.011.163) must equal '"01'" for the same
Lme period
5. If value equals '"13'", then State Plan
OpLon Type (ELG.011.163) must equal '"02'"
for the same Lme period

CIP130

CIP.002.130

PLAN-IDNUMBER

Plan ID Number

CondiLonal A unique number assigned by the state which
represents a disLnct comprehensive managed
care plan, prepaid health plan, primary care
case management program, a program for allinclusive care for the elderly enLty, or other
approved plans.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(12)

11466

651494

662505

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal
4. Value must match Managed Care Plan ID
(ELG.014.192)
5. Value must match State Plan ID Number
(MCR.002.019)
6. When Type of Claim (CIP.002.100) in
([3,C,W, 2, B, V)] value must have a managed
care enrollment (ELG.014) for the beneﬁciary
where the Admission Date (CIP.002.094)
occurs between the managed care plan
enrollment eﬀ/end dates (ELG.014.197/198)
7. When Type of Claim (CIP.002.100) in
([3,C,W, 2, B, V)] value must have a managed
care main record (MCR.002) for the plan
where the Admission Date (CIP.002.094)
occurs between the managed care contract
eﬀ/end dates (MCR.002.020/021)

CIP131

CIP.002.131

NATIONALHEALTH-CAREENTITY-ID

National Health
Care Entity ID

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(10)

115

663

672

1. Not Applicable

CIP132

CIP.002.132

PAYMENT-LEVELIND

Payment Level
Indicator

Mandatory

The field denotes whether the payment amount was
determined at the claim header or line/detail
level.The ﬁeld denotes whether the payment

amount was determined at the claim header or
line/detail level. For claims where payment is
NOT determined at the individual line level
(PAYMENT-LEVEL-IND = 1), the claim lines’
associated allowed (ALLOWED-AMT) and paid
(MEDICAID-PAID-AMT) amounts are lef blank
and the total allowed (TOT-ALLOWED-AMT) and
total paid (TOT-MEDICAID-PAID-AMT) amount is
reported at the header level only. For claims
where payment/allowed amount is determined
at the individual lines and when applicable, costsharing and/or coordinaLon of beneﬁts were
deducted from one or more speciﬁc line-level
payment/allowed amounts (PAYMENT-LEVELIND = 2), the allowed (ALLOWED-AMT) and paid
(MEDICAID-PAID-AMT) amounts on the
associated claim lines should sum to the total
allowed (TOT-ALLOWED-AMT) and total paid
(TOT-MEDICAID-PAID-AMT) amounts reported
on the claim header.
For claims where payment/allowed amount is
determined at the individual lines but then cost
sharing or coordinaLon of beneﬁts was
deducted from the total paid/allowed amount at
the header only (PAYMENT-LEVEL-IND = 3), then
the line-level paid amount (MEDICAID-PAIDAMT) would be blank and line-level allowed
(ALLOWED-AMT) and header level total allowed
(TOT-ALLOWED-AMT) and total paid (TOTMEDICAID-PAID-AMT) amounts must all be
populated but the line level allowed amounts
are not expected to sum exactly to the header
level total allowed.

PAYMENTLEVEL-IND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

11667

673506

1.1. Value must be 1 character

2. Value must be in Payment Level Indicator
List (VVL)
2. Value must be 1 character
3.3. Mandatory

For example, if a claim for an oﬃce visit and a
procedure is assigned a separate line-level
allowed amount for each line, but then at the
header level a copay is deducted from the
header-level total allowed and/or total paid
amounts, then the sum of line-level allowed
amounts may not be equal to the header-level
total allowed amounts or correspond directly to
the total paid amount. If the state cannot
disLnguish between the scenarios for value 1
and value 3, then value 1 can be used for all
claims with only header-level total allowed/paid
amounts.

CIP133

CIP.002.133

MEDICAREREIM-TYPE

Medicare
Reimbursement
Type

CondiLonal A code to indicate the type of Medicare
reimbursement.

MEDICAREREIM-TYPE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

11768

674507

675508

1.1. Value must be 2 characters

2. Value must be in Medicare Reimbursement
Type List (VVL)
2. (Crossover Claim) if associated Crossover
Indicator value indicates a crossover claim,3.

Value is mandatory and must be provided
3. Value must be 2 characters

, when Crossover Indicator is equal to "1"

(Crossover Claim)
4. CondiLonal

CIP134

CIP.002.134

NON-COV-DAYS

Non-Covered
Days

CondiLonal The number of days of inpaLent care not
covered by the payer for this sequence as
qualiﬁed by the payer organizaLon. The number
of non-covered days does not refer to days not
covered for any other service.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(5)

11869

676509

680513

1. Value must be a positive integer
2. Value must be between 0:99999999999
(inclusive)
3. Conditional
4.1. Value must be 5 digits or less

2. CondiLonal

CIP135

CIP.002.135

NON-COVCHARGES

Non-Covered
Charges

CondiLonal The charges for inpaLent care, which are not
reimbursable by the primary payer. The noncovered charges do not refer to charges not
covered for any other service.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

11970

681514

693526

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP136

CIP.002.136

MEDICAID-COVINPATIENT-DAYS

Medicaid
Covered
InpaLent Days

CondiLonal The number of days covered by Medicaid on this
claim. For states that combine delivery/birth
services on a single claim, include covered days
for both the mother and the neonate in this
ﬁeld.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(7)

12071

694527

700533

1. Value must be a posiLve integer
2. Value must be between
0:999999999990000000:9999999 (inclusive)
3. CondiLonal
4. Value must be less than or equal to double
the number of days between Admission Date
Discharge Date (CIP.002.094) and Discharge
Date Discharge Date (CIP.002.096) plus one
day
5. Value must be 7 digits or less
6. Value is required if the associated Type of
Service (CIP.002.257) is in
[001,058,060,084,086,090,091,092,093, 123,
132]
7. Value is required if at least one associated
Revenue Code (CIP.003.245) is in [100-219]

CIP137

CIP.002.137

CLAIM-LINECOUNT

Claim Line
Count

Mandatory

The total number of lines on the claim.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(4)

12172

701534

704537

1. Value must be 4 characters or less
2. Value must be a posiLve integer
23. Value must be between 00000:9999
(inclusive)
34. Value must not include commas or other
non-numeric characters
45. Value must be equal to the number of
claim lines (e.g. Original Claim Line Number
or Adjustment Claim Line Number instances)
reported in the associated claim record being
reported
5. Value must be 4 characters or less

6. Mandatory
CIP138

CIP.002.138

FORCED-CLAIMIND

Forced Claim
Indicator

CondiLonal Indicates if the claim was processed by forcing it
through a manual override process.

FORCEDCLAIM-IND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

12273

705538

1.1. Value must be 1 character

2. Value must be in Forced Claim Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CIP139

CIP140

CIP.002.139

CIP.002.140

HEALTH-CAREACQUIREDCONDITION-IND

OCCURRENCECODE-01

Healthcare
Acquired
CondiLon
Indicator

CondiLonal This code indicates whether the claim has a
Health Care Acquired CondiLon. For addiLonal
coding informaLon refer to the following site ::
haps://www.cms.gov/Medicare/Medicare-Feefor-ServicePayment/HospitalAcqCond/index.html?redirect
=/hospitalacqcond/05_Coding.asp#TopOfPage

HEALTH-CAREACQUIREDCONDITIONIND

CIP00002

Occurrence
Code 1

CondiLonal A code to describe speciﬁc event(s) relaLng to
this billing period covered by the claim. (These
are FLsFrom Locators 31, 32, 33, 34, 35, and 36 Occurrence Codes on the UB04.) These ﬁelds
can be used for either occurrences or
occurrence spans.

OCCURRENCECODE

CIP00002

CLAIMHEADERRECORD-IP

X(1)

12374

706539

1.1. Value must be 1 character

2. Value must be in Healthcare Acquired
CondiLon Indicator List (VVL).
2. Value must be 1 character

)
3. CondiLonal
CLAIMHEADERRECORD-IP

X(2)

12475

707540

708541

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP141

CIP142

CIP143

CIP144

CIP145

CIP.002.141

CIP.002.142

CIP.002.143

CIP.002.144

CIP.002.145

OCCURRENCECODE-02

OCCURRENCECODE-03

OCCURRENCECODE-04

OCCURRENCECODE-05

OCCURRENCECODE-06

Occurrence
Code 2

Occurrence
Code 3

Occurrence
Code 4

Occurrence
Code 5

Occurrence
Code 6

OCCURRENCECODE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

12576

709542

710543

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

12677

711544

712545

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

12778

713546

714547

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

12879

715548

716549

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

12980

717550

718551

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP146

CIP147

CIP148

CIP149

CIP150

CIP.002.146

CIP.002.147

CIP.002.148

CIP.002.149

CIP.002.150

OCCURRENCECODE-07

OCCURRENCECODE-08

OCCURRENCECODE-09

OCCURRENCECODE-10

OCCURRENCECODE-EFF-DATE01

Occurrence
Code 7

Occurrence
Code 8

Occurrence
Code 9

Occurrence
Code 10

Occurrence
Code EﬀecLve
Date 1

OCCURRENCECODE

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(2)

13081

719552

720553

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

13182

721554

722555

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

13283

723556

724557

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

X(2)

13384

725558

726559

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

9(8)

13485

727560

734567

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal

54. Value must be less than or equal to

Occurrence Code End Date

CIP151

CIP.002.151

OCCURRENCECODE-EFF-DATE02

Occurrence
Code EﬀecLve
Date 2

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

13586

735568

742575

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CIP152

CIP.002.152

OCCURRENCECODE-EFF-DATE03

Occurrence
Code EﬀecLve
Date 3

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

13687

743576

750583

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

CIP153

CIP.002.153

OCCURRENCECODE-EFF-DATE04

Occurrence
Code EﬀecLve
Date 4

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

13788

751584

758591

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CIP154

CIP.002.154

OCCURRENCECODE-EFF-DATE05

Occurrence
Code EﬀecLve
Date 5

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

13889

7592

766599

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CIP155

CIP.002.155

OCCURRENCECODE-EFF-DATE06

Occurrence
Code EﬀecLve
Date 6

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

13990

767600

774607

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

CIP156

CIP.002.156

OCCURRENCECODE-EFF-DATE07

Occurrence
Code EﬀecLve
Date 7

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14091

775608

782615

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CIP157

CIP.002.157

OCCURRENCECODE-EFF-DATE08

Occurrence
Code EﬀecLve
Date 8

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14192

783616

790623

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CIP158

CIP.002.158

OCCURRENCECODE-EFF-DATE09

Occurrence
Code EﬀecLve
Date 9

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14293

791624

798631

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

CIP159

CIP.002.159

OCCURRENCECODE-EFF-DATE10

Occurrence
Code EﬀecLve
Date 10

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14394

799632

806639

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CIP160

CIP.002.160

OCCURRENCECODE-ENDDATE-01

Occurrence
Code End Date
1

CondiLonal The last date that the corresponding occurrence
code or occurrence span code was applicable. If
occurrence date span is a single day, value must
be equal to the value of the associated
Occurrence Code EﬀecLve Date.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14495

807640

814647

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP161

CIP.002.161

OCCURRENCECODE-ENDDATE-02

Occurrence
Code End Date
2

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14596

815648

822655

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

CIP162

CIP.002.162

OCCURRENCECODE-ENDDATE-03

Occurrence
Code End Date
3

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14697

823656

830663

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP163

CIP.002.163

OCCURRENCECODE-ENDDATE-04

Occurrence
Code End Date
4

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14798

831664

838671

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP164

CIP.002.164

OCCURRENCECODE-ENDDATE-05

Occurrence
Code End Date
5

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

14899

839672

846679

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

CIP165

CIP.002.165

OCCURRENCECODE-ENDDATE-06

Occurrence
Code End Date
6

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

149100

847680

854687

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP166

CIP.002.166

OCCURRENCECODE-ENDDATE-07

Occurrence
Code End Date
7

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

1501

855688

862695

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP167

CIP.002.167

OCCURRENCECODE-ENDDATE-08

Occurrence
Code End Date
8

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

151102

863696

8703

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

CIP168

CIP.002.168

OCCURRENCECODE-ENDDATE-09

Occurrence
Code End Date
9

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

152103

871704

878711

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP169

CIP.002.169

OCCURRENCECODE-ENDDATE-10

Occurrence
Code End Date
10

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

153104

879712

886719

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CIP170

CIP.002.170

BIRTH-WEIGHTGRAMS

Birth Weight
Grams

CondiLonal The weight of a newborn at Lme of birth in
grams (applicable to newborns only). The ﬁeld is
required when a claim involves a child birth.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(6)V
999

1054

887720

895728

1. Value must not be greater than 6 digits to
the lef of the decimal and have no more
than 3 digits to the right of the decimal (i.e.
999999.999)
2. CondiLonal

CIP171

CIP.002.171

PATIENTCONTROL-NUM

PaLent Control
Number

CondiLonal A paLent's unique number assigned by the
provider agency during claim submission, which
idenLﬁes the client or the client's episode of
service within the provider's system to facilitate
retrieval of individual ﬁnancial and clinical
records and posLng of payment

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(20)

155106

896729

915748

1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk
symbol
3. CondiLonal

CIP172

CIP.002.172

ELIGIBLE-LASTNAME

Eligible Last
Name

CondiLonal The last name of the individual to whom the
services were provided. (The paLents name
should be captured as it appears on the claim
record, it does not need to be the same as it
appears on the eligibility ﬁle. The MSIS
IdenLﬁcaLon Number will be used to associate
a claim record with the appropriate eligibility
data.)

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(30)

156107

916749

945778

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CIP173

CIP.002.173

ELIGIBLE-FIRSTNAME

Eligible First
Name

CondiLonal The ﬁrst name of the individual to whom the
services were provided. (The paLents name
should be captured as it appears on the claim
record, it does not need to be the same as it
appears on the eligibility ﬁle. The MSIS
IdenLﬁcaLon Number will be used to associate
a claim record with the appropriate eligibility
data.)

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(30)

157108

946779

975808

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CIP174

CIP.002.174

ELIGIBLEMIDDLE-INIT

Eligible Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(1)

158109

976809

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
CIP175

CIP.002.175

DATE-OF-BIRTH

Date of Birth

Mandatory

Date of birth of the individual to whom the
services were provided. A paLent's age should
not be greater than 112 years.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

159110

977810

984817

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Mandatory

CIP176

CIP.002.176

HEALTH-HOMEPROV-IND

Health Home
Provider
Indicator

HEALTH-HOMEPROV-IND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

160111

985818

1. Value must be in Health Home Provider
Indicator List (VVL)
2. Value must be 1 character
3. If there is an associated Health Home
EnLty Name value, then value must be "1"
3. Value must be 1 character
4.4. CondiLonal

records for an eligible individual that indicate the
claim was submitted by a provider or provider group
enrolled in a health home model if the eligible
individual is not enrolled in the health home
program. States that do not specify an eligible

individual's health home provider number, if
applicable, should not report claims that
indicate the claim is submiaed by a provider or
provider group enrolled in the health home
model.
CIP177

CIP.002.177

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which claim
is submiaed.

WAIVER-TYPE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

1612

986819

987820

1.1. Value must be 2 characters

2. Value must be in Waiver Type List (VVL)
2. Value must be 2 characters
3.3. Value must be in [ '06', '07', '08', '09', '10',
'11', '12', '13', '14', '15', '16', '17', '18', '19', '20',
'33'] when associated Program match Eligible
Waiver Type equals "07"
4.(ELG.012.173) for the enrollee for the same

Lme period (by date of service)
4. Value must have a corresponding value in
Waiver ID (CIP.002.178)
5. CondiLonal

CIP178

CIP179

CIP.002.178

CIP.002.179

WAIVER-ID

BILLING-PROVNUM

Waiver ID

Billing Provider
Number

CondiLonal Field specifying the waiver or demonstraLon
which authorized payment for a claim. These IDs
must be the approved, full federal waiver ID
number assigned during the state submission
and CMS approval process. Waiver IDs should
actually only be the "core" part of the waiver
IDs, without including suﬃxes for renewals or
amendments.

N/A

CondiLonal A unique idenLﬁcaLon number assigned by the
state to a provider or capitationmanaged care
plan. This data element should represent the
enLty billing for the service. For encounter
records, if associated Type of Claim value equals
3, C, or W, then value must be the state
idenLﬁer of the provider or enLty (billing or
reporLng) to the managed care plan.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(20)

162113

988821

100784

1.1. Value must be 20 characters or less

2. Value must be associated with a populated
Waiver Type
2. Value must be 20 characters or less
3.3. (1115 demonstraLon waivers) If value

begins with "11-W-" or "21-W-", the
associated Claim Waiver Type value must be
01 or in [21-30]
4. (1115 demonstraLon) If value begins
with"11-W-" or "21-W-", then the value must
include slash “/” in the 11th posiLon followed
by the last digit of the CMS Region [0-9] in
the 12th posiLon
5. (1915(b) or 1915(c) waivers) If value begins
with the two-leaer state abbreviaLon
followed by a period (.), the associated Claim
Waiver Type value must be in [02-20,32,33]
56. CondiLonal
CIP00002

CLAIMHEADERRECORD-IP

X(30)

163114

100884

103787

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal
43. When Type of Claim not in
('Z','3','C','W',"2","B","V"," 4","D","X")[3,C,W]

6. Discharge Date (CIP.002.096) may be
between Provider IdenLﬁer EﬀecLve Date
(PRV.005.079) and Provider IdenLﬁer End
Date (PRV.005.080)

CIP180

CIP.002.180

BILLING-PROVNPI-NUM

Billing Provider
NPI Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

digit identification number issued to health care
providers in the United States by CMS. Healthcare
providers acquire their unique 10-digit NPIs to
identify themselves in a standard way throughout
their industry. The NPI is a 10-position, intelligencefree numeric identifier (10-digit number).The

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(10)

164115

103887

104788

1. Value must be 10 digits, consisting of 9

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal
45. When populated, value must match
Provider IdenLﬁer (PRV.005.081) and Facility
Group Individual Code (PRV.002.028) must
equal '01'"01"
6. NPPES EnLty Type Code associated with
this NPI must equal "2" (OrganizaLon)

CIP181

CIP.002.181

BILLING-PROVTAXONOMY

Billing Provider
Taxonomy

CondiLonal The taxonomy code for the insLtuLon billing for
the beneﬁciary.

PROVTAXONOMY

CIP00002

CLAIMHEADERRECORD-IP

X(12)

1165

104888

105989

1.1. Value must be 12 characters or less

2. Value must be in Provider Taxonomy List
(VVL)
2. Value must be 12 characters or less
3.3. CondiLonal

CIP182

CIP.002.182

BILLING-PROVTYPE

Billing Provider
Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

CIP00002

CLAIMHEADERRECORD-IP

X(2)

166117

106089

106189

1.1. Value must be 2 characters

2. Value must be in Provider Type Code List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CIP183

CIP.002.183

BILLING-PROVSPECIALTY

Billing Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CIP00002

CLAIMHEADERRECORD-IP

X(2)

167118

106289

106389

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CIP184

CIP.002.184

ADMITTINGPROV-NPI-NUM

Admieng
Provider NPI
Number

Not
ApplicableC

ondiLonal

A National Provider Identifier (NPI) is a unique 10digit identification number issued to health care
providers in the United States by CMS. Healthcare
providers acquire their unique 10-digit NPIs to
identify themselves in a standard way throughout
their industry. The NPI is a 10-position, intelligencefree numeric identifier (10-digit number).The

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(10)

168119

106489

107390

1. Value must be 10 digits, consisting of 9

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
4. Value must exist in the NPPES NPI File

NaLonal Provider ID (NPI) of the doctor
responsible for admieng a paLent to a hospital
or other inpaLent health facility.
CIP185

CIP186

CIP.002.185

CIP.002.186

ADMITTINGPROV-NUM

ADMITTINGPROV-SPECIALTY

Admieng
Provider
Number

CondiLonal The Medicaid ID of the doctor responsible for
admieng a paLent to a hospital or other
inpaLent health facility.

N/A

Admieng
Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CIP00002

CLAIMHEADERRECORD-IP

X(30)

CLAIMHEADERRECORD-IP

X(2)

169120

19074

110393

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal

170121

110493

110593

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal

CIP187

CIP.002.187

ADMITTINGPROVTAXONOMY

Admieng
Provider
Taxonomy

CondiLonal Taxonomic classiﬁcaLon (code) for a given
healthcare provider, as deﬁned by the NaLonal
Uniform Claim Commiaee.

PROVTAXONOMY

CIP00002

CLAIMHEADERRECORD-IP

X(12)

171122

110693

111795

1.1. Value must be 12 characters or less

2. Value must be in Provider Taxonomy List
(VVL)
2. Value must be 12 characters or less
3.3. CondiLonal

CIP188

CIP189

CIP190

CIP.002.188

CIP.002.189

CIP.002.190

ADMITTINGPROV-TYPE

Admieng
Provider Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

CIP00002

REFERRINGPROV-NUM

Referring
Provider
Number

CondiLonal A unique idenLﬁcaLon number assigned to a
provider which idenLﬁes the physician or other
provider who referred the paLent. For
physicians, this must be the individual's ID
number, not a group idenLﬁcaLon number. If
the referring provider number is not available,
but the physician's Drug Enforcement Agency
(DEA) ID is on the State ﬁle, then the State
should use the DEA ID for this data element.

N/A

CIP00002

Referring
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

REFERRINGPROV-NPI-NUM

CIP00002

CLAIMHEADERRECORD-IP

X(2)

CLAIMHEADERRECORD-IP

X(30)

CLAIMHEADERRECORD-IP

X(10)

1723

173124

111895

111995

112095

114998

CIP.002.191

REFERRINGPROV-TAXONOMY

Referring
Provider
Taxonomy

Not
Applicable

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal

174125

115098

115999

1. Value must be 10 digits, consisting of 9

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

NaLonal Provider ID (NPI) of the provider who
recommended the servicing provider to the
paLent.
CIP191

1. Value must be 12 characters or less
2. Value must be in Provider Type
CodeTaxonomy List (VVL).
2. Value must be 2 characters)
3. CondiLonal

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

175

1160

1171

1. Not Applicable

CIP192

CIP.002.192

REFERRINGPROV-TYPE

Referring
Provider Type

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

176

1172

1173

1. Not Applicable

CIP193

CIP.002.193

REFERRINGPROV-SPECIALTY

Referring
Provider Specialty

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

177

1174

1175

1. Not Applicable

CIP194

CIP.002.194

DRG-OUTLIERAMT

DRG Outlier
Amount

CondiLonal The addiLonal payment on a claim that is
N/A
associated with either a cost outlier or length of
stay outlier. Outlier payments compensate
hospitals paid on a ﬁxed amount per Medicare
"'diagnosis related group"' discharge with extra
dollars for paLent stays that substanLally exceed
the typical requirements for paLent stays in the
same DRG category.

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

178126

117699

118810

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Conditional
4. Value must not be populated when Outlier
Code (CIP.002.197) is '01' ,'02' or '10'in
[01,02,10]
4. CondiLonal

DRG-RELWEIGHT

DRG RelaLve
Weight

CondiLonal The relaLve weight for the DRG on the claim.
N/A
Each year CMS assigns a relaLve weight to each
DRG. These weights indicate the relaLve costs
for treaLng paLents during the prior year. The
naLonal average charge for each DRG is
compared to the overall average. This raLo is
published annually in the Federal Register for
each DRG. A DRG with a weight of 2.0000 means
that charges were historically twice the average;
a DRG with a weight of 0.5000 was half the
average. This data element in T-MSIS is expected
to capture the relaLve weight of the DRG in the
state's system regardless of which DRG system
the state uses.

CIP00002

CLAIMHEADERRECORD-IP

X(8)S9(

1279

118910

101963

CIP195

CIP.002.195

3)V999
99

1. Value must be 8 characters or less
2.may include up to 3 digits to the lef of the
decimal point, and 5 digits to the right e.g.
123.45678
2. CondiLonal
3. When populated value must be zero or
greater

CIP196

CIP.002.196

MEDICARE-HICNUM

Medicare HIC
Number

CondiLonal The Medicare HIC Number (HICN) is an idenLﬁer
formerly used by SSA and CMS to idenLfy all
Medicare beneﬁciaries. For many beneﬁciaries,
their SSN was a major component of their HICN.
To prevent idenLfy thef, among other reasons,
HICN gradually were reLred and replaced by the
Medicare Beneﬁciary IdenLﬁer (MBI) over the
course of 2018 and 2019. HICN conLnue to be
used by Medicare for limited administraLve
purposes afer 2019 but starLng in 2020 the
MBI became the primary idenLﬁer for Medicare
beneﬁciaries. HICN consists of two components:
SSN &and alpha-suﬃx or (for Railroad IDs) preﬁx
and ID (not always SSN based)).

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(12)

1280

101974

120825

1. Conditional
2. Value must be 12 characters or less
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols
4. (Not Dual Eligible) if Dual Eligible Code
(ELG.DE.085) value =equals "00", then value
must not be populated.
5. Value must be populated when Crossover
Indicator (CIP.002.023) equals '1'"1" and
Medicare Beneﬁciary IdenLﬁer (CIP.002.222)
is not populated.

CIP197

CIP.002.197

OUTLIER-CODE

Outlier Code

CondiLonal This code indicates the Type of Outlier Code or
DRG Source. The ﬁeld idenLﬁes two mutually
exclusive condiLons. The ﬁrst, for PPS providers
(codes 0, 1, and 2), classiﬁes stays of excepLonal
cost or length (outliers). The second, for nonPPS providers (codes 6, 7, 8, and 9), denotes the
source for developing the DRG.
haps://www.resdac.org/cmsdata/variables/medpar-drgoutlier-stay-code

OUTLIER-CODE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

181129

120926

121027

1.1. Value must be 2 characters

CondiLonal This ﬁeld speciﬁes the number of days paid as
outliers under ProspecLve Payment System
(PPS) and the days over the threshold for the
DRG.

N/A

CIP198

CIP.002.198

OUTLIER-DAYS

Outlier Days

2. Value must be in Outlier Code List (VVL)
2. (Day Outlier) If Outlier Code3. Value is 01, then
mandatory if either DRG Outlier Amount
(CIP.002.194) or Outlier Days (CIP.002.198)
must beare populated.
3. Value must be 2 characters

4. CondiLonal
5. If value equals '00' or '09', then DRG Outlier
Amount (CIP.002.194) must not be populated

CIP00002

CLAIMHEADERRECORD-IP

S9(5)

182130

102118

103215

1. Value must be 5 digits or less
2. Value must be numeric
2. The value may be up to 5 digits in length

3. Value must be populated, if Outlier Code
(CIP.002.197) equals "01"
4. CondiLonal

CIP199

CIP.002.199

PATIENT-STATUS

PaLent Status

Mandatory

A code indicaLng the paLent's status as of the
last day the claim covers. Values used are from
UB-04. This is also referred to as paLent
discharge status. A valid list of codes can be
purchased at:
haps://www.nubc.org/license

PATIENTSTATUS

CIP00002

CLAIMHEADERRECORD-IP

X(2)

1831

121610

121710

1.1. Value must be 2 characters

2. Value must be in PaLent Status List (VVL).
2. Value must be 2 characters

)
3. Mandatory
4. When value in ["[20", ",40", ",41", ",42"],],
then associated Discharge Date (CIP.002.096)
must be less than or equal to Date of Death
(ELG.002.025)

CIP201

CIP.002.201

BMI

Body Mass Index

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(5)V
9

184

1218

1223

1. Not Applicable

CIP202

CIP.002.202

REMITTANCENUM

Remiaance
Number

Mandatory

The Remiaance Advice Number is a sequenLal
number that idenLﬁes the current Remiaance
Advice (RA) produced for a provider. The
number is incremented by one each Lme a new
RA is generated. The first five (5) positions are
Julian date following a YYDDD format. The RA is the
detailed explanaLon of the reason for the
payment amount. The RA number is not the check

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(30)

185132

122410

125310

1. Value must be 30 characters or less
2. First five (5) characters of the value must be a
Julian date express in the form YYDDD (e.g.
19095, 95th day of 20(19))
3. Value must not contain a pipe or asterisk

symbols
43. Mandatory

number.

CIP203

CIP204

CIP.002.203

CIP.002.204

SPLIT-CLAIM-IND

BORDER-STATEIND

Split Claim
Indicator

Border State
Indicator

CondiLonal An indicator that denotes that claims in excess
of a pre-determined number of claim lines
(threshold determined by the individual state)
will be split during processing.

SPLIT-CLAIMIND

CondiLonal A code to indicate whether an individual
received services or equipment across state
borders. (The provider locaLon is out of state,
but for payment purposes the provider is
treated as an in-state provider.)

BORDER-STATEIND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

186133

120654

1.1. Value must be 1 character

2. Value must be in Split Claim Indicator List
(VVL).
2. Value must be 1 character

)
3. CondiLonal
CIP00002

CLAIMHEADERRECORD-IP

X(1)

187134

125510

1.1. Value must be 1 character

2. Value must be in Border State Indicator List
(VVL)
2. Value must be 1 character
3.3. CondiLonal

CIP206

CIP207

CIP.002.206

CIP.002.207

TOTBENEFICIARYCOINSURANCEPAID-AMOUNT

BENEFICIARYCOINSURANCEDATE-PAID

Beneﬁciary
Coinsurance
Paid Amount

Beneﬁciary
Coinsurance
Date Paid

CondiLonal The amount of money the beneﬁciary or his or
her representaLve (e.g., their guardian) paid
towards their coinsurance for the covered
services on the claim. Do not include
coinsurance payments made by a third party/s
on behalf of the beneﬁciary.

N/A

CondiLonal The date the beneﬁciary paid the coinsurance
amount.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

188135

125067

126810

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Must have an associated Beneficiary
Coinsurance Date Paid
4. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

9(8)

189136

126910

120876

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Coinsurance Amount
43. CondiLonal
CIP208

CIP209

CIP.002.208

CIP.002.209

TOTBENEFICIARYCOPAYMENTPAID-AMOUNT

BENEFICIARYCOPAYMENTDATE-PAID

Total
Beneﬁciary
Copayment Paid
Amount

Beneﬁciary
Copayment
Date Paid

CondiLonal The amount of money the beneﬁciary or his or
her representaLve (e.g., their guardian) paid
towards their copayment for the covered
services on the claim. Do not include copayment
payments made by a co-paymentthird party/s on
behalf of the beneﬁciary.

N/A

CondiLonal The date the beneﬁciary paid the copayment
amount.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

190137

127710

128911

CIP00002

CLAIMHEADERRECORD-IP

9(8)

191138

129101

129711

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Copayment Amount
43. CondiLonal

CIP210

CIP211

CIP.002.210

CIP.002.211

TOTBENEFICIARYDEDUCTIBLEPAID-AMOUNT

BENEFICIARYDEDUCTIBLEDATE-PAID

Total
Beneﬁciary
DeducLble Paid
Amount

Beneﬁciary
DeducLble Date
Paid

CondiLonal The amount of money the beneﬁciary or his or
her representaLve (e.g., their guardian) paid
towards an annualtheir deducLble for the
covered services on the claim. Do not include
deducLble payments made by a third party/s on
behalf of the beneﬁciary.

N/A

CondiLonal The date the beneﬁciary paid the deducLble
amount.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

1392

121098

131021

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Must have an associated Beneficiary
Deductible Date Paid
4. CondiLonal

CIP00002

CLAIMHEADERRECORD-IP

9(8)

193140

131122

131829

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary DeducLble Date Paid
4Amount
3. CondiLonal
CIP212

CIP.002.212

CLAIM-DENIEDINDICATOR

Claim Denied
Indicator

Mandatory

An indicator to idenLfy a claim that the state
refused pay in its enLrety.

CLAIM-DENIEDINDICATOR

CIP00002

CLAIMHEADERRECORD-IP

X(1)

1941

131930

1.1. Value must be 1 character

2. Value must be in Claim Denied Indicator
List (VVL)
23. If value is '0',equals "0", then Claim Status
Category must equal "F2"
3. Value must be 1 character
4.4. Mandatory

CIP213

CIP.002.213

COPAY-WAIVEDIND

Copayment
Waived
Indicator

OpSituaLo

nal

An indicator signifying that the copay was
discounted or waived by the provider (e.g.,
physician or hospital). Do not use to indicate
administraLve-level, Medicaid State Agency or
Medicaid MCO copayment waived decisions.

COPAYWAIVED-IND

CIP00002

CLAIMHEADERRECORD-IP

X(1)

195142

113201

1.1. Value must be 1 character

2. Value must be in Copay Waived Indicator
List (VVL)
2. Value must be 1 character
3. Optional3. SituaLonal

CIP214

CIP216

CIP217

CIP.002.214

CIP.002.216

CIP.002.217

HEALTH-HOMEENTITY-NAME

Health Home
EnLty Name

CondiLonal A free-form text ﬁeld to indicate the health
home program that authorized payment for the
service on the claim. or to idenLfy the health
home SPA in which an individual is enrolled. The
name entered should be the name that the
state uses to uniquely idenLfy the team. A
"Health Home EnLty" can be a designated
provider (e.g., physician, clinic, behavioral
health organizaLon), a health team which links
to a designated provider, or a health team
(physicians, nurses, behavioral health
professionals). Because an idenLﬁcaLon
numbering schema has not been established,
the enLLes' names are being used instead.

N/A

THIRD-PARTYCOINSURANCEAMOUNT-PAID

Third Party
Coinsurance
Amount Paid

OpSituaLo

N/A

THIRD-PARTYCOINSURANCEDATE-PAID

Third Party
Coinsurance
Date Paid

CondiLonal The date a Third Partythe third party paid the
coinsurance amount was paid on this claim or

nal

The amount of money paid by a third party on
behalf of the beneﬁciary towards coinsurance on
the claim or claim line item.

N/A

CIP00002

adjustment.

CLAIMHEADERRECORD-IP

X(50)

196143

CLAIMHEADERRECORD-IP

S9(11)
V99

197144

CLAIMHEADERRECORD-IP

9(8)

198145

11321

137011

137182

138311

138411

139112

1. Value must 50 characters or less
2.1. Value must not contain a pipe or asterisk

symbols
2. Value must 50 characters or less
3. CondiLonal

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. OpSituaLonal
1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

2. When populated, value must have an
associated Third Party Coinsurance Amount
3. CondiLonal
CIP218

CIP.002.218

THIRD-PARTYCOPAYMENTAMOUNT-PAID

Third Party
Copayment
Amount Paid

OpSituaLo

nal

The amount of money paid by a third -party on
behalf of the beneﬁciary paid towards a
copayment.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

199146

139203

140412

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. OpSituaLonal

CIP219

CIP.002.219

THIRD-PARTYCOPAYMENTDATE-PAID

Third Party
Copayment
Date Paid

OpSituaLo

nal

The date a Third Partythe third party paid the
copayment amount was paid on a claim or
adjustment.

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

200147

140512

141223

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

2. When populated, value must have an
associated Third Party Copayment Amount
3. OpSituaLonal
CIP220

CIP.002.220

MEDICAIDAMOUNT-PAIDDSH

Medicaid
Amount Paid
DSH

CondiLonal The amount included in the Total Medicaid
Amount (CIP.002.114) that is aaributable to a
DisproporLonate Share Hospital (DSH) payment,
when the state makes DSH payments by claim.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

201148

122413

142536

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP221

CIP.002.221

HEALTH-HOMEPROVIDER-NPI

Health Home
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(10)

202149

142637

124356

1. Value must be 10 digits, consisting of 9

NaLonal Provider ID (NPI) of the health home
provider.

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer, where Provider IdenLﬁer Type
equal to '2'(PRV.005.077) equals "2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

CIP222

CIP223

CIP.002.222

CIP.002.223

MEDICAREBENEFICIARYIDENTIFIER

Medicare
Beneﬁciary
IdenLﬁer

CondiLonal The Medicare Beneﬁciary IdenLﬁer (MBI) is a
randomly generated idenLﬁer used to idenLfy
all Medicare beneﬁciaries. It replaced the
previously-used SSN-based Medicare HIC
Number (HICN). To prevent idenLfy thef,
among other reasons, HICN gradually were
reLred and replaced by the MBI over the course
of 2018 and 2019. StarLng in 2020, the MBI
became the primary idenLﬁer for Medicare
beneﬁciaries.

N/A

OPERATINGPROVTAXONOMY

OperaLng
Provider
Taxonomy

CondiLonal Taxonomic classiﬁcaLon (code) for a given
healthcare provider, as deﬁned by the NaLonal
Uniform Claim Commiaee.

PROVTAXONOMY

CIP00002

CLAIMHEADERRECORD-IP

X(12)

CLAIMHEADERRECORD-IP

X(12)

203150

124367

144712

204151

144812

145912

1.1. Value must be 12 characters or less

2. Value must be in Provider Taxonomy List
(VVL)
2. Value must be 12 characters or less
3.3. CondiLonal

CIP224

CIP.002.224

UNDERDIRECTION-OFPROV-NPI

Under Direction
of Provider NPI

Not
Applicable

[No longer essential - Both data element and
associated requirement(s); preserved for file
submission integrity. See Data Dictionary v2.3 for

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(10)

205

1460

1469

1. Not Applicable

specific definition and coding requirement
description(s).]
CIP225

CIP.002.225

UNDERDIRECTION-OFPROV-TAXONOMY

Under Direction
of Provider
Taxonomy

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

206

1470

1481

1. Not Applicable

CIP226

CIP.002.226

UNDERSUPERVISION-OFPROV-NPI

Under
Supervision of
Provider NPI

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(10)

207

1482

1491

1. Not Applicable

CIP227

CIP.002.227

UNDERSUPERVISION-OFPROV-TAXONOMY

Under
Supervision of
Provider
Taxonomy

Not
Applicable

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

208

1492

1503

1. Not Applicable

CIP228

CIP.002.228

MEDICARE-PAIDAMT

Medicare Paid
Amount

CondiLonal The amount paid by Medicare on this claim or
adjustment. For claims where Medicare payment
is only available at the line level, report the sum
of all the line level Medicare payment amounts
at the header.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

209152

150412

151612

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value
isequals "0", then the Medicare Paid Amount
value must not be populated.
4. CondiLonal
5. If value is populated, Crossover Indicator
must be equal to "1"

STATE-NOTATION

State NotaLon

OpSituaLo

N/A

CLAIMHEADERRECORD-IP

X(500)

210177

151789

201622

CIP229

CIP.002.229

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

CIP00002

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

CIP231

CIP.003.231

RECORD-ID

Record ID

Mandatory

RECORD-ID

CIP00003

CLAIM-LINERECORD-IP

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CIP00003"

STATE

CIP00003

CLAIM-LINERECORD-IP

X(2)

1.1. Value must be 2 characters

CIP.003.232

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (CIP.001.007)
CIP233

CIP.003.233

RECORDNUMBER

Record Number

Mandatory

N/A

CIP00003

CLAIM-LINERECORD-IP

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

CIP234

CIP.003.234

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

N/A

CIP00003

CLAIM-LINERECORD-IP

X(50)

141

CIP235

CIP.003.235

ICN-ORIG

Original ICN

Mandatory

CIP236

CIP.003.236

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

CIP00003

CLAIM-LINERECORD-IP

X(20)

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. When Type of Claim (CIP.002.100) = 4, D or X
(lump sum payment) value must begin with an
'&'1. Value must be 20 characters or less

2. Mandatory

CIP237

CIP.003.237

LINE-NUM-ORIG

Original Line
Number

Mandatory

A unique number to idenLfy the transacLon line
number that is being reported on the original
claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(3)

142

144

1. Value must be 3 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory
4. When populated, Value must be one or
greater

CIP238

CIP.003.238

LINE-NUM-ADJ

Adjustment Line CondiLonal A unique number to idenLfy the transacLon line
Number
number that idenLﬁes the line number on the
adjustment claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(3)

145

147

1. Value must be 3 characters or less
2. If associated Line Adjustment Indicator
value is equals "0,", then value must not be
populated
3. If associated Line Adjustment Indicator
value is equals "1,", then value is mandatory
and must be provided
4. CondiLonal
5. When populated, value must be one or
greater

CIP239

CIP.003.239

LINEADJUSTMENTIND

Line Adjustment CondiLonal A code to indicate the type of adjustment record
Indicator
claim/encounter represents at claim detail level.

LINEADJUSTMENTIND

CIP00003

CLAIM-LINERECORD-IP

X(1)

148

1.1. Value must be 1 character

2. Value must be in Line Adjustment Indicator
List (VVL)
2. If associated Type of Claim value is in [ 1, 3, 5,
A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]
3. If associated Type of Claim value is in [ 4, D, X ],
then. Value must be in [5, 6]
4. Value must be 1 character
5.0,1,4]

4. CondiLonal
65. If associated Line Adjustment Number is
populated, then value must be populated
CIP240

CIP.003.240

LINEADJUSTMENTREASON-CODE

Line Adjustment CondiLonal Claim adjustment reason codes communicate
Reason Code
why a service line was paid diﬀerently than it
was billed.

LINEADJUSTMENTREASON-CODE

CIP00003

CLAIM-LINERECORD-IP

X(3)

149

151

1.1. Value must be 3 characters or less

2. Value must be in Line Adjustment Reason
Code List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. When populated, Line Adjustment
IndicatorValue must be populated when the

total paid amount is diﬀerent from the total
billed amount

CIP241

CIP.003.241

SUBMITTER-ID

Submiaer ID

Mandatory

CIP242

CIP.003.242

CLAIM-LINESTATUS

Claim Line
Status

CIP243

CIP.003.243

BEGINNINGDATE-OFSERVICE

Beginning Date
of Service

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(12)

152

163

1. Value must be 12 characters or less
2. Mandatory

CondiLonal The claim line status conveyscodes from the 277
transacLon set idenLfy the status of a speciﬁc
servicedetail claim line usingrather than the X12
Claim Status Codes fromenLre claim. Only report
the claim adjudication processline for the ﬁnal,
adjudicated claim.

CLAIM-STATUS

CIP00003

CLAIM-LINERECORD-IP

X(3)

164

166

1.1. Value must be 3 characters or less

Mandatory

N/A

For services received during a single encounter
with a provider, the date the service covered by
this claim was received. For services involving
mulLple encounters on diﬀerent days, or
periods of care extending over two or more
days, this would be the date on which the
service covered by this claim began. For
capitation premium payments, the date on which the
period of coverage related to this payment began.
For financial transactions reported to the OT file,
populate with the first day of the time period
covered by this financial transaction.

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal

4. If value in [545,585,654], then Claim
Denied Indicator must be "0" and Claim
Status Category must be"F2"
CIP00003

CLAIM-LINERECORD-IP

9(8)

167

174

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V']

in the form "CCYYMMDD"
2. Value must be less than or equal to
associated End of Time Period value
43. Value must be less than or equal to
associated Ending Date of Service value
5. When Type of Claim is not in ['2', '4', 'B', 'D',
'V']4. Value must be less than or equal to

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value
when populated
76. Value must be less than or equal to at

least one of the eligible's Enrollment End
Date (ELG.021.254) values
87. Mandatory

CIP244

CIP.003.244

ENDING-DATEOF-SERVICE

Ending Date of
Service

Mandatory

For services received during a single encounter
with a provider, the date the service covered by
this claim was received. For services involving
mulLple encounters on diﬀerent days, or
periods of care extending over two or more
days, the date on which the service covered by
this claim ended. For capitation premium
payments, the date on which the period of coverage
related to this payment ends/ended. For financial
transactions reported to the OT file, populate with
the first day of the time period covered by this
financial transaction.

N/A

CIP00003

CLAIM-LINERECORD-IP

9(8)

175

182

in the form "CCYYMMDD"
2. Value must be less than or equal to
associated End of Time Period value
43. Value must be greater than or equal to
associated Beginning Date of Service value
5. When Type of Claim is not in ['2', '4', 'B', 'D',
'V']4. Value must be less than or equal to

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value
when populated
76. Value must be equal to or greater than
associated Date of Birth (ELG.002.024) value
87. Mandatory

CIP245

CIP.003.245

REVENUE-CODE

Revenue Code

Mandatory

A code which idenLﬁes a speciﬁc
accommodaLon, ancillary service or billing
calculaLon (as deﬁned by UB-04 Billing Manual).
Revenue Code should be passed through to TMSIS exactly as it was billed by the provider on
the provider's 837I or UB-04 claim. It is only
required on InpaLent, Long-Term Care and
Other Fee for Service claims and managed care
encounters that have a valid Type of Bill value.
It's not required on ﬁnancial transacLons or
non-insLtuLonal claims.

REVENUECODE

CIP00003

CLAIM-LINERECORD-IP

X(4)

183

186

1.1. Value must be 4 characters or less

2. Value must be in Revenue Code List (VVL)
23. A Revenue Code value requires an
associated Revenue Charge
3. Value must be 4 characters or less
4.4. Mandatory

CIP248

CIP.003.248

IMMUNIZATIONTYPE

Immunization
Type

Conditional

This field identifies the type of immunization
provided in order to track additional detail not
currently contained in Current Procedural
Terminology codes.

IMMUNIZATION
-TYPE

CIP00003

CLAIM-LINERECORD-IP

X(2)

187

188

1. Value must be in Immunization Type List (VVL)
2. Value must be 2 characters
3. Conditional

CIP249

CIP.003.249

IP-LTREVENUE-

IP LTRevenue

Mandatory

CIP00003

CLAIM-LINERECORD-IP

S9(6)V
999

1716

1897

1975

Center QuanLty
of Service Actual

On facility claim entriesclaims/encounters, this
ﬁeld is to capture the actual service quanLty by
revenue code category, e.g., number of days in a
parLcular type of accommodaLon, pints of
blood, etc. However, when HCPCS codes are
required for services, the units are equal to the
number of Lmes the procedure/service being
reported was performed. For CLAIMOT
claims/encounters use Service QuanLty Actual
and CLAIMRX claims/encounters use the
PrescripLon QuanLty Actual ﬁeld

N/A

CENTERQUANTITY-OFSERVICE-ACTUAL

1. Value must be numeric
2. Value may include up to 6 digits to the lef
of the decimal point, and 3 digits to the right
e.g. 123456.789
3. Mandatory

CIP250

CIP.003.250

IP-LTREVENUE-

IP LTRevenue

CENTERQUANTITY-OF-

Center QuanLty

SERVICE-

of Service

Allowed

ALLOWED

CIP251

CIP.003.251

REVENUECHARGE

Revenue Charge

CondiLonal On facility claim entriesclaims/encounters, this
N/A
ﬁeld is to capture maximum allowable quanLty
by revenue code category, e.g., number of days
in a parLcular type of accommodaLon, pints of
blood, etc. However, when HCPCS codes are
required for services, the units are equal to the
number of Lmes the procedure/service being
reported was performedallowed. This ﬁeld is only
applicable when the service being billed can be
quanLﬁed in discrete units, e.g., a number of
visits or the number of units of a
prescripLon/reﬁll that were ﬁlled. For CLAIMOT
claims/encounters use Service QuanLty Allowed
and CLAIMRX claims/encounters use the
PrescripLon QuanLty Allowed ﬁeld.

CIP00003

CLAIM-LINERECORD-IP

S9(6)V
999

1817

1986

2064

1. Value must be numeric
2. Value may include up to 6 digits to the lef
of the decimal point, and 3 digits to the right,
e.g. 123456.789
3. CondiLonal

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

1918

2075

2197

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Value must be less than or equal to
associated Total Billed Amount value.
4. When populated, associated claim line
Revenue Charge must be populated
5. CondiLonal

For sub-capitated encounters from a subcapitated enLty that is not a sub-capitated
network provider, report the amount that the
provider billed the sub-capitated enLty at the
claim line detail level. Report a null value in this
ﬁeld if the provider is a sub-capitated network
provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

N/A

CIP252

CIP.003.252

ALLOWED-AMT

Allowed
Amount

CondiLonal The maximum amount displayed at the claim
N/A
line level as determined by the payer as being
"'allowable"' under the provisions of the
contract prior to the determinaLon of actual
payment. On Fee for Service claims the Allowed
Amount is determined by the state's MMIS (or
PBM). On managed care encounters the Allowed
Amount is determined by the managed care
organizaLon. For sub-capitated encounters from
a sub-capitated enLty that is not a sub-capitated
network provider, report the amount that the
sub-capitated enLty allowed at the claim line
detail level. Report a null value in this ﬁeld if the
provider is a sub-capitated network provider.

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

2019

220218

2320

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

233

245

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. Conditional

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.
CIP253

CIP.003.253

TPL-AMT

Third Party
Liability Amount

Conditional

Third-party liability refers to the legal obligation of
third parties, i.e., certain individuals, entities, or
programs, to pay all or part of the expenditures for
medical assistance furnished under a state plan. This
is the total amount denoted at the claim detail level
paid by the third party.

N/A

CIP254

CIP.003.254

MEDICAID-PAIDAMT

Medicaid Paid
Amount

CondiLonal The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For claims

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

2220

246231

258243

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50 )
3. Conditional)
3. CondiLonal
4. Value should not be populated or should
be equal to zero, when associated Claim Line
Status is in [542,585,654]

where Medicaid payment is only available at the
header level, report the entire payment amount on
the T-MSIS record corresponding to the line item
with the highest charge or the 1st detail. Zero fill
Medicaid Amount Paid on all other MSIS records
created from the original claim.For sub-capitated

encounters from a sub-capitated enLty that is
not a sub-capitated network provider, report the
amount that the sub-capitated enLty paid the
provider at the claim line detail level. Report a
null value in this ﬁeld if the provider is a subcapitated network provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.
CIP255

CIP.003.255

MEDICAID-FFSEQUIVALENTAMT

Medicaid FFS
Equivalent
Amount

CondiLonal The amount that would have been paid had the
services been provided on a Fee for Service
basis.

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

2321

259244

271256

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Type of Claim value equals '3,
in [3,C,W'], then value is mandatory and must
be provided
4. CondiLonal

CIP256

CIP.003.256

BILLING-UNIT

Billing Unit

CondiLonal Unit of billing that is used for billing services by
the facility.

BILLING-UNIT

CIP00003

CLAIM-LINERECORD-IP

X(2)

2422

2572

273258

1.1. Value must be 2 characters

2. Value must be in Billing Unit List (VVL).
2. Value must be 2 characters

)
3. CondiLonal

CIP257

CIP.003.257

TYPE-OFSERVICE

Type of Service

Mandatory

A code to categorize the services provided to a
Medicaid or CHIP enrollee.

TYPE-OFSERVICE-IP

CIP00003

CLAIM-LINERECORD-IP

X(3)

2523

274259

2761

1. Value must be 3 characters
2. Mandatory
3. Value must not equal '086'be in Type of
Service IP List (VVL)
4. If Sex (ELG.002.023) equals 'M'
4. Value must satisfy the requirements of Type of
Service (Inpatient Claim) List (VVL)"M", then

value must not equal "086"
CIP260

CIP261

CIP262

CIP.003.260

CIP.003.261

CIP.003.262

SERVICINGPROV-NUM

SERVICINGPROV-NPI-NUM

SERVICING-PROVTAXONOMY

Servicing
Provider
Number

Servicing
Provider NPI
Number

Servicing
Provider
Taxonomy

CondiLonal A unique number to idenLfy the provider who
treated the recipient. The Servicing Provider
Number should be for the individual doctor who
rendered the service. If "Servicing" provider and
the "Billing" provider such as a sole-pracLLoner
are the same then use the same number in both
ﬁelds. The value is condiLonal as its usage varies
by state.

N/A

CondiLonal The NPI of the health care professional who
delivers or completes a parLcular medical
service or non-surgical procedure. The Servicing
Provider NPI Number is required when
rendering provider is diﬀerent than the
aaending provider and state or federal
regulatory requirements call for a "combined
claim" (i.e., a claim that includes both facility
and professional components). Examples are
Medicaid clinic bills or criLcal access hospital
claims.

N/A

Not
Applicable

N/A

[No longer essential - Both data element and
associated requirement(s); preserved for file
submission integrity. See Data Dictionary v2.3 for

CIP00003

CLAIM-LINERECORD-IP

X(30)

2624

277262

306291

then value may match (PRV.005.081) Provider
IdenLﬁer or
4. When Type of Claim not in
('Z','3','C','W',"2","B","V"," 4","D","X") [3,C,W],
then value may match (PRV.002.019)
Submieng State Provider ID
CIP00003

CLAIM-LINERECORD-IP

X(10)

2725

307292

3016

1. Value must be 10 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

CIP00003

CLAIM-LINERECORD-IP

X(12)

317

328

1. Not Applicable

specific definition and coding requirement
description(s).]

CIP263

CIP.003.263

SERVICINGPROV-TYPE

Servicing
Provider Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

CIP00003

CLAIM-LINERECORD-IP

X(2)

2926

3029

3303

1.1. Value must be 2 characters

2. Value must be in Provider Type Code List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CIP264

CIP.003.264

SERVICINGPROV-SPECIALTY

Servicing
Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CIP00003

CLAIM-LINERECORD-IP

X(2)

3027

331304

332305

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CIP265

CIP.003.265

OPERATINGPROV-NPI-NUM

OperaLng
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

CIP00003

CLAIM-LINERECORD-IP

X(10)

3128

333306

342315

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. CondiLonal
4. Value must exist in the NPPES NPI data ﬁle

NaLonal Provider ID (NPI) of the provider who
performed the surgical procedures on the
beneﬁciary.
CIP266

CIP267

CIP.003.266

CIP.003.267

OTHER-TPLCOLLECTION

PROV-FACILITYTYPE

Other TPL
CollecLon

Provider Facility
Type

Conditional

Mandatory

1. Value must be 10 digits, consisting of 9

OTHER-TPLCOLLECTION

The type of facility in which services on the
claim were rendered. The Provider Facility Type
code set is based on corresponding groups of
HIPAA provider taxonomy codes.

PROV-FACILITYTYPE

CIP00003

CLAIM-LINERECORD-IP

X(3)

3229

343316

345318

1.1. Value must be 3 characters

2. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

CIP00003

CLAIM-LINERECORD-IP

X(9)

3330

346319

354327

1.1. Value must be 9 characters or less

2. Value must be in Provider Facility Type List
(VVL)

2. Value must be 9 characters or less
3.3. Mandatory

CIP268

CIP.003.268

BENEFIT-TYPE

Benefit Type

Mandatory

CIP269

CIP.003.269

CMS-64-

CMS 64 Category

CondiLonal A code to indicate the Federal funding source
for the payment.

CATEGORY-FORFEDERALREIMBURSEMEN
T

for Federal
Reimbursement

The benefit category corresponding to the service
reported on the claim or encounter record. Note:
The code definitions in the valid value list originate
from the Medicaid and CHIP Program Data System
(MACPro) benefit type list. See Appendix H: Benefit
Types

BENEFIT-TYPE

CIP00003

CLAIM-LINERECORD-IP

X(3)

355

357

1. Value must be in Benefit Type Code List (VVL)
2. Value must be 3 characters
3. Mandatory

CMS-64-

CIP00003

CLAIM-LINERECORD-IP

X(2)

3531

3528

3529

1. Value must be 2 characters
2. Value must be in CMS 64 Category for
Federal Reimbursement List (VVL)

CATEGORYFOR-FEDERALREIMBURSEME
NT

2. Value must be 2 characters
3.3. (Federal Funding under Title XXI) if value
equals '"02'", then the eligible's CHIP Code
(ELG.003.054) must be in ['2', '3'2,3]

4. (Federal Funding under Title XIX) if value
equals '"01'" then the eligible's CHIP Code
(ELG.003.054) must be '1'"1"
5. CondiLonal
6. If Type of Claim is in
['1','2','5','A','B','E','U','V','Y'1,A,U] and the Total
Medicaid Paid Amount is populated on the
corresponding claim header, then value must
be reported.
7. If Type of Claim is in ['4','D'] and the Service
Tracking Payment Amount on the relevant record
is populated, then value must be reported.
CIP270

CIP.003.270

XIX-MBESCBESCATEGORY-OFSERVICE

XIX MBESCBES
Category of
Service

Conditional

A code indicating the category of service for the paid
claim. The category of service is the line item from
the CMS-64 form that states use to report their
expenditures and request federal financial
participation.

XIX-MBESCBESCATEGORY-OFSERVICE

CIP00003

CLAIM-LINERECORD-IP

X(4)

360

363

1. Value must be in XIX MBESCBES Category of
Service List (VVL)
2. Value must be 4 characters or less
3. Conditional
4. (Medicaid Claim) if the associated CMS-64
Category for Federal Reimbursement value is '1',
then a valid value is mandatory and must be
reported
5. If value is in ['14', '35', '42' or '44'], then Sex

(ELG.002.023) must not equals 'M'
6. If XXI MBESCBES Category of Service is
populated then must not be populated
CIP271

CIP.003.271

XXI-MBESCBESCATEGORY-OFSERVICE

XXI MBESCBES
Category of
Service

Conditional

CIP272

CIP.003.272

OTHERINSURANCEAMT

Other Insurance
Amount

CIP273

CIP.003.273

STATE-NOTATION

State NotaLon

XXI-MBESCBESCATEGORY-OFSERVICE

CIP00003

CLAIM-LINERECORD-IP

X(3)

364

366

1. Value must be in XXI MBESCBES Category of
Service List (VVL)
2. Conditional
3. (CHIP Claim) if the associated CMS-64 Category
for Federal Reimbursement value is '2', then a
valid value is mandatory and must be reported
4. If XIX MBESCBES Category of Service is
populated then value must not be populated
5. Value must be 3 characters or less

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

3832

367330

379342

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(500)

3949

380616

879111

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

To enable states to sequenLally number ﬁles,
when related, follow-on ﬁles are necessary (i.e.
update ﬁles, replace ﬁles). This should begin
with 1 for the original Create submission type
and be incremented by one for each
Replacement or Update submission for the
same reporLng period and ﬁle type (subject
area).

N/A

FILE-HEADERRECORD-IP

X(4)

nal

CIP275

CIP278

CIP.001.275

CIP.003.278

SEQUENCENUMBER

NDC-QUANTITY

Sequence
Number

NDC QuanLty

Mandatory

A code to indicate the category of service for the
paid claim. The category of service is the line item
from the CMS-21 form that states use to report their
expenditures and request federal financial
participation.

CondiLonal This ﬁeld is to capture the actual quanLty of the
NaLonal Drug Code being prescribed on the
claim/encounter.

CIP00001

1.1. Value must be 4 characters or less

2. Value must between 1 and 9999
23. Value must be equal to the largest of any
prior values for the same reporLng period
and ﬁle type, plus 1 (i.e. incremented by 1)
34. Value must not contain a pipe symbol
4. Value must be 4 characters or less

5. Mandatory
N/A

CIP00003

CLAIM-LINERECORD-IP

S9(6)V9
999)V(
9)

4333

908343

916360

1. Value may include up to 69 digits to the lef
of the decimal point, and 39 digits to the right
e.g. 123456.789123456789.123456789
2. CondiLonal

CIP279

CIP.003.279

HCPCS-RATE

HCPCS Rate

Conditional

CIP284

CIP.003.284

NATIONALDRUG-CODE

NaLonal Drug
Code

CIP285

CIP.003.285

NDC-UNIT-OFMEASURE

NDC Unit of
Measure

This data element is expected to capture data from
the HIPAA 837I claim loop 2400 SV206 or UB-04 FL
44. (NOTE: This element varies slightly by claim file
time, and claim-file-specific requirements will be
specified at in the file specification for each claim
type.)

HCPCS-RATE

CIP00003

CLAIM-LINERECORD-IP

X(14)

880

893

1. Value must be in HCPCS Rate List (VVL).
2. Value must be 14 characters or less
3. Value must not contain a pipe or asterisk
symbols
4. Conditional

CondiLonal A code following the NaLonal Drug Code format
indicaLng the drug, device, or medical supply
covered by this claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(12)

4134

894361

905372

1. Characters 1-5 of value must be numeric
2. Characters 6-9 of value must be numeric
3. Characters 10-12 of value must be numeric or
blank
4.1. Value must be 12 digits or less
52. Value must be a valid NaLonal Drug Code
63. CondiLonal

CondiLonal A code to indicate the basis by which the
quanLty of the NaLonal Drug Code is expressed.

NDC-UNIT-OFMEASURE

CIP00003

CLAIM-LINERECORD-IP

X(2)

4235

906373

907374

1.1. Value must be 2 characters

2. Value must be in NDC Unit of Measure List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CIP286

CIP.003.286

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CIP00003

CLAIM-LINERECORD-IP

9(8)

4436

917375

924382

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in associated T-MSIS File
Header Record
4. (CRX.001.010)

3. Mandatory
54. Value should be on or afer associated
Admission Date value
CIP287

CIP.003.287

SELF-DIRECTIONTYPE

Self DirecLon
Type

Conditional

Mandatory

This data element is not applicable to this ﬁle
type.

SELFDIRECTIONTYPE

CIP00003

CLAIM-LINERECORD-IP

X(3)

4537

925383

927385

1.1. Value must be 3 characters

2. Value must be in Self DirecLon Type List
(VVL)

2. Value must be 3 characters
3. Conditional3. Mandatory

CIP288

CIP.003.288

PREAUTHORIZATION
-NUM

PreauthorizaLo
n Number

CIP289

CIP.002.289

PROV-LOCATION- Provider
ID
LocaLon ID

CondiLonal A number, code or other value that indicates the
services provided on this claim have been
authorized by the payee or other service
organizaLon, or that a referral for services has
been approved. (Also referred to as a Prior
AuthorizaLon or Referral Number).

N/A

CIP00003

CLAIM-LINERECORD-IP

X(18)

4638

928386

945403

1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

Mandatory

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(5)

211153

201712

202112

1.1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols

A code to uniquely idenLfy the geographic
locaLon where the provider's services were
performed. The Provider LocaLon IdenLﬁer
values reported on InpaLent, Long-Term Care,
Other, and Pharmacy Claim Header Segments
must correspond to an acLve Provider LocaLon
IdenLﬁer value on a Provider LocaLon &and
Contact Info (PRV00003PRV.003) segment. If a
parLcular license (e.g., a physician's medical
license) or provider idenLﬁer (e.g., an individual
provider's NPI or SSN) is applicable to all of their
servicing locaLons, value "000" (a string of
exactly three zeros) can be used in the
PRV00004PRV.004 or PRV00005PRV.005,
respecLvely, to represent all locaLons, however
that locaLon idenLﬁer must not be aaributed to
claims or provider bed type info.

2. Value must be 5 characters or less
3.3. Mandatory

CIP290

CIP.002.290

BEGINNINGDATE-OFSERVICE

Beginning Date
of Service

Mandatory

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

154

1289

1296

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be less than or equal to
associated End of Time Period value
3. Value must be less than or equal to
associated Ending Date of Service value
4. Value must be less than or equal to
associated AdjudicaLon Date value
5. Value must be less than or equal to
associated Date of Death (ELG.002.025) value
when populated
6. Value must be less than or equal to at least
one of the eligible's Enrollment End Date
(ELG.021.254) values
7. Mandatory

CIP291

CIP.002.291

ENDING-DATEOF-SERVICE

Ending Date of
Service

Mandatory

N/A

CIP00002

CLAIMHEADERRECORD-IP

9(8)

155

1297

1304

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be less than or equal to
associated End of Time Period value
3. Value must be greater than or equal to
associated Beginning Date of Service value
4. Value must be less than or equal to
associated AdjudicaLon Date value
5. Value must be less than or equal to
associated Date of Death (ELG.002.025) value
when populated
6. Value must be equal to or greater than
associated Date of Birth (ELG.002.024) value
7. Mandatory

CIP292

CIP.002.292

TOTBENEFICIARYCOPAYMENTLIABLE-AMOUNT

Total
Beneﬁciary
Copayment
Liable Amount

CondiLonal The total copayment amount on a claim that the
beneﬁciary is obligated to pay for covered
services. This is the total Medicaid or contract
negoLated beneﬁciary copayment liability for

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

156

1305

1317

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

covered service on the claim. Do not subtract
out any payments made toward the copayment.

CIP293

CIP.002.293

TOTBENEFICIARYCOINSURANCELIABLE-AMOUNT

Total
Beneﬁciary
Coinsurance
Liable Amount

CondiLonal The total coinsurance amount on a claim the
beneﬁciary is obligated to pay for covered
services. This amount is the total Medicaid or
contract negoLated beneﬁciary coinsurance
liability for covered services on the claim. Do
not subtract out any payments made toward the
coinsurance.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

157

1318

1330

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP294

CIP.002.294

TOTBENEFICIARYDEDUCTIBLELIABLE-AMOUNT

Total
Beneﬁciary
DeducLble
Liable Amount

CondiLonal The total deducLble amount on a claim the
beneﬁciary is obligated to pay for covered
services. This amount is the total Medicaid or
contract negoLated beneﬁciary deducLble
liability minus previous beneﬁciary payments
that went toward their deducLble. Do not
subtract out any payments for the given claim
that went toward the deducLble.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

158

1331

1343

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP295

CIP.002.295

COMBINEDBENE-COSTSHARING-PAIDAMOUNT

Combined
Beneﬁciary Cost
Sharing Paid
Amount

CondiLonal The combined amounts the beneﬁciary or his or N/A
her representaLve (e.g., their guardian) paid
towards their copayment, coinsurance, and/or
deducLble for the covered services on the claim.
Only report this data element when the claim
does not diﬀerenLate among copayment,
coinsurance, and/or deducLble payments made
by the beneﬁciary. Do not include beneﬁciary
cost sharing payments made by a third party/ies
on behalf of the beneﬁciary.

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

159

1344

1356

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP296

CIP.003.296

IHS-SERVICE-IND

IHS Service
Indicator

Mandatory

CIP297

CIP.002.297

LTC-RCP-LIABAMT

LTC RCP Liability
Amount

CIP298

CIP.002.298

BILLING-PROVADDR-LN-1

CIP299

CIP.002.299

CIP300

CIP301

To indicate Services received by Medicaideligible individuals who are American Indian or
Alaska NaLve (AI/AN) through faciliLes of the
Indian Health Service (IHS), whether operated
by IHS or by Tribes.

IHS-SERVICEIND

CIP00003

CLAIM-LINERECORD-IP

X(1)

404

1. Value must be 1 character
2. Value must be in the IHS Service Indicator
List (VVL)
3. Mandatory

CondiLonal The total amount paid by the paLent for
services where they are required to use their
personal funds to cover part of their care before
Medicaid funds can be uLlized.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

160

1357

1369

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

Billing Provider
Address Line 1

Mandatory

Billing provider address line 1 from X12 837I
loop 2010AA.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(60)

161

1370

1429

1. Value must not be more than 60 characters
long
2. Mandatory
3. Value must not contain a pipe or asterisk
symbols

BILLING-PROVADDR-LN-2

Billing Provider
Address Line 2

CondiLonal Billing provider address line 2 from X12 837I
loop 2010AA.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(60)

162

1430

1489

1. Value must not be more than 60 characters
long
2. CondiLonal
3. Value must not be equal to associated
Address Line 1
4. Value must not contain a pipe or asterisk
symbols
5. There must be an Address Line 1 in order
to have an Address Line 2

CIP.002.300

BILLING-PROVCITY

Billing Provider
City

Mandatory

Billing provider address city name from X12 837I
loop 2010AA.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(28)

163

1490

1517

1. Value must not be more than 28 characters
long
2. Mandatory

CIP.002.301

BILLING-PROVSTATE

Billing Provider
State Code

Mandatory

Billing provider address state code from X12
837I loop 2010AA.

STATE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

164

1518

1519

1. Value must not be more than 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

CIP302

CIP.002.302

BILLING-PROVZIP-CODE

Billing Provider
ZIP Code

Mandatory

CIP303

CIP.002.303

SERVICEFACILITYLOCATION-ORGNPI

Service Facility
LocaLon
OrganizaLon
NPI

CIP304

CIP.002.304

SERVICEFACILITYLOCATIONADDR-LN-1

CIP305

CIP.002.305

CIP306

CIP.002.306

Billing provider address ZIP code from X12 837I
loop 2010AA.

ZIP-CODE

CIP00002

CLAIMHEADERRECORD-IP

X(9)

165

1520

1528

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. Mandatory

CondiLonal Service facility locaLon organizaLon NPI from
X12 837I loop 2310E.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(10)

166

1529

1538

1.Value must be 10 digits
2. Value must have an associated Provider
IdenLﬁer Type equal to "2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal
5. When populated, value must match
Provider IdenLﬁer (PRV.005.081) and Facility
Group Individual Code (PRV.002.028) must
equal "01"
6. NPPES EnLty Type Code associated with
this NPI must equal "2" (OrganizaLon)

Service Facility
LocaLon
Address Line 1

CondiLonal Service facility locaLon address line 1 from X12
837I loop 2310E.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(60)

167

1539

1598

1. Value must not be more than 60 characters
long
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols

SERVICEFACILITYLOCATIONADDR-LN-2

Service Facility
LocaLon
Address Line 2

CondiLonal Service facility locaLon address line 2 from X12
837I loop 2310E.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(60)

168

1599

1658

1. Value must not be more than 60 characters
long
2. CondiLonal
3. Value must not be equal to associated
Address Line 1
4. There must be an Address Line 1 in order
to have an Address Line 2
5. Value must not contain a pipe or asterisk
symbols

SERVICEFACILITYLOCATION-CITY

Service Facility
LocaLon City

CondiLonal Service facility locaLon address city name from
X12 837I loop 2310E.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(28)

169

1659

1686

1. Value must not be more than 28 characters
long
2. CondiLonal

CIP307

CIP.002.307

SERVICEFACILITYLOCATION-STATE

Service Facility
LocaLon State

CondiLonal Service facility locaLon address state code from
X12 837I loop 2310E.

STATE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

170

1687

1688

1. Value must not be more than 2 characters
2. Value must be in State Code List (VVL)
3. CondiLonal

CIP308

CIP.002.308

SERVICEFACILITYLOCATION-ZIPCODE

Service Facility
LocaLon ZIP
Code

CondiLonal Service facility locaLon address ZIP code from
X12 837I loop 2310E.

ZIP-CODE

CIP00002

CLAIMHEADERRECORD-IP

X(9)

171

1689

1697

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. CondiLonal

CIP309

CIP.002.309

PROVIDERCLAIM-FORMCODE

Provider Claim
Form Code

Mandatory

PROVIDERCLAIM-FORMCODE

CIP00002

CLAIMHEADERRECORD-IP

X(2)

172

1698

1699

1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code
List (VVL)
3. Mandatory

CIP310

CIP.002.310

PROVIDERCLAIM-FORMOTHER-TEXT

Provider Claim
Form Other Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the "other" claim form used by the provider to
submit their claim. Required when "Other" is
reported to Provider Claim Form Code.

N/A

CIP00002

CLAIMHEADERRECORD-IP

X(50)

173

1700

1749

1. Value must not be more than 50 characters
long
2. CondiLonal
3. Value must be provided when
corresponding Provider Claim Form Code is
"Other"

CIP311

CIP.002.311

TOT-GMEAMOUNT-PAID

Total GME
Amount Paid

CondiLonal The amount included in the Total Medicaid
Amount (CIP.002.114) that is aaributable to a
Graduate Medical EducaLon (GME) payment,
when the state makes GME payments by claim.

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

174

1750

1762

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP314

CIP.003.314

UNIQUE-DEVICEIDENTIFIER

Unique Device
IdenLﬁer

CondiLonal An unique idenLﬁer assigned to every medical
device that meets the requirements of 21 CFR
801 and 830.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(76)

405

480

1. Value must not be more than 76 characters
long
2. CondiLonal

A code indicaLng the format in which the
provider submiaed their claim. Very few if any
claims should be classiﬁed as "Other".

CIP315

CIP.003.315

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

CondiLonal A code indicaLng the category of service for the
paid claim. The category of service is the line
item from the MBES/CBES expenditure form
(e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.)
that states use to report their expenditures and
request federal ﬁnancial parLcipaLon.

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

CIP00003

CLAIM-LINERECORD-IP

X(5)

532

536

1. Value must be 5 characters or less
2. When MBESCBES Form equals "21.P",
value must be in 21.P Form List (VVL)
3. When MBESCBES Form equals "21BASE",
value must be in 21BASE Form List (VVL)
4. When MBESCBES Form equals "64.21U",
value must be in 64.21U Form List (VVL)
5. When MBESCBES Form equals
"64.10BASE", value must be in 64.10BASE
Form List (VVL)
6. When MBESCBES Form equals "64.9P",
value must be in 64.9P Form List (VVL)
7. When MBESCBES Form equals "64.9A",
value must be in 64.9A Form List (VVL)
8. When MBESCBES Form equals "64.9BASE",
value must be in 64.9BASE Form List (VVL)
9. When MBESCBES Form equals "64.21UP",
value must be in 64.21UP Form List (VVL)
10. CondiLonal
11. If Type of Claim in [1,A,U], then value
must be populated on all claim lines with a
Medicaid Paid Amount greater than $0
12. When populated, an associated
MBESCBES Form Group and MBESCBES Form
must be populated

CIP316

CIP.003.316

MBESCBESFORM

MBESCBES
Form

CondiLonal The MBES or CBES form to which the
expenditure will be mapped (e.g., CMS-64 Base,
CMS-64.21U, CMS-21, etc.). This should be
determined by the state's MBES/CBES reporLng
process. The MBES or CBES form reported here
will determine what the meaning of the
corresponding MBES/CBES category of service
value is.

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

CIP00003

CLAIM-LINERECORD-IP

X(50)

482

531

1. Value must be 50 characters or less
2. When MBESCBES Form Group equals "1",
value must be in MBESCBES Form Group 1
List (VVL)
3. When MBESCBES Form Group equals "2",
value must be in MBESCBES Form Group 2
List (VVL)
4. When MBESCBES Form Group equals "3",
value must be in MBESCBES Form Group 3
List (VVL)
5. CondiLonal
6. If Type of Claim in [1,A,U], then value must
be populated on all claim lines with a
Medicaid Paid Amount greater than $0

CIP317

CIP.003.317

GME-AMOUNTPAID

GME Amount
Paid

CondiLonal The amount included in the Medicaid Amount
(CIP.003.254) that is aaributable to a Graduate
Medical EducaLon (GME) payment, when the
state makes GME payments by claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

537

549

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP318

CIP.003.318

REFERRINGPROV-NUM

Referring
Provider
Number

N/A

CIP00003

CLAIM-LINERECORD-IP

X(30)

550

579

1. Value must be 30 characters or less
2. CondiLonal

CIP319

CIP.003.319

REFERRINGPROV-NPI-NUM

Referring
Provider NPI
Number

CondiLonal The NaLonal Provider ID (NPI) of the provider
who recommended the servicing provider to the
paLent.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(10)

580

589

1. Value must be 10 digits
2. Value must have an associated Provider
IdenLﬁer Type equal to "2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

CIP322

CIP.004.322

RECORD-ID

Record ID

Mandatory

The Record ID represents the type of segment
being reported. The Record ID communicates
how the contents of a given row of data should
be interpreted depending on which segment
type the Record ID represents. Each type of
segment collects diﬀerent data elements so
each segment type has a disLnct layout. The
ﬁrst 3 characters idenLfy the relevant ﬁle (e.g.,
ELG, PRV, CIP, etc.). The last 5 digits are the
segment idenLﬁer padded with leading zeros
(e.g., 00001, 00002, 00003, etc.).

RECORD-ID

CIP00004

CLAIM-DX-IP

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "CIP00004"

CIP323

CIP.004.323

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CIP00004

CLAIM-DX-IP

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
4. Value must be the same as Submieng
State (CIP.001.007)

CIP324

CIP.004.324

RECORDNUMBER

Record Number

Mandatory

N/A

CIP00004

CLAIM-DX-IP

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

CIP325

CIP.004.325

ICN-ORIG

Original ICN

Mandatory

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CIP00004

CLAIM-DX-IP

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

CIP326

CIP.004.326

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

CIP00004

CLAIM-DX-IP

X(50)

121

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. If associated Adjustment Indicator value
equals "0", then value must not be populated
4. CondiLonal
5. If associated Adjustment Indicator value
equals "4", then value must be populated

CIP327

CIP.004.327

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

CIP00004

CLAIM-DX-IP

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Value must be in [0,1,4]
4. Mandatory
5. If value equals "0", then associated
Adjustment ICN must not be populated
6. Value must equal "1", when associated
Claim Status equals "686"
7. Value must match the adjustment indicator
in the header (CIP.002.026)

CIP328

CIP.004.328

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CIP00004

CLAIM-DX-IP

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value should be on or before End of Time
Period (CIP.001.010)
3. Mandatory
4. Value should be on or afer associated
Admission Date value

CIP329

CIP.004.329

DIAGNOSIS-TYPE

Diagnosis Type

Mandatory

Indicates the context of the diagnosis code from
the provider's claim (i.e., an 837I claim can have
one principal diagnosis code, one admieng
diagnosis code, up to 12 external cause of injury
diagnosis codes, and up to 24 other diagnosis
codes; a UB-04 claim can have one principal
diagnosis code, one admieng diagnosis code,
and up to 17 other diagnosis codes). The type of
diagnosis code (e.g., principal, admieng,
external cause of injury, or other) is captured
here. The order in which the diagnosis code was
reported is captured in the Diagnosis Sequence
Number.

DIAGNOSISTYPE

CIP00004

CLAIM-DX-IP

X(1)

131

1. Value must be 1 character
2. Value must be in Diagnosis Type Code List
(VVL)
3. Value must be in [P,A,E,O]
4. Mandatory

CIP330

CIP.004.330

DIAGNOSISSEQUENCENUMBER

Diagnosis
Sequence
Number

Mandatory

The order in which the diagnosis occurred on
the provider's claim for a given type of diagnosis
code (e.g., an 837I claim can have up to 12
external cause of injury diagnosis codes and up
to 24 other diagnosis codes).

N/A

CIP00004

CLAIM-DX-IP

9(2)

132

133

1. Value must be in [01-24]
2. Mandatory

CIP331

CIP.004.331

DIAGNOSISCODE-FLAG

Diagnosis Code
Flag

Mandatory

Flag used to idenLfy wither the associated
Diagnosis Code value is a ICD-9 or ICD-10 code.

DIAGNOSISCODE-FLAG

CIP00004

CLAIM-DX-IP

X(1)

134

1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List
(VVL)
3. Mandatory

CIP332

CIP.004.332

DIAGNOSISCODE

Diagnosis Code

Mandatory

ICD-9 or ICD-10 diagnosis codes used as a tool to DIAGNOSISgroup and idenLfy diseases, disorders,
CODE
symptoms, poisonings, adverse eﬀects of drugs
and chemicals, injuries and other reasons for
paLent encounters. Diagnosis codes should be
passed through to T-MSIS exactly as they were
submiaed by the provider on their claim (with
the excepLon of removing the decimal). For
example: 210.5 is coded as '21051'.

CIP00004

CLAIM-DX-IP

X(7)

135

141

1. Value must be a minimum of 3 characters
2. If associated Diagnosis Code Flag value
equals "1" (ICD-9), then value must be in
ICD-9 Diagnosis Code List (VVL)
3. If associated Diagnosis Code Flag value
equals "2" (ICD-10), then value must be in
ICD-10 Diagnosis Code List (VVL)
4. Value must not contain a decimal point
5. Mandatory

CIP333

CIP.004.333

DIAGNOSIS-POAFLAG

Diagnosis POA
Flag

CondiLonal A code to idenLfy condiLons that are present at
the Lme the order for inpaLent admission
occurs; condiLons that develop during an
outpaLent encounter, including emergency
department, observaLon, or outpaLent surgery.
POA indicator is used to idenLfy certain
preventable condiLons that are: (a) high cost or
high volume or both, (b) result in the
assignment of a case to a Diagnosis Related
Group (DRG)* that has a higher payment when
present as a secondary diagnosis, and (c) could
reasonably have been prevented through the
applicaLon of evidence-based guidelines.
*States that do not use the grouper
methodology may use CMS-approved
methodology that is prospecLve in nature.

DIAGNOSISPOA-FLAG

CIP00004

CLAIM-DX-IP

X(1)

142

1. Value must be 1 character
2. Value must be in Diagnosis POA Flag List
(VVL)
3. CondiLonal

CIP334

CIP.004.334

STATE-NOTATION

State NotaLon

SituaLonal

N/A

CIP00004

CLAIM-DX-IP

X(500)

143

642

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

CIP336

CIP.003.336

SDP-ALLOWEDAMT

State Directed
Payment
Allowed
Amount

CondiLonal The component (in dollar and cents) of the
allowed amount that represents the diﬀerence
between what would have been the managed
care plan's typical contractual allowed amount
and the enhanced allowed amount for this
speciﬁc claim as deﬁned by the State's SPA,
waiver, or demonstraLon for a State Directed
Payment model per 42 CFR 438.6(c)(1)(iii).

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

590

602

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

CIP337

CIP.003.337

SDP-PAID-AMT

State Directed
Payment Paid
Amount

CondiLonal The component (in dollar and cents) of the paid
amount that represents the diﬀerence between
what would have been the managed care plan's
typical contractual paid amount and the
enhanced paid amount for this speciﬁc claim as
deﬁned by the State's SPA, waiver, or
demonstraLon for a State Directed Payment
model per 42 CFR 438.6(c)(1)(iii).

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)
V99

603

615

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP338

CIP.002.338

TOT-SDPALLOWED-AMT

Total State
Directed
Payment
Allowed
Amount

CondiLonal The component (in dollar and cents) of the total
allowed amount that represents the diﬀerence
between what would have been the managed
care plan's typical contractual allowed amount
and the enhanced allowed amount for this
speciﬁc claim as deﬁned by the State's SPA,
waiver, or demonstraLon for a State Directed
Payment model per 42 CFR 438.6(c)(1)(iii).

N/A

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

175

1763

1775

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP339

CIP.002.339

TOT-SDP-PAIDAMT

Total State
Directed
Payment Paid
Amount

CondiLonal The component (in dollar and cents) of the total N/A
paid amount that represents the diﬀerence
between what would have been the managed
care plan's typical contractual paid amount and
the enhanced paid amount for this speciﬁc claim
as deﬁned by the State's SPA, waiver, or
demonstraLon for a State Directed Payment
model per 42 CFR 438.6(c)(1)(iii).

CIP00002

CLAIMHEADERRECORD-IP

S9(11)
V99

176

1776

1788

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CIP340

CIP.003.340

MBESCBESFORM-GROUP

MBESCBES
Form Group

CondiLonal Indicates group of MBES/CBES forms that this
payment applies to (e.g., the CMS-64.9 Base
form is for Title XIX-funded Medicaid, the CMS64.21 form is for Title XXI-funded Medicaidexpansion CHIP (M-CHIP), and the CMS-21 Base
form is for Title XXI-funded separate CHIP (SCHIP)).

CIP00003

CLAIM-LINERECORD-IP

X(1)

481

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. CondiLonal
4. If Type of Claim in [1,A,U], then value must
be populated on all claim lines with a
Medicaid Paid Amount greater than $0

MBESCBESFORM-GROUP

T-MSIS Data Dic,onary – CLT File Changes Between Versions 2.4.0 and 4.0.0

CLT001

CLT.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

CLT00001

FILE-HEADERRECORD-LT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CLT00001"

DATADICTIONARYVERSION

CLT00001

FILE-HEADERRECORD-LT

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

CLT00001

FILE-HEADERRECORD-LT

X(1)

1. Value must be 1 character
2. Value must be in Submission Transaction
TypeSubcapLtaLon Indicator List (VVL)

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

CLT.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

CLT003

CLT004

CLT.001.003

CLT.001.004

SUBMISSIONTRANSACTIONTYPE

FILE-ENCODINGSPECIFICATION

Submission
TransacLon
Type

File Encoding
SpeciﬁcaLon

Mandatory

2. Value must be 1 character

3. Mandatory
CLT00001

FILE-HEADERRECORD-LT

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

CLT005

CLT.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state

N/A

CLT00001

FILE-HEADERRECORD-LT

X(9)

1. Value must be 9 characters or less
2. Mandatory

submission ﬁle. Use the version number specified
on the title page of the data mapping document

CLT006

CLT.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

CLT007

CLT008

CLT.001.007

CLT.001.008

SUBMITTINGSTATE

DATE-FILECREATED

Submieng
State

Date File
Created

Mandatory

CLT00001

FILE-HEADERRECORD-LT

X(8)

1. Value must equal 'CLAIM-LT'"CLAIM-LT"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CLT00001

FILE-HEADERRECORD-LT

X(2)

1.1. Value must be 2 characters

The date on which the ﬁle was created.

N/A

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory
CLT00001

FILE-HEADERRECORD-LT

9(8)

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory
CLT009

CLT.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

CLT00001

FILE-HEADERRECORD-LT

9(8)

2. Value must be equal to or earlier than

associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"

CLT010

CLT.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

CLT00001

FILE-HEADERRECORD-LT

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
CLT011

CLT.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

CLT00001

FILE-HEADERRECORD-LT

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
CLT012

CLT.001.012

SSN-INDICATOR

SSN Indicator

Mandatory

SSN-INDICATOR

CLT00001

FILE-HEADERRECORD-LT

X(1)

1.1. Value must be 1 character

2. Value must be in SSN Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

CLT013

CLT.001.013

TOT-REC-CNT

Total Record
Count

Mandatory

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

CLT00001

FILE-HEADERRECORD-LT

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory
CLT014

CLT.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

CLT016

CLT.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CLT00001

FILE-HEADERRECORD-LT

X(500)

582

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

CLT00002

CLAIMHEADERRECORD-LT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CLT00002"

CLT017

CLT.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (CLT.001.007)
CLT018

CLT.002.018

RECORDNUMBER

Record Number

Mandatory

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(11)

1.1. Value must be 11 digits or less

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

CLT019

CLT.002.019

ICN-ORIG

Original ICN

Mandatory

CLT020

CLT.002.020

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(50)

121

CLT021

CLT.002.021

SUBMITTER-ID

Submiaer ID

Mandatory

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(12)

122

133

1. Value must be 12 characters or less
2. Mandatory

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

CLT022

CLT023

CLT.002.022

CLT.002.023

MSISIDENTIFICATIONNUM

CROSSOVERINDICATOR

MSIS
IdenLﬁcaLon
Number

Crossover
Indicator

Mandatory

Conditional

Mandatory

N/A

An indicator specifying whether the claim is a
crossover claim where a porLon is paid by
Medicare.

CROSSOVERINDICATOR

CLT00002

CLAIMHEADERRECORD-LT

X(20)

134

153

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. Populated value must begin with an '&', when
TYPE-OF-CLAIM = 4, D or X (lump sum payment)
6..

3. The Beginning Date of Service on the claim
must fall between (ELG.021.253) enrollment
eﬀecLve and (ELG.021.253) end date

CLT00002

CLAIMHEADERRECORD-LT

X(1)

154

1.1. Value must be 1 character

CLT024

CLT025

CLT.002.024

CLT.002.025

1115ADEMONSTRATIO
N-IND

ADJUSTMENTIND

1115A
DemonstraLon
Indicator

Adjustment
Indicator

1115ADEMONSTRATI
ON-IND

Mandatory

ADJUSTMENTIND

Indicates the type of adjustment record.

CLT00002

CLAIMHEADERRECORD-LT

X(1)

155

1.1. Value must be 1 character

2. Value must be in 1115A DemonstraLon
Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal
4. When value equals '"0'", is invalid or not

populated, then the associated 1115A
DemonstraLon Indicator (ELG.018.2233) must
equal '"0'", is invalid or not populated
CLT00002

CLAIMHEADERRECORD-LT

X(1)

156

1.1. Value must be 1 character

2. Value must be in Adjustment Indicator List
(VVL)
2. If associated Type of Claim value is in [ 1, 3, 5,
A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]
3. If associated Type of Claim value is '4, D, X',
then value. Value must be in [ 5, 6 0,1,4]
4. Value must be 1 character
5. Mandatory

5. If value equals "0", then associated
Adjustment ICN must not be populated
6. Value must equal "1", when associated
Claim Status equals "686"
7. Value must match the adjustment indicator
in the header (CIP.002.026)
CLT026

CLT.002.026

ADJUSTMENTREASON-CODE

Adjustment
Reason Code

CondiLonal Claim adjustment reason codes communicate
why a claim was paid diﬀerently than it was
billed. If the amount paid is different from the
amount billed you need an adjustment reason code.

ADJUSTMENTREASON-CODE

CLT00002

CLAIMHEADERRECORD-LT

X(3)

157

159

1.1. Value must be 3 characters or less

2. Value must be in Adjustment Reason Code
List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. Value must not be populated when
associated Adjustment Indicator equals "0"the

total paid amount is diﬀerent from the total
billed amount

CLT027

CLT.002.027

ADMITTINGDIAGNOSIS-CODE

Admitting
Diagnosis Code

Conditional

ADMITTINGDIAGNOSISCODE

CLT00002

CLAIM-HEADERRECORD-LT

X(7)

160

166

CLT028

CLT.002.028

ADMITTINGDIAGNOSIS-CODEFLAG

Admitting
Diagnosis Code
Flag

Mandatory

A flag that identifies the coding system used for the
Admitting Diagnosis Code.

ADMITTINGDIAGNOSISCODE-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

167

1. Value must be in Diagnosis Code Flag(VVL)
2. Value must be 1 character
3. Mandatory

CLT029

CLT.002.029

DIAGNOSISCODE-1

Diagnosis Code 1

Conditional

DIAGNOSISCODE

CLT00002

CLAIM-HEADERRECORD-LT

X(7)

168

174

"C", "U", "W") then Diagnosis Code 1
(CLT.002.032) must be populated.
CLT030

CLT.002.030

DIAGNOSISCODE-FLAG-1

Diagnosis Code
Flag 1

Conditional

DIAGNOSISCODE-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

175

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CLT031

CLT.002.031

DIAGNOSIS-POAFLAG-1

Diagnosis POA
Flag 1

Conditional

DIAGNOSISPOA-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

176

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CLT00002

CLAIM-HEADERRECORD-LT

X(7)

177

183

CLT.002.032

DIAGNOSISCODE-2

Diagnosis Code 2

Conditional

their claim (with the exception of removing the
decimal). For example: 210.5 is coded as "2105".

CLT033

CLT.002.033

DIAGNOSISCODE-FLAG-2

Diagnosis Code
Flag 2

Conditional

DIAGNOSISCODE-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

184

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CLT034

CLT.002.034

DIAGNOSIS-POAFLAG-2

Diagnosis POA
Flag 2

Conditional

DIAGNOSISPOA-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

185

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

only one, Diagnosis Code in a given file segment
record. For example, Diagnosis Code n is associated
with Diagnosis Code Flag n, where n can be any
integer greater than or equal to 1.
CLT035

CLT.002.035

DIAGNOSISCODE-3

Diagnosis Code 3

Conditional

DIAGNOSISCODE

CLT00002

CLAIM-HEADERRECORD-LT

X(7)

186

192

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 2 (CLT.002.032) is not populated

CLT036

CLT.002.036

DIAGNOSISCODE-FLAG-3

Diagnosis Code
Flag 3

Conditional

DIAGNOSISCODE-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

193

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CLT037

CLT.002.037

DIAGNOSIS-POAFLAG-3

Diagnosis POA
Flag 3

Conditional

DIAGNOSISPOA-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

194

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

POA indicator is used to identify certain preventable
conditions that are: (a) high cost or high volume or

CLT.002.038

DIAGNOSISCODE-4

Diagnosis Code 4

Conditional

DIAGNOSISCODE

CLT00002

CLAIM-HEADERRECORD-LT

X(7)

195

201

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 3 (CLT.002.035) is not populated

CLT039

CLT.002.039

DIAGNOSISCODE-FLAG-4

Diagnosis Code
Flag 4

Conditional

DIAGNOSISCODE-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

202

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional

Diagnosis Code Flag n, where n can be any integer
greater than or equal to 1.
CLT040

CLT.002.040

DIAGNOSIS-POAFLAG-4

Diagnosis POA
Flag 4

Conditional

4. Value should not be populated, if the
associated diagnosis code is not populated
DIAGNOSISPOA-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

203

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

CLT00002

CLAIM-HEADERRECORD-LT

X(7)

204

210

CLT.002.041

DIAGNOSISCODE-5

Diagnosis Code 5

Conditional

8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. Value must not be populated when Diagnosis
Code 4 (CLT.002.038) is not populated
CLT042

CLT.002.042

DIAGNOSISCODE-FLAG-5

Diagnosis Code
Flag 5

Conditional

DIAGNOSISCODE-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

211

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

CLT043

CLT.002.043

DIAGNOSIS-POAFLAG-5

Diagnosis POA
Flag 5

Conditional

DIAGNOSISPOA-FLAG

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

212

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

CLT044

CLT.002.044

ADMISSIONDATE

Admission Date

Mandatory

The date on which the recipient was admiaed to
a psychiatric or long-term care facility.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

2912

213160

220167

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be less than or equal to
associated Discharge Date value in the claim
header.
4

3. Value must be greater than or equal to
associated eligible Date of Birth value.
5

4. Value must be less than or equal to
associated eligible Date of Death value.
6

5. Mandatory
7. When associated Type of Claim (CLT.002.052) is
not '2','B' or 'V' (capitated payment) value must
be 6. Value must be before AdjudicaLon Date

(CLT.002.050)
8. When associated Type of Claim (CLT.002.052) is
not '2','B' or 'V' (capitated payment) and Type of
Service (CLT.003.211) is not '119, '120', '121', 122'
value must be before Adjudication Date
(CLT.003.233)

CLT045

CLT.002.045

ADMISSIONHOUR

Admission Hour

CondiLonal The Lme of admission to a psychiatric or longterm care facility.

HOUR

CLT00002

CLAIMHEADERRECORD-LT

X(2)

3013

221168

222169

1.1. Value must be 2 characters

2. Value must be in Hour List (VVL)
2. Value must be 2 characters

3. CondiLonal

CLT046

CLT.002.046

DISCHARGEDATE

Discharge Date

CondiLonal The date on which the recipient was discharged
from a psychiatric or long-term care facility.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

3114

223170

230177

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be less than or equal to
associated AdjudicaLon Date value.
43. Value must be greater than or equal to
associated Admission Date value.
54. Value must be greater than or equal to
associated eligible Date of Birth value.
65. Value must be less than or equal to
associated eligible Date of Death value.
76. CondiLonal
7. When populated, Discharge Hour
(CLT.002.047) must be populated
CLT047

CLT.002.047

DISCHARGEHOUR

Discharge Hour

CondiLonal The Lme of discharge from a psychiatric or longterm care facility.

HOUR

CLT00002

CLAIMHEADERRECORD-LT

X(2)

3215

231178

232179

1.1. Value must be 2 characters

2. Value must be in Hour List (VVL)
2. Value must be 2 characters
3.3. CondiLonal

4. When populated, Discharge Date
(CLT.002.046) must be populated

CLT048

CLT.002.048

BEGINNINGDATE-OFSERVICE

Beginning Date
of Service

Mandatory

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

3316

233180

240187

2. Value must be less than or equal to
associated End of Time Period value
43. Value must be less than or equal to
associated Ending Date of Service value

covered by this claim began. For capitation premium
payments, the date on which the period of coverage
related to this payment began. For financial
transactions reported to the OT file, populate with
the first day of the time period covered by this
financial transaction.covered by this claim began.

CLT049

CLT.002.049

ENDING-DATEOF-SERVICE

Ending Date of
Service

Mandatory

For services received during a single encounter
with a provider, the date the service covered by
this claim was received. For services involving
mulLple encounters on diﬀerent days, or
periods of care extending over two or more
days, the date on which the service covered by
this claim ended. For capitation premium
payments, the date on which the period of coverage
related to this payment ends/ended. For financial
transactions reported to the OT file, populate with
the first day of the time period covered by this
financial transaction.

5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V']
value4. Value must be less than or equal to

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value
when populated
76. Value must be less than or equal to at
least one of the eligible's Enrollment End
Date (ELG.021.254) values
87. Mandatory
N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

3417

241188

248195

2. Value must be less than or equal to
associated End of Time Period value
43. Value must be greater than or equal to
associated Beginning Date of Service value
5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V']
value4. Value must be less than or equal to

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value

when populated
76. Value must be equal to or greater than
associated Date of Birth (ELG.002.024) value
87. Mandatory

CLT050

CLT.002.050

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

3518

249196

256203

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in associated T-MSIS File
Header Record
4. (CIP.001.010)

3. Mandatory
54. Value should be on or afer associated
Admission Date value
CLT051

CLT.002.051

MEDICAID-PAIDDATE

Medicaid Paid
Date

Mandatory

The date Medicaid paid this claim or
adjustment. For Encounter Records (Type of
Claim = 3, C, W), the date the managed care
organizaLon paid the provider for the claim or
adjustment.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

3619

257204

264211

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Total Medicaid

Paid Amount
43. Mandatory

CLT052

CLT053

CLT054

CLT.002.052

CLT.002.053

CLT.002.054

TYPE-OF-CLAIM

TYPE-OF-BILL

CLAIM-STATUS

Type of Claim

Type of Bill

Claim Status

Mandatory

A code to indicate what type of payment is
covered in this claim. For sub-capitated
encounters from a sub-capitated enLty or subcapitated network provider, report TYPE-OFCLAIM = '3' for a Medicaid sub-capitated
encounter record or “C” for an S-CHIP subcapitated encounter record.

TYPE-OF-CLAIM

TYPE-OF-BILL

CondiLonal The health care claim status codes convey the
status of an enLre claim. status codes from the
277 transacLon set. Only report the claim status
for the ﬁnal, adjudicated claim.

CLT00002

CLAIMHEADERRECORD-LT

X(1)

CLAIMHEADERRECORD-LT

X(4)

3720

265212

1.1. Value must be 1 character

2. Value must be in Type of Claim List (VVL)
2. Value must be 1 character
3.3. Mandatory
4. When value equals 'Z', claim denied indicator
must equal '0'

3821

266213

2169

1.1. Value must be 4 characters

2. Value must be in Type of Bill List (VVL)
2. Value must be 4 characters
3.3. First character must be a '0'"0"

4. Mandatory
CLAIM-STATUS

CLT00002

CLAIMHEADERRECORD-LT

X(3)

3922

2170

272219

1.1. Value must be 3 characters or less

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. If value in [ 26, 87, 542,585,654 ],], then
Claim Denied Indicator must be '0'"0" and

Claim Status Category must be "F2"
CLT055

CLT.002.055

CLAIM-STATUSCATEGORY

Claim Status
Category

Mandatory

The Claim Status Category conveys the status
general category of the entire claim using the X12
Claim Status Category Codesstatus (accepted,
rejected, pended, ﬁnalized, addiLonal
informaLon requested, etc.) from the 277
transacLon set which is then further detailed in
the companion data element claim adjudication
processstatus.

CLAIM-STATUSCATEGORY

CLT00002

CLAIMHEADERRECORD-LT

X(3)

4023

273220

275222

1.1. Value must be 3 characters or less

4. Value must be 3 characters or less

5. Mandatory

CLT056

CLT.002.056

SOURCELOCATION

Source LocaLon

Mandatory

The field denotes the claims payment system from
which the claim was extracted.The ﬁeld denotes

the claims payment system from which the
claim was extracted.
For sub-capitated encounters from a subcapitated enLty that is not a sub-capitated
network provider, report a SOURCE-LOCATION =
'22' to indicate that the sub-capitated enLty
paid a provider for the service to the enrollee on
a FFS basis.
For sub-capitated encounters from a subcapitated network provider that were submiaed
to sub-capitated enLty, report a SOURCELOCATION = '23' to indicate that the subcapitated network provider provided the service
directly to the enrollee.
For sub-capitated encounters from a subcapitated network provider, report a SOURCELOCATION = “23” to indicate that the subcapitated network provider provided the service
directly to the enrollee.

SOURCELOCATION

CLT00002

CLAIMHEADERRECORD-LT

X(2)

4124

276223

277224

1.1. Value must be 2 characters

2. Value must be in Source LocaLon List (VVL)
2. Value must be 2 characters
3.3. Mandatory

CLT057

CLT.002.057

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(15)

4225

278225

2392

1. Value must be 15 characters or less
2. Value must have an associated Check
EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

CLT058

CLT.002.058

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

4326

293240

300247

2. Must have an associated Check Number
53. CondiLonal
CLT059

CLT.002.059

CLAIM-PYMTREM-CODE-1

Claim
PaymentRemiaa

nce Advice
Remark Code 1

CLAIM-PYMTREM-CODE

CLT00002

CLAIMHEADERRECORD-LT

X(5)

4427

301248

305252

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

Claim Payment Remark Code 1 through Claim
Payment Remark Code 4 is populated on a
claim, all values must be unique

CLT060

CLT061

CLT.002.060

CLT.002.061

CLAIM-PYMTREM-CODE-2

CLAIM-PYMTREM-CODE-3

Claim
PaymentRemiaa

nce Advice
Remark Code 2

Claim
PaymentRemiaa

nce Advice
Remark Code 3

CLAIM-PYMTREM-CODE

CLT00002

CLAIMHEADERRECORD-LT

X(5)

4528

306253

310257

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

CLT00002

CLAIMHEADERRECORD-LT

X(5)

4629

311258

315262

1. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3. CondiLonal
4. When more than one codeoccurrence of
Claim Payment Remark Code 1 through Claim
Payment Remark Code 4 is populated on a
claim, all values must be unique
5. Value must not be populated when Claim
PaymentRemiaance Advice Remark Code 2
(CLT.002.060) is not populated

CLT062

CLT063

CLT.002.062

CLT.002.063

CLAIM-PYMTREM-CODE-4

Claim
PaymentRemiaa

TOT-BILLED-AMT

Total Billed
Amount

nce Advice
Remark Code 4

CLAIM-PYMTREM-CODE

CLT00002

CLAIMHEADERRECORD-LT

X(5)

4730

316263

320267

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

4831

321268

333280

1. Value must be between -99999999999.99
and 99999999999.99.
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50 )).
3. Value must equal the sum of all Billed
Amount instances for the associated claim.
4. CondiLonal
5. Value should not be populated when
associated Type of Claim is in [2, 4, 5, B, D E or X]
6. Value should not be populated when
associated Type of Claim (CIP.002.100) is equal to
'4', 'D' or 'X'
7. (individual line item payments) when

populated and Payment Level Indicator
(CLT.002.082) equals = '2' value must be
greater than or equal to the sum of all claim
line Revenue Charges (CLT.003.204)).

CLT064

CLT.002.064

TOT-ALLOWEDAMT

Total Allowed
Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

4932

334281

346293

CLT065

CLT.002.065

TOT-MEDICAIDPAID-AMT

Total Medicaid
Paid Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

5033

347294

359306

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)
V99

360

372

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. Conditional

CLT.002.066

TOT-COPAY-AMT

Total Copayment
Amount

Conditional

The total amount paid by Medicaid/CHIP enrollee
for each office or emergency department visit or
purchase of prescription drugs in addition to the
amount paid by Medicaid/CHIP.

CLT067

CLT.002.067

TOT-MEDICAREDEDUCTIBLEAMT

Total Medicare
DeducLble
Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

5234

3073

385319

CLT068

CLT.002.068

TOT-MEDICARECOINS-AMT

Total Medicare
Coinsurance
Amount

CondiLonal The total amount paid by the Medicaid/CHIP
agency or a managed care plan towards the
porLon of the Medicare allowed charges that
Medicare applied to coinsurance.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

5335

386320

398332

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value is
'0'equals "0" (not a crossover claim), then
value should not be populated.
4. CondiLonal
5. If associated Medicare Combined
DeducLble Indicator is '1',equals "1", then
value must not be populated
6. When populated, value must be less than
or equal to Total Billed Amount

CLT069

CLT.002.069

TOT-TPL-AMT

Total Third Party
LiabilityTPL
Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

5436

399333

411345

CLT070

CLT.002.070

TOT-OTHERINSURANCEAMT

Total Other
Insurance
Amount

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

5537

412346

424358

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT071

CLT.002.071

OTHERINSURANCE-IND

Other Insurance
Indicator

CondiLonal The ﬁeld denotes whether the insured party is
covered under an other insurance plan other
than Medicare or Medicaid.

OTHERINSURANCEIND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

5638

425359

1.1. Value must be 1 character

2. Value must be in Other Insurance Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CLT072

CLT.002.072

OTHER-TPLCOLLECTION

Other TPL
CollecLon

Conditional

CLT073

CLT.002.073

SERVICETRACKING-TYPE

Service Tracking
Type

Conditional

Mandatory

OTHER-TPLCOLLECTION

CLT00002

CLAIMHEADERRECORD-LT

X(3)

5739

426360

428362

1. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. ConditionalMandatory

A code to categorize service tracking claims. A
"service tracking claim" is used to report lump sum
payments that cannot be attributed to a single
enrollee.

SERVICETRACKING-TYPE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

429

430

CLT074

CLT.002.074

SERVICETRACKINGPAYMENT-AMT

Service Tracking
Payment Amount

Conditional

CLT075

CLT.002.075

FIXED-PAYMENTIND

Fixed Payment
Indicator

CLT076

CLT.002.076

FUNDING-CODE

Funding Code

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)
V99

431

443

FIXEDPAYMENT-IND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

6040

444363

1.1. Value must be 1 character

MandatoryC

FUNDINGCODE

ondiLonal

On service tracking claims, the payment amount is
the lump sum that cannot be attributed to any one
beneficiary paid to the provider.

A code to indicate the source of non-federal
share funds.

2. Value must be in Fixed Payment Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

6141

445364

446365

1.1. Value must be 1 character

2. Value must be in Funding Code List (VVL)
2. Value must be 1 character
3. Mandatory3. If Type of Claim is not in

[3,C,W], then value must be populated
4. CondiLonal

CLT077

CLT078

CLT.002.077

CLT.002.078

FUNDINGSOURCENONFEDERALSHARE

MEDICARECOMB-DED-IND

Funding Source
Non-Federal
Share

Medicare
Combined
DeducLble
Indicator

Not
ApplicableC

ondiLonal

FUNDINGSOURCENONFEDERALSHARE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

6242

447366

448367

1.1. Value must be 2 characters

2. Value must be in Funding Source NonFederal Share List (VVL)
2. Value must be 2 characters
3. Required3. If Type of Claim is in [3,C,W],

then value must be populated
4. CondiLonal
MEDICARECOMB-DEDIND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

6343

449368

1.1. Value must be 1 character

Crossover Indicator must equals "0"
5. If value equals "1", then Crossover
Indicator must equals "1"
6. CondiLonal
CLT079

CLT.002.079

PROGRAM-TYPE

Program Type

Mandatory

A code to indicate special Medicaid program
under which the service was provided.

PROGRAMTYPE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

6444

450369

451370

1.1. Value must be 2 characters

2. Value must be in Program Type List (VVL)
2. Value must be 2 characters
3.3. Mandatory

CLT080

CLT.002.080

PLAN-IDNUMBER

Plan ID Number

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(12)

6545

452371

463382

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal
4. Value must match Managed Care Plan ID
(ELG.014.192)).
5. Value must match State Plan ID Number
(MCR.002.019)).
6. Value should not be populated when Type
of Claim is not equal to '3', 'C' or 'W'in [3,C,W]
7. When Type of Claim in ([3,C,W, 2, B, V)]
value must have a managed care enrollment
(ELG.014) for the beneﬁciary where the
Beginning DOS (CLT.002.048) occurs between
the managed care plan enrollment eﬀ/end
dates (ELG.014.197/198)
8. When Type of Claim in ([3,C,W, 2, B, V)]
value must have a managed care main record
(MCR.002) for the plan where the Beginning
DOS (CLT.002.048) occurs between the
managed care contract eﬀ/end dates
(MCR.002.020/021)

CLT081

CLT.002.081

NATIONALHEALTH-CAREENTITY-ID

National Health
Care Entity ID

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(10)

464

473

1. Not Applicable

CLT082

CLT.002.082

PAYMENT-LEVELIND

Payment Level
Indicator

Mandatory

The field denotes whether the payment amount was
determined at the claim header or line/detail
level.The ﬁeld denotes whether the payment

PAYMENTLEVEL-IND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

6746

474383

1.1. Value must be 1 character

2. Value must be in Payment Level Indicator
List (VVL)
2. Value must be 1 character
3.3. Mandatory

CLT083

CLT.002.083

MEDICAREREIM-TYPE

Medicare
Reimbursement
Type

CondiLonal A code to indicate the type of Medicare
reimbursement.

MEDICAREREIM-TYPE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

6847

475384

476385

1.1. Value must be 2 characters

2. Value must be in Medicare Reimbursement
Type List (VVL)
2. (Crossover Claim) if associated Crossover
Indicator value indicates a crossover claim,
value3. Value is mandatory and must be

provided
3. Value must be 2 characters

, when Crossover Indicator is equal to "1"

(Crossover Claim)
4. CondiLonal

CLT084

CLT.002.084

NON-COV-DAYS

Non-Covered
Days

CondiLonal The number of days of insLtuLonal long-term
care not covered by the payer for this sequence
as qualiﬁed by the payer organizaLon. The
number of non-covered days does not refer to
days not covered for any other service.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(5)

6948

477386

481390

1. Value must be a positive integer
2. Value must be between 0:99999999999
(inclusive)
3. Conditional
4.1. Value must be 5 digits or less

2. CondiLonal

CLT085

CLT.002.085

NON-COVCHARGES

Non-Covered
Charges

CondiLonal The charges for insLtuLonal long-term care,
which are not reimbursable by the primary
payer. The non-covered charges do not refer to
charges not covered for any other service.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

7049

482391

494403

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT086

CLT.002.086

MEDICAID-COVINPATIENT-DAYS

Medicaid
Covered
InpaLent Days

CondiLonal The number of inpaLent psychiatric days
covered by Medicaid on this claim.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(5)

7150

495404

499408

1. Value must be a posiLve integer
2. Value must be between
0:9999999999900000:99999 (inclusive)
3. CondiLonal
4. Value must be less than or equal to double
the number of days between Admission Date
(CLT.002.044) and Discharge Date
(CLT.002.046) plus one day
5. Value must be 5 digits or less
6. (inpaLent mental health/psychiatric
services) when associated Type of Service
(CLT.003.211) in [044,048,050], this ﬁeld must
be populated

CLT087

CLT.002.087

CLAIM-LINECOUNT

Claim Line
Count

Mandatory

The total number of lines on the claim.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(4)

7251

500409

503412

6. Mandatory
CLT090

CLT.002.090

FORCED-CLAIMIND

Forced Claim
Indicator

CondiLonal Indicates if the claim was processed by forcing it
through a manual override process.

FORCEDCLAIM-IND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

7352

504413

1.1. Value must be 1 character

2. Value must be in Forced Claim Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CLT091

CLT092

CLT.002.091

CLT.002.092

HEALTH-CAREACQUIREDCONDITION-IND

OCCURRENCECODE-01

Healthcare
Acquired
CondiLon
Indicator

CondiLonal This code indicates whether the claim has a
Health Care Acquired CondiLon. For addiLonal
coding informaLon refer to the following site:
haps://www.cms.gov/Medicare/Medicare-Feefor-ServicePayment/HospitalAcqCond/index.html?redirect
=/hospitalacqcond/05_Coding.asp#TopOfPage

HEALTH-CAREACQUIREDCONDITIONIND

CLT00002

Occurrence
Code 1

CondiLonal A code to describe speciﬁc event(s) relaLng to
this billing period covered by the claim. (These
are FLsForm Locators 31, 32, 33, 34, 35, and 36 Occurrence Codes on the UB04.) These ﬁelds
can be used for either occurrences or
occurrence spans.

OCCURRENCECODE

CLT00002

CLAIMHEADERRECORD-LT

X(1)

7453

505414

1.1. Value must be 1 character

2. Value must be in Healthcare Acquired
CondiLon Indicator List (VVL).
2. Value must be 1 character

)
3. CondiLonal
CLAIMHEADERRECORD-LT

X(2)

7554

506415

507416

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT093

CLT094

CLT095

CLT096

CLT097

CLT.002.093

CLT.002.094

CLT.002.095

CLT.002.096

CLT.002.097

OCCURRENCECODE-02

OCCURRENCECODE-03

OCCURRENCECODE-04

OCCURRENCECODE-05

OCCURRENCECODE-06

Occurrence
Code 2

Occurrence
Code 3

Occurrence
Code 4

Occurrence
Code 5

Occurrence
Code 6

OCCURRENCECODE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

7655

508417

509418

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

7756

510419

511420

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

7857

512421

513422

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

7958

514423

515424

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

8059

516425

517426

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT098

CLT099

CLT100

CLT101

CLT102

CLT.002.098

CLT.002.099

CLT.002.100

CLT.002.101

CLT.002.102

OCCURRENCECODE-07

OCCURRENCECODE-08

OCCURRENCECODE-09

OCCURRENCECODE-10

OCCURRENCECODE-EFF-DATE01

Occurrence
Code 7

Occurrence
Code 8

Occurrence
Code 9

Occurrence
Code 10

Occurrence
Code EﬀecLve
Date 1

OCCURRENCECODE

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(2)

8160

518427

519428

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

8261

520429

521430

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

8362

522431

523432

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

X(2)

8463

524433

525434

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

9(8)

8564

526435

533442

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal

54. Value must be less than or equal to

Occurrence Code End Date

CLT103

CLT.002.103

OCCURRENCECODE-EFF-DATE02

Occurrence
Code EﬀecLve
Date 2

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

8665

534443

541450

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CLT104

CLT.002.104

OCCURRENCECODE-EFF-DATE03

Occurrence
Code EﬀecLve
Date 3

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

8766

542451

549458

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

CLT105

CLT.002.105

OCCURRENCECODE-EFF-DATE04

Occurrence
Code EﬀecLve
Date 4

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

8867

550459

557466

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CLT106

CLT.002.106

OCCURRENCECODE-EFF-DATE05

Occurrence
Code EﬀecLve
Date 5

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

8968

558467

565474

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CLT107

CLT.002.107

OCCURRENCECODE-EFF-DATE06

Occurrence
Code EﬀecLve
Date 6

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9069

566475

573482

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

CLT108

CLT.002.108

OCCURRENCECODE-EFF-DATE07

Occurrence
Code EﬀecLve
Date 7

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9170

574483

581490

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CLT109

CLT.002.109

OCCURRENCECODE-EFF-DATE08

Occurrence
Code EﬀecLve
Date 8

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9271

582491

589498

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CLT110

CLT.002.110

OCCURRENCECODE-EFF-DATE09

Occurrence
Code EﬀecLve
Date 9

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9372

590499

597506

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

CLT111

CLT.002.111

OCCURRENCECODE-EFF-DATE10

Occurrence
Code EﬀecLve
Date 10

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9473

598507

605514

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
CLT112

CLT.002.112

OCCURRENCECODE-ENDDATE-01

Occurrence
Code End Date
1

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9574

606515

613522

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT113

CLT.002.113

OCCURRENCECODE-ENDDATE-02

Occurrence
Code End Date
2

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9675

614523

621530

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

CLT114

CLT.002.114

OCCURRENCECODE-ENDDATE-03

Occurrence
Code End Date
3

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9776

622531

629538

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT115

CLT.002.115

OCCURRENCECODE-ENDDATE-04

Occurrence
Code End Date
4

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9877

630539

637546

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT116

CLT.002.116

OCCURRENCECODE-ENDDATE-05

Occurrence
Code End Date
5

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

9978

638547

645554

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

CLT117

CLT.002.117

OCCURRENCECODE-ENDDATE-06

Occurrence
Code End Date
6

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

10079

646555

653562

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT118

CLT.002.118

OCCURRENCECODE-ENDDATE-07

Occurrence
Code End Date
7

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

10180

654563

661570

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT119

CLT.002.119

OCCURRENCECODE-ENDDATE-08

Occurrence
Code End Date
8

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

10281

662571

669578

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

CLT120

CLT.002.120

OCCURRENCECODE-ENDDATE-09

Occurrence
Code End Date
9

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

10382

670579

677586

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT121

CLT.002.121

OCCURRENCECODE-ENDDATE-10

Occurrence
Code End Date
10

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

10483

678587

685594

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
CLT122

CLT.002.122

PATIENTCONTROL-NUM

PaLent Control
Number

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(20)

10584

686595

705614

1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk
symbol
3. CondiLonal

CLT123

CLT.002.123

ELIGIBLE-LASTNAME

Eligible Last
Name

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(30)

10685

706615

735644

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CLT124

CLT.002.124

ELIGIBLE-FIRSTNAME

Eligible First
Name

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(30)

10786

736645

765674

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CLT125

CLT.002.125

ELIGIBLEMIDDLE-INIT

Eligible Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(1)

10887

766675

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
CLT126

CLT.002.126

DATE-OF-BIRTH

Date of Birth

Mandatory

An individual's date of birth.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

10988

7676

774683

1. Value must be 8 characters in the form
"CCYYMMDD"
2. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
3. Mandatory
4. Value must equal Date of Birth (ELG.002.024)
when Conception to Birth Indicator (ELG.005.094)
does not equal '1' and Eligibility Group
(ELG.005.087) does not equal '64'1. The date

must be a valid calendar date in the form
"CCYYMMDD"
2. Mandatory

CLT127

CLT.002.127

HEALTH-HOMEPROV-IND

Health Home
Provider
Indicator

HEALTH-HOMEPROV-IND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

11089

775684

individual's health home provider number, if
applicable, should not report claims that
indicate the claim is submiaed by a provider or
provider group enrolled in the health home
model.
CLT128

CLT.002.128

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which claim
is submiaed.

WAIVER-TYPE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

11190

776685

777686

1.1. Value must be 2 characters

Lme period (by date of service)
4. Value must have a corresponding value in
Waiver ID (CLT.002.129)
5. CondiLonal

CLT129

CLT130

CLT.002.129

CLT.002.130

WAIVER-ID

BILLING-PROVNUM

Waiver ID

Billing Provider
Number

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(20)

11291

778687

797706

1.1. Value must be 20 characters or less

2. Value must be associated with a populated
Waiver Type
2. Value must be 20 characters or less
3.3. (1115 demonstraLon waivers) If value

CLAIMHEADERRECORD-LT

X(30)

11392

798707

827736

Ending6. Discharge Date of Service
(CLT(CIP.002.0496) may be between Provider

IdenLﬁer EﬀecLve Date (PRV.005.079) and
Provider IdenLﬁer End Date (PRV.005.080)

CLT131

CLT.002.131

BILLING-PROVNPI-NUM

Billing Provider
NPI Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(10)

11493

828737

837746

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal
45. When Type of Claim (CLT.002.052) not in
('3','C','W') thenpopulated, value must match
Provider IdenLﬁer (PRV.0025.081) and Facility
Group Individual Code (PRV.002.028) must
equal "01"
6. NPPES EnLty Type Code associated with
this NPI must equal "2" (OrganizaLon)

CLT132

CLT.002.132

BILLING-PROVTAXONOMY

Billing Provider
Taxonomy

CondiLonal The taxonomy code for the insLtuLon billing for
the beneﬁciary.

1. Value must be 10 digits, consisting of 9

PROVTAXONOMY

CLT00002

CLAIMHEADERRECORD-LT

X(12)

11594

838747

849758

1.1. Value must be 12 characters or less

2. Value must be in Provider Taxonomy List
(VVL)

2. Value must be 12 characters or less
3.3. CondiLonal

CLT133

CLT.002.133

BILLING-PROVTYPE

Billing Provider
Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

CLT00002

CLAIMHEADERRECORD-LT

X(2)

11695

850759

851760

1.1. Value must be 2 characters

2. Value must be in Provider Type Code List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CLT134

CLT.002.134

BILLING-PROVSPECIALTY

Billing Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CLT00002

CLAIMHEADERRECORD-LT

X(2)

11796

852761

853762

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CLT135

CLT136

CLT.002.135

CLT.002.136

REFERRINGPROV-NUM

REFERRINGPROV-NPI-NUM

Referring
Provider
Number

N/A

Referring
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

NaLonal Provider ID (NPI) of the provider who

CLT00002

CLAIMHEADERRECORD-LT

X(30)

CLAIMHEADERRECORD-LT

X(10)

11897

854763

883792

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal

11998

884793

893802

1. Value must be 10 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

recommended the servicing provider to the
paLent.

CLT137

CLT.002.137

REFERRINGPROV-TAXONOMY

Referring
Provider
Taxonomy

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

120

894

905

1. Not Applicable

CLT138

CLT.002.138

REFERRINGPROV-TYPE

Referring
Provider Type

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

121

906

907

1. Not Applicable

CLT139

CLT.002.139

REFERRINGPROV-SPECIALTY

Referring
Provider Specialty

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

122

908

909

1. Not Applicable

CLT140

CLT.002.140

MEDICARE-HICNUM

Medicare HIC
Number

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(12)

12399

910803

921814

1. Conditional
2. Value must be 12 characters or less
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols
4. (Not Dual Eligible) if Dual Eligible Code
(ELG.DE.085) value =equals "00", then value
must not be populated.
5. Value must be populated when Crossover
Indicator (CLT.002.023) equals '1'"1" and
Medicare Beneﬁciary IdenLﬁer (CLT.002.168)
is not populated.

CLT141

CLT.002.141

PATIENT-STATUS

PaLent Status

Mandatory

PATIENTSTATUS

CLT00002

CLAIMHEADERRECORD-LT

X(2)

124100

922815

923816

1.1. Value must be 2 characters

2. Value must be in PaLent Status List (VVL).
2. Value must be 2 characters

)
3. Mandatory

CLT143

CLT.002.143

BMI

Body Mass Index

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(5)V
9

125

924

929

1. Not Applicable

CLT144

CLT.002.144

REMITTANCENUM

Remiaance
Number

Mandatory

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(30)

126101

930817

959846

symbols
43. Mandatory

number.

CLT145

CLT.002.145

LTC-RCP-LIABAMT

LTC RCP Liability
Amount

CondiLonal The total amount paid by the paLent for
services where they are required to use their
personal funds to cover part of their care before
Medicaid funds can be uLlized.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

1027

960847

972859

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT146

CLT.002.146

DAILY-RATE

Daily Rate

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(5)V
99

128

973

979

1. Value must be between 0.00 and 99999.99
2. Conditional
3. Value must be expressed as a number with 2digit precision (e.g. 100.50)

The amount a policy will pay per day for a covered
service.

CLT147

CLT.002.147

ICF-IID-DAYS

ICF IID Days

CondiLonal The number of days of intermediate care for
individuals with an intellectual disability that
were paid for in whole or in part by Medicaid. If
value exceeds 99998 days, code as 99998. (e.g.,
code 100023 as 99998).

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(5)

129103

9860

9864

1. Value must be 5 digits or less
2. CondiLonal
3. Value is mandatory when associated Type
of Service (CLT.003.211) = '046'equals "046"
4. Value must be less than or equal to the
number of days between (ending date of
service minus beginning date of service) plus
one day
5. When populated, if value is greater than 0
and less than 99998, then Level of Care
Status (ELG.005.088) for the associated MSIS
IdenLﬁcaLon Number (CLT.002.022) must
equal '"004'" (ICF/IID) for the same month as
the begin and end date of service

CLT148

CLT.002.148

LEAVE-DAYS

Leave Days

CondiLonal The number of days, during the period covered
by Medicaid, on which the paLent did not reside
in the long term care facility.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(5)

1304

9865

9869

1. Value must be numeric
2. Value must be 5 digits or less
3. CondiLonal
4. (Intermediate Care Facility for Individuals
with Intellectual DisabiliLes) value is required
when Type of Service (CLT.003.211) in
[009,045,046,047,059]

CLT149

CLT150

CLT151

CLT153

CLT.002.149

CLT.002.150

CLT.002.151

CLT.002.153

NURSINGFACILITY-DAYS

Nursing Facility
Days

CondiLonal The number of days of nursing care included in
this claim that were paid for, in whole or in part,
by Medicaid. Includes days during which nursing
facility received parLal payment for holding a
bed during paLent leave days. If value exceeds
99998 days, code as 99998.

N/A

SPLIT-CLAIM-IND

Split Claim
Indicator

CondiLonal An indicator that denotes that claims in excess
of a pre-determined number of claim lines
(threshold determined by the individual state)
will be split during processing.

SPLIT-CLAIMIND

BORDER-STATEIND

N/A

BORDER-STATEIND

TOTBENEFICIARYCOINSURANCEPAID-AMOUNT

Border State
Indicator

Total
Beneﬁciary
Coinsurance
Paid Amount

CLT00002

CLAIMHEADERRECORD-LT

S9(5)

CLAIMHEADERRECORD-LT

X(1)

131105

990870

994874

1. Value must be numeric
2.1. Value must be 5 digits or less

2. Value must be numeric
3. CondiLonal
4. When populated, value must be less than
or equal to the number of days between
(ending date of service minus beginning date
of service) plus one day
5. (nursing facility) value is required when the
Type of Service in [009,045,047,059]
6. When populated, if value is greater than
zero, then Level of Care Status (ELG.005.088)
for the associated MSIS IdenLﬁcaLon
Number (CLT.002.022) must equal '"003'"
(Nursing Facility) for the same month as the
beginning and ending date of service
132106

995875

1.1. Value must be 1 character

2. Value must be in Split Claim Indicator List
(VVL).
2. Value must be 1 character

)
3. CondiLonal
CLT00002

CLAIMHEADERRECORD-LT

X(1)

133107

996876

1.1. Value must be 1 character

2. Value must be in Border State Indicator List
(VVL)
2. Value must be 1 character
3.3. CondiLonal

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

134108

997877

100988

CLT154

CLT.002.154

BENEFICIARYCOINSURANCEDATE-PAID

Beneﬁciary
Coinsurance
Date Paid

CondiLonal The date the beneﬁciary paid the coinsurance
amount.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

135109

101089

101789

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Must in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Coinsurance Amount
43. CondiLonal
CLT155

CLT156

CLT.002.155

CLT.002.156

TOTBENEFICIARYCOPAYMENTPAID-AMOUNT

BENEFICIARYCOPAYMENTDATE-PAID

Total
Beneﬁciary
Copayment Paid
Amount

Beneﬁciary
Copayment
Date Paid

N/A

CondiLonal The date the beneﬁciary paid the copayment
amount.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

136110

101889

91030

CLT00002

CLAIMHEADERRECORD-LT

9(8)

137111

91031

91038

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Must in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Copayment Amount
43. CondiLonal
CLT157

CLT.002.157

TOTBENEFICIARYDEDUCTIBLEPAID-AMOUNT

Total
Beneﬁciary
DeducLble Paid
Amount

CondiLonal The amount of money the beneﬁciary or his or
her representaLve (e.g., their guardian) paid
towards an annual deductibletheir copayment for
the covered services on the claim. Do not
include copayment payments made by a third
party/s on behalf of the beneﬁciary.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

138112

91039

105193

CLT158

CLT.002.158

BENEFICIARYDEDUCTIBLEDATE-PAID

Beneﬁciary
DeducLble Date
Paid

CondiLonal The date the beneﬁciary paid the deducLble
amount.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

1139

105293

105993

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Must in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary DeducLble Date Paid
4Amount
3. CondiLonal
CLT159

CLT.002.159

CLAIM-DENIEDINDICATOR

Claim Denied
Indicator

Mandatory

An indicator to idenLfy a claim that the state
refused pay in its enLrety.

CLAIM-DENIEDINDICATOR

CLT00002

CLAIMHEADERRECORD-LT

X(1)

1140

106094

1.1. Value must be 1 character

2. Value must be in Claim Denied Indicator
List (VVL)
23. If value is '0',equals "0", then Claim Status
Category must equal "F2"
3. Value must be 1 character
4.4. Mandatory

CLT160

CLT161

CLT.002.160

CLT.002.161

COPAY-WAIVEDIND

HEALTH-HOMEENTITY-NAME

Copayment
Waived
Indicator

Health Home
EnLty Name

OpSituaLo

nal

COPAYWAIVED-IND

CLT00002

CLAIMHEADERRECORD-LT

X(1)

1415

106194

1.1. Value must be 1 character

2. Value must be in Copay Waived Indicator
List (VVL)
2. Value must be 1 character
3. Optional3. SituaLonal

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(50)

142116

106294

111199

1. Value must 50 characters or less
2.1. Value must not contain a pipe or asterisk

symbols
2. Value must 50 characters or less
3. CondiLonal

numbering schema has not been established,
the enLLes' names are being used instead.

CLT163

CLT164

CLT.002.163

CLT.002.164

THIRD-PARTYCOINSURANCEAMOUNT-PAID

Third Party
Coinsurance
Amount Paid

OpSituaLo

THIRD-PARTYCOINSURANCEDATE-PAID

Third Party
Coinsurance
Date Paid

CondiLonal The date a Third Party Coinsurancethe third party
paid the coinsurance amount was paid on this

nal

The amount of money paid by a third party on
behalf of the beneﬁciary towards coinsurance on
the claim or claim line item.

N/A

CLT00002

claim or adjustment.

CLAIMHEADERRECORD-LT

S9(11)
V99

143117

CLAIMHEADERRECORD-LT

9(8)

144118

111299

112004

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. OpSituaLonal

10132

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

112005

2. When populated, value must have an
associated Third Party Coinsurance Amount
3. CondiLonal
CLT165

CLT.002.165

THIRD-PARTYCOPAYMENTAMOUNT-PAID

Third Party
Copayment
Amount Paid

OpSituaLo

nal

The amount of money paid by a third -party on
behalf of the beneﬁciary paid towards a
copayment.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

145119

10133

114025

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. OpSituaLonal

CLT166

CLT.002.166

THIRD-PARTYCOPAYMENTDATE-PAID

Third Party
Copayment
Date Paid

OpSituaLo

nal

The date a Third Partythe third party paid the
copayment amount was paid on a claim or
adjustment.

N/A

CLT00002

CLAIMHEADERRECORD-LT

9(8)

146120

114026

115033

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

2. When populated, value must have an
associated Third Party Copayment Amount
3. OpSituaLonal
CLT167

CLT.002.167

HEALTH-HOMEPROVIDER-NPI

Health Home
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

NaLonal Provider ID (NPI) of the health home
provider.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(12)

147121

115034

116045

1. Value must be 1012 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer, where Provider IdenLﬁer Type
equal to '2'(PRV.005.077) equals "2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

CLT168

CLT.002.168

MEDICAREBENEFICIARYIDENTIFIER

Medicare
Beneﬁciary
IdenLﬁer

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(12)

148122

110466

110577

CLT169

CLT.002.169

UNDERDIRECTION-OFPROV-NPI

Under Direction
of Provider NPI

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

149

1178

1189

1. Not Applicable

CLT170

CLT.002.170

UNDERDIRECTION-OFPROV-TAXONOMY

Under Direction
of Provider
Taxonomy

Not
Applicable

[No longer essential - Both data element and
associated requirement(s); preserved for file
submission integrity. See Data Dictionary v2.3 for

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

150

1190

1201

1. Not Applicable

specific definition and coding requirement
description(s).]
CLT171

CLT.002.171

UNDERSUPERVISION-OFPROV-NPI

Under
Supervision of
Provider NPI

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

151

1202

1213

1. Not Applicable

CLT172

CLT.002.172

UNDERSUPERVISION-OFPROV-TAXONOMY

Under
Supervision of
Provider
Taxonomy

Not
Applicable

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

152

1214

1225

1. Not Applicable

CLT173

CLT.002.173

STATE-NOTATION

State NotaLon

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(500)

1590

129516

179421

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

CLAIMHEADERRECORD-LT

X(10)

122610

123510

1. Value must be 10 digits, consisting of 9

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

nal

CLT174

CLT.002.174

ADMITTINGPROV-NPI-NUM

Admieng
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

digit identification number issued to health care
providers in the United States by CMS. Healthcare
providers acquire their unique 10-digit NPIs to
identify themselves in a standard way throughout
their industry. The NPI is a 10-position,
intelligence-free numeric identifier (10-digit
number).The NaLonal Provider ID (NPI) of the

N/A

CLT00002

1523

2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to '2'
3. Conditional"2"
4. Value must exist in the NPPES NPI File

doctor responsible for admieng a paLent to a
hospital or other inpaLent health facility.
CLT175

CLT.002.175

ADMITTINGPROV-NUM

Admieng
Provider
Number

CondiLonal The Medicaid ID of the doctor responsible for
admieng a paLent to a hospital or other
inpaLent health facility.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(30)

1524

123068

126510

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal

CLT176

CLT.002.176

ADMITTINGPROV-SPECIALTY

Admieng
Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CLT00002

CLAIMHEADERRECORD-LT

X(2)

1255

126610

126710

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CLT177

CLT.002.177

ADMITTINGPROVTAXONOMY

Admieng
Provider
Taxonomy

CondiLonal Taxonomic classiﬁcaLon (code) for a given
healthcare provider, as deﬁned by the NaLonal
Uniform Claim Commiaee.

PROVTAXONOMY

CLT00002

CLAIMHEADERRECORD-LT

X(12)

1526

126811

127911

1.1. Value must be 12 characters or less

2. Value must be in Provider Taxonomy List
(VVL)
2. Value must be 12 characters or less
3.3. CondiLonal

CLT178

CLT.002.178

ADMITTINGPROV-TYPE

Admieng
Provider Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

CLT00002

CLAIMHEADERRECORD-LT

X(2)

1527

111280

128113

1. Value must be 12 characters or less
2. Value must be in Provider Type
CodeTaxonomy List (VVL).
2. Value must be 2 characters)
3. CondiLonal

CLT179

CLT.002.179

MEDICARE-PAIDAMT

Medicare Paid
Amount

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

1528

128211

112946

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value
isequals "0", then the Medicare Paid Amount
value must not be populated.
4. CondiLonal
5. If value is populated, Crossover Indicator
must be equal to "1"

N/A

CLT184

CLT.003.184

RECORD-ID

Record ID

Mandatory

RECORD-ID

CLT00003

CLAIM-LINERECORD-LT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CLT00003"

STATE

CLT00003

CLAIM-LINERECORD-LT

X(2)

1.1. Value must be 2 characters

CLT.003.185

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (CLT.001.007)
CLT186

CLT.003.186

RECORDNUMBER

Record Number

Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

CLT187

CLT.003.187

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

X(50)

141

CLT188

CLT.003.188

ICN-ORIG

Original ICN

Mandatory

CLT189

CLT.003.189

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

CLT00003

CLAIM-LINERECORD-LT

X(20)

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. When Type of Claim (CLT.002.052) equals 4, D
or X (lump sum payment) value must begin with
an '&'1. Value must be 20 characters or less

2. Mandatory

CLT190

CLT.003.190

LINE-NUM-ORIG

Original Line
Number

Mandatory

A unique number to idenLfy the transacLon line
number that is being reported on the original
claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(3)

142

144

1. Value must be 3 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory
4. When populated, valueValue must be one or
greater

CLT191

CLT.003.191

LINE-NUM-ADJ

Adjustment Line CondiLonal A unique number to idenLfy the transacLon line
Number
number that idenLﬁes the line number on the
adjustment claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(3)

145

147

CLT192

CLT.003.192

LINEADJUSTMENTIND

Line Adjustment CondiLonal A code to indicate the type of adjustment record
Indicator
claim/encounter represents at claim detail level.

LINEADJUSTMENTIND

CLT00003

CLAIM-LINERECORD-LT

X(1)

148

1.1. Value must be 1 character

2. Value must be in Line Adjustment Indicator
List (VVL)
2. If associated Type of Claim value is in [ 1, 3, 5,
A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]
3. If associated Type of Claim value is in [ 4, D, X ],
then value. Value must be in [5, 6]
4. Value must be 1 character
5.0,1,4]

4. CondiLonal
65. If associated Line Adjustment Number is
populated, then value must be populated
CLT193

CLT.003.193

LINEADJUSTMENTREASON-CODE

Line Adjustment CondiLonal Claim adjustment reason codes communicate
Reason Code
why a service line was paid diﬀerently than it
was billed.

LINEADJUSTMENTREASON-CODE

CLT00003

CLAIM-LINERECORD-LT

X(3)

149

151

1.1. Value must be 3 characters or less

2. Value must be in Line Adjustment Reason
Code List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. When populated, Line Adjustment
IndicatorValue must be populated when the

total paid amount is diﬀerent from the total
billed amount

CLT194

CLT.003.194

SUBMITTER-ID

Submiaer ID

Mandatory

CLT195

CLT.003.195

CLAIM-LINESTATUS

Claim Line
Status

CLT196

CLT.003.196

BEGINNINGDATE-OFSERVICE

Beginning Date
of Service

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(12)

152

163

1. Value must be 12 characters or less
2. Mandatory

CondiLonal The Claim Line Status conveysclaim line status
codes from the 277 transacLon set idenLfy the
status of a speciﬁc servicedetail claim line
usingrather than the X12 Claim Status Codes
fromenLre claim. Only report the claim
adjudication processline for the ﬁnal, adjudicated
claim.

CLAIM-STATUS

CLT00003

CLAIM-LINERECORD-LT

X(3)

164

166

1.1. Value must be 3 characters or less

Mandatory

N/A

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal

4. If value in [545,585,654], then Claim
Denied Indicator must be "0" and Claim
Status Category must be"F2"
CLT00003

CLAIM-LINERECORD-LT

9(8)

167

174

2. Value must be less than or equal to
associated End of Time Period value
43. Value must be less than or equal to
associated Ending Date of Service value
5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V']
value4. Value must be less than or equal to

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value
when populated
76. Value must be less than or equal to at

least one of the eligible's Enrollment End
Date (ELG.021.254) values
87. Mandatory

CLT197

CLT.003.197

ENDING-DATEOF-SERVICE

Ending Date of
Service

Mandatory

For services received during a single encounter
with a provider, the date the service covered by
this claim was received. For services involving
mulLple encounters on diﬀerent days, or
periods of care extending over two or more
days, the date on which the service covered by
this claim ended. For capitation premium
payments, the date on which the period of coverage
related to this payment ends/ended. For financial
transactions reported to the OT file, populate with
the first day of the time period covered by this
financial transaction.

N/A

CLT00003

CLAIM-LINERECORD-LT

9(8)

175

182

CLT198

CLT.003.198

REVENUE-CODE

Revenue Code

Mandatory

REVENUECODE

CLT00003

CLAIM-LINERECORD-LT

X(4)

183

186

1.1. Value must be 4 characters or less

2. Value must be in Revenue Code List (VVL)
23. A Revenue Code value requires an
associated Revenue Charge
3. Value must be 4 characters or less
4.4. Mandatory

CLT201

CLT.003.201

IMMUNIZATIONTYPE

Immunization
Type

Not
Applicable

N/A

CLT00003

CLAIM-LINERECORD-LT

X(2)

187

188

1. Not Applicable

CLT202

CLT.003.202

IP-LTREVENUE-

IP LTRevenue

CLT00003

CLAIM-LINERECORD-LT

S9(6)V
999

1716

1897

1975

1. Not Applicable1. Value must be numeric

Center QuanLty
of Service Actual

N/A

CENTERQUANTITY-OFSERVICE-ACTUAL

Not
Applicable

Mandatory

ﬁeld is to capture the actual service quanLty by
revenue code category, e.g., number of days in a
parLcular type of accommodaLon, pints of
blood, etc. However, when HCPCS codes are
required for services, the units are equal to the
number of Lmes the procedure/service being
reported was performed. For CLAIMOT
claims/encounter records use Service QuanLty
Actual and CLAIMRX claims/encounter records
use the PrescripLon QuanLty Actual ﬁeld

2. Value may include up to 6 digits to the lef
of the decimal point, and 3 digits to the right
e.g. 123456.789
3. Mandatory

CLT203

CLT.003.203

IP-LTREVENUE-

IP LTRevenue

CENTERQUANTITY-OF-

Center QuanLty

SERVICE-

ALLOWED

of Service

Allowed

Not
ApplicableC

ondiLonal

ﬁeld is to capture maximum allowable quanLty
by revenue code category, e.g., number of days
in a parLcular type of accommodaLon, pints of
blood, etc. However, when HCPCS codes are
required for services, the units are equal to the
number of Lmes the procedure/service being
reported was allowed. This ﬁeld is only
applicable when the service being billed can be
quanLﬁed in discrete units, e.g., a number of
visits or the number of units of a
prescripLon/reﬁll that were ﬁlled. For CLAIMOT
claims/encounters use Service QuanLty Allowed
and CLAIMRX claims/encounters use the
PrescripLon QuanLty Allowed ﬁeld.

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(6)V
999

1817

1986

2064

1. Not Applicable1. Value must be numeric

2. Value may include up to 6 digits to the lef
of the decimal point, and 3 digits to the right,
e.g. 123456.789
3. CondiLonal

CLT204

CLT.003.204

REVENUECHARGE

Revenue Charge

CondiLonal The total amount billed for the related Revenue
Code. Total amount billed includes both covered
and non-covered charges (as deﬁned by UB-04
Billing Manual). For encounter records, Type of
Claim = 3, C, or W, this ﬁeld should be populated
with the amount that the provider billed to the
managed care plan.
For sub-capitated encounters from a subcapitated enLty that is not a sub-capitated
network provider, report the amount that the
provider billed the sub-capitated enLty at the
claim line detail level. Report a null value in this
ﬁeld if the provider is a sub-capitated network
provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

1918

2075

2197

CLT205

CLT.003.205

ALLOWED-AMT

Allowed
Amount

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

2019

220218

2320

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT.003.206

TPL-AMT

Third Party
LiabilityTPL

Amount

CLT207

CLT.003.207

OTHERINSURANCEAMT

Other Insurance
Amount

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

2120

2331

2453

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

2221

2464

2586

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT208

CLT.003.208

MEDICAID-PAIDAMT

Medicaid Paid
Amount

CondiLonal The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For claims

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

2322

2597

271269

CLT.003.209

MEDICAID-FFSEQUIVALENTAMT

Medicaid FFS
Equivalent
Amount

CondiLonal The amount that would have been paid had the
services been provided on a Fee for Service
basis.

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

2423

2720

2842

CLT210

CLT.003.210

BILLING-UNIT

Billing Unit

CondiLonal Unit of billing that is used for billing services by
the facility.

BILLING-UNIT

CLT00003

CLAIM-LINERECORD-LT

X(2)

2524

2853

2864

1.1. Value must be 2 characters

2. Value must be in Billing Unit List (VVL).
2. Value must be 2 characters

)
3. CondiLonal

CLT211

CLT.003.211

TYPE-OFSERVICE

Type of Service

Mandatory

CLT212

CLT.003.212

SERVICINGPROV-NUM

Servicing
Provider
Number

CLT213

CLT.003.213

SERVICINGPROV-NPI-NUM

Servicing
Provider NPI
Number

A code to categorize the services provided to a
Medicaid or CHIP enrollee.

TYPE-OFSERVICE-LT

CLT00003

CLAIM-LINERECORD-LT

X(3)

2625

2875

2897

1. Value must be 3 characters
2. Mandatory
3. Value must satisfy the requirements ofbe in
Type of Service (Long Term Claim)LT List (VVL)

N/A

CLT00003

CLAIM-LINERECORD-LT

X(30)

2726

290288

3197

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

the health care professional who delivers or
completes a parLcular medical service or nonsurgical procedure. The Servicing Provider NPI
Number is required when rendering provider is
diﬀerent than the aaending provider and state
or federal regulatory requirements call for a
"combined claim" (i.e., a claim that includes
both facility and professional components).
Examples are Medicaid clinic bills or criLcal
access hospital claims.

(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal
43. When Type of Claim not in
('Z','3','C','W',"2","B","V"," 4","D","X")[3,C,W],

CLAIM-LINERECORD-LT

X(10)

2827

320318

3297

1. Value must be 10 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. CondiLonal
4. WhenIf Type of Claim (CLT.002.052) not in
('3','C','W')[3,C,W], then value must match
Provider IdenLﬁer (PRV.005.081)
5. Value must exist in the NPPES NPI data ﬁle

CLT214

CLT.003.214

SERVICING-PROVTAXONOMY

Servicing
Provider
Taxonomy

Not
Applicable

N/A

CLT215

CLT.003.215

SERVICINGPROV-TYPE

Servicing
Provider Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

CLT00003

CLAIM-LINERECORD-LT

X(12)

330

341

1. Not Applicable

CLT00003

CLAIM-LINERECORD-LT

X(2)

3028

3428

343329

1.1. Value must be 2 characters

2. Value must be in Provider Type Code List
(VVL).
2. Value must be 2 characters
3.3. CondiLonal

CLT216

CLT.003.216

SERVICINGPROV-SPECIALTY

Servicing
Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CLT00003

CLAIM-LINERECORD-LT

X(2)

3129

344330

345331

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CLT217

CLT218

CLT.003.217

CLT.003.218

OTHER-TPLCOLLECTION

BENEFIT-TYPE

Other TPL
CollecLon

Benefit Type

Conditional

Mandatory

OTHER-TPLCOLLECTION

BENEFIT-TYPE

CLT00003

CLAIM-LINERECORD-LT

X(3)

3230

346332

3348

1.1. Value must be 3 characters

2. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

CLT00003

CLAIM-LINERECORD-LT

X(3)

349

351

1. Value must be in Benefit Type Code List (VVL)
2. Value must be 3 characters
3. Mandatory

CLT219

CLT.003.219

CMS-64-

CATEGORY-FORFEDERALREIMBURSEMEN
T

CMS 64 Category

for Federal
Reimbursement

CondiLonal A code to indicate the Federal funding source
for the payment.

CMS-64-

CATEGORYFOR-FEDERALREIMBURSEME
NT

CLT00003

CLAIM-LINERECORD-LT

X(2)

3431

3352

3536

1. Value must be 2 characters
2. Value must be in CMS 64 Category for
Federal Reimbursement List (VVL)
2. Value must be 2 characters
3.3. (Federal Funding under Title XXI) if value
equals '"02'", then the eligible's CHIP Code
(ELG.003.054) must be in ['2', '3'2,3]

CLT221

CLT224

CLT.003.221

CLT.003.224

PROV-FACILITYTYPE

XIX-MBESCBESCATEGORY-OFSERVICE

Provider Facility
Type

XIX MBESCBES
Category of
Service

Mandatory

Conditional

The type of facility in which services on the
claim were rendered. The Provider Facility Type
code set is based on corresponding groups of
HIPAA provider taxonomy codes.

PROV-FACILITYTYPE

XIX-MBESCBESCATEGORY-OFSERVICE

CLT00003

CLAIM-LINERECORD-LT

X(9)

3532

354337

362345

1.1. Value must be 9 characters or less

2. Value must be in Provider Facility Type List
(VVL)
2. Value must be 9 characters or less
3.3. Mandatory

CLT00003

CLAIM-LINERECORD-LT

X(4)

363

366

CLT225

CLT.003.225

XXI-MBESCBESCATEGORY-OFSERVICE

XXI MBESCBES
Category of
Service

Conditional

XXI-MBESCBESCATEGORY-OFSERVICE

CLT00003

CLAIM-LINERECORD-LT

X(3)

367

369

CLT226

CLT.003.226

STATE-NOTATION

State NotaLon

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(500)

3849

370619

869111

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

N/A

FILE-HEADERRECORD-LT

X(4)

nal

CLT227

CLT.001.227

SEQUENCENUMBER

Sequence
Number

Mandatory

CLT00001

1.1. Value must be 4 characters or less

5. Mandatory

CLT228

CLT.003.228

NATIONALDRUG-CODE

NaLonal Drug
Code

CondiLonal A code following the NaLonal Drug Code format
indicaLng the drug, device, or medical supply
covered by this claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(12)

3933

870346

881357

CLT229

CLT.003.229

NDC-UNIT-OFMEASURE

NDC Unit of
Measure

CondiLonal A code to indicate the basis by which the
quanLty of the NaLonal Drug Code is expressed.

NDC-UNIT-OFMEASURE

CLT00003

CLAIM-LINERECORD-LT

X(2)

4034

882358

883359

1.1. Value must be 2 characters

2. Value must be in NDC Unit of Measure List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal

CLT230

CLT.003.230

NDC-QUANTITY

NDC QuanLty

CondiLonal This ﬁeld is to capture the actual quanLty of the
NaLonal Drug Code being prescribed on the
claim/encounters.

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(6)V9
999)V(
9)

4135

884360

892377

1. Value may include up to 69 digits to the lef
of the decimal point, and 39 digits to the right
e.g. 123456.789123456789.123456789
2. CondiLonal

CLT231

CLT.003.231

HCPCS-RATE

HCPCS Rate

Conditional

HCPCS-RATE

CLT00003

CLAIM-LINERECORD-LT

X(14)

893

906

1. Value must be in HCPCS Rate List (VVL).
2. Value must be 14 characters or less
3. Value must not contain a pipe or asterisk
symbols
4. Conditional

CLT233

CLT.003.233

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CLT00003

CLAIM-LINERECORD-LT

9(8)

4336

907378

914385

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in associated T-MSIS File
Header Record
4. (CLT.001.010)

3. Mandatory
54. Value should be on or afer associated
Admission Date value
CLT234

CLT.003.234

SELF-DIRECTIONTYPE

Self DirecLon
Type

Conditional

Mandatory

This data element is not applicable to this ﬁle
type.

SELFDIRECTIONTYPE

CLT00003

CLAIM-LINERECORD-LT

X(3)

4437

915386

917388

1.1. Value must be 3 characters

2. Value must be in Self DirecLon Type List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

CLT235

CLT.003.235

PREAUTHORIZATION
-NUM

PreauthorizaLo
n Number

N/A

CLT00003

CLAIM-LINERECORD-LT

X(18)

4538

918389

935406

1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CLT237

CLT.002.237

PROV-LOCATION- Provider
ID
LocaLon ID

Mandatory

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(5)

160129

112795

179911

1.1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
2. Value must be 5 characters or less
3.3. Mandatory

CLT239

CLT.002.239

TOTBENEFICIARYCOPAYMENTLIABLE-AMOUNT

Total
Beneﬁciary
Copayment
Liable Amount

CondiLonal The total copayment amount on a claim that the
beneﬁciary is obligated to pay for covered
services. This is the total Medicaid or contract
negoLated beneﬁciary copayment liability for
covered service on the claim. Do not subtract
out any payments made toward the copayment.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

130

1132

1144

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT240

CLT.002.240

TOTBENEFICIARYCOINSURANCELIABLE-AMOUNT

Total
Beneﬁciary
Coinsurance
Liable Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

131

1145

1157

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT241

CLT.002.241

TOTBENEFICIARYDEDUCTIBLELIABLE-AMOUNT

Total
Beneﬁciary
DeducLble
Liable Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

132

1158

1170

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT242

CLT.002.242

COMBINEDBENE-COSTSHARING-PAIDAMOUNT

Combined
Beneﬁciary Cost
Sharing Paid
Amount

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

133

1171

1183

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT243

CLT.003.243

IHS-SERVICE-IND

IHS Service
Indicator

Mandatory

IHS-SERVICEIND

CLT00003

CLAIM-LINERECORD-LT

X(1)

407

1. Value must be 1 character
2. Value must be in the IHS Service Indicator
List (VVL)
3. Mandatory

CLT244

CLT.002.244

BILLING-PROVADDR-LN-1

Billing Provider
Address Line 1

Mandatory

Billing provider address line 1 from X12 837I
loop 2010AA.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(60)

134

1184

1243

1. Value must not be more than 60 characters
long
2. Mandatory
3. Value must not contain a pipe or asterisk
symbols

CLT245

CLT.002.245

BILLING-PROVADDR-LN-2

Billing Provider
Address Line 2

CondiLonal Billing provider address line 2 from X12 837I
loop 2010AA.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(60)

135

1244

1303

CLT246

CLT.002.246

BILLING-PROVCITY

Billing Provider
City

Mandatory

Billing provider address city name from X12 837I
loop 2010AA.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(28)

136

1304

1331

1. Value must not be more than 28 characters
long
2. Mandatory

CLT247

CLT.002.247

BILLING-PROVSTATE

Billing Provider
State Code

Mandatory

Billing provider address state code from X12
837I loop 2010AA.

STATE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

137

1332

1333

1. Value must not be more than 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

CLT248

CLT.002.248

BILLING-PROVZIP-CODE

Billing Provider
ZIP Code

Mandatory

Billing provider address ZIP code from X12 837I
loop 2010AA.

ZIP-CODE

CLT00002

CLAIMHEADERRECORD-LT

X(9)

138

1334

1342

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. Mandatory

CLT249

CLT.002.249

SERVICEFACILITYLOCATION-ORGNPI

Service Facility
LocaLon
OrganizaLon
NPI

CondiLonal Service facility locaLon organizaLon NPI from
X12 837I loop 2310E.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(10)

139

1343

1352

CLT250

CLT.002.250

SERVICEFACILITYLOCATIONADDR-LN-1

Service Facility
LocaLon
Address Line 1

CondiLonal Service facility locaLon address line 1 from X12
837I loop 2310E.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(60)

140

1353

1412

1. Value must not be more than 60 characters
long
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols

CLT251

CLT.002.251

SERVICEFACILITYLOCATIONADDR-LN-2

Service Facility
LocaLon
Address Line 2

CondiLonal Service facility locaLon address line 2 from X12
837I loop 2310E.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(60)

141

1413

1472

CLT252

CLT.002.252

SERVICEFACILITYLOCATION-CITY

Service Facility
LocaLon City

CondiLonal Service facility locaLon address city name from
X12 837I loop 2310E.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(28)

142

1473

1500

1. Value must not be more than 28 characters
long
2. CondiLonal

CLT253

CLT.002.253

SERVICEFACILITYLOCATION-STATE

Service Facility
LocaLon State

CondiLonal Service facility locaLon address state code from
X12 837I loop 2310E.

STATE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

143

1501

1502

1. Value must not be more than 2 characters
2. Value must be in State Code list (VVL)
3. CondiLonal

CLT254

CLT.002.254

SERVICEFACILITYLOCATION-ZIPCODE

Service Facility
LocaLon ZIP
Code

CondiLonal Service facility locaLon address ZIP code from
X12 837I loop 2310E.

ZIP-CODE

CLT00002

CLAIMHEADERRECORD-LT

X(9)

144

1503

1511

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. CondiLonal

CLT255

CLT.002.255

PROVIDERCLAIM-FORMCODE

Provider Claim
Form Code

Mandatory

PROVIDERCLAIM-FORMCODE

CLT00002

CLAIMHEADERRECORD-LT

X(2)

145

1512

1513

1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code
List (VVL)
3. Mandatory

A code indicaLng the format in which the
provider submiaed their claim. Very few if any
claims should be classiﬁed as "Other".

CLT256

CLT.002.256

PROVIDERCLAIM-FORMOTHER-TEXT

Provider Claim
Form Other Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the "other" claim form used by the provider to
submit their claim. Required when "Other" is
reported to Provider Claim Form Code.

N/A

CLT00002

CLAIMHEADERRECORD-LT

X(50)

146

1514

1563

1. Value must not be more than 50 characters
long
2. CondiLonal
3. Value must be provided when
corresponding Provider Claim Form Code is
"Other"

CLT257

CLT.002.257

TOT-GMEAMOUNT-PAID

Total GME
Amount Paid

CondiLonal The amount included in the Total Medicaid
Amount (CLT.002.065) that is aaributable to a
Graduate Medical EducaLon (GME) payment,
when the state makes GME payments by claim.

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

147

1564

1576

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT258

CLT.002.258

TOT-SDPALLOWED-AMT

Total State
Directed
Payment
Allowed
Amount

N/A

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

148

1577

1589

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT259

CLT.002.259

TOT-SDP-PAIDAMT

Total State
Directed
Payment Paid
Amount

CLT00002

CLAIMHEADERRECORD-LT

S9(11)
V99

149

1590

1602

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT260

CLT.003.260

UNIQUE-DEVICEIDENTIFIER

Unique Device
IdenLﬁer

CondiLonal An unique idenLﬁer assigned to every medical
device that meets the requirements of 21 CFR
801 and 830.

CLT00003

CLAIM-LINERECORD-LT

X(76)

408

483

1. Value must not be more than 76 characters
long
2. CondiLonal

N/A

CLT261

CLT.003.261

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

CLT00003

CLAIM-LINERECORD-LT

X(5)

535

539

CLT262

CLT.003.262

MBESCBESFORM

MBESCBES
Form

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

CLT00003

CLAIM-LINERECORD-LT

X(50)

485

534

CLT263

CLT.003.263

GME-AMOUNTPAID

GME Amount
Paid

CondiLonal The amount included in the Medicaid Amount
(CLT.003.208) that is aaributable to a Graduate
Medical EducaLon (GME) payment, when the
state makes GME payments by claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

540

552

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT264

CLT.003.264

REFERRINGPROV-NUM

Referring
Provider
Number

N/A

CLT00003

CLAIM-LINERECORD-LT

X(30)

553

582

1. Value must be 30 characters or less
2. CondiLonal

CLT265

CLT.003.265

REFERRINGPROV-NPI-NUM

Referring
Provider NPI
Number

CondiLonal The NaLonal Provider ID (NPI) of the provider
who recommended the servicing provider to the
paLent.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(10)

583

592

1. Value must be 10 digits
2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to "2"
4. Value must exist in the NPPES NPI File

CLT266

CLT.003.266

SDP-ALLOWEDAMT

State Directed
Payment
Allowed
Amount

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

593

605

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT267

CLT.003.267

SDP-PAID-AMT

State Directed
Payment Paid
Amount

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)
V99

606

618

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CLT268

CLT.004.268

RECORD-ID

Record ID

Mandatory

RECORD-ID

CLT00004

CLAIM-DX-LT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "CLT00004"

CLT269

CLT.004.269

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CLT00004

CLAIM-DX-LT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
4. Value must be the same as Submieng
State (CLT.001.007)

CLT270

CLT.004.270

RECORDNUMBER

Record Number

Mandatory

N/A

CLT00004

CLAIM-DX-LT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

CLT271

CLT.004.271

ICN-ORIG

Original ICN

Mandatory

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CLT00004

CLAIM-DX-LT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

CLT272

CLT.004.272

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

CLT00004

CLAIM-DX-LT

X(50)

121

CLT273

CLT.004.273

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

ADJUSTMENTIND

CLT00004

CLAIM-DX-LT

X(1)

122

Indicates the type of adjustment record.

CLT274

CLT.004.274

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CLT00004

CLAIM-DX-LT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value should be on or before End of Time
Period (CLT.001.010)
3. Mandatory
4. Value should be on or afer associated
Admission Date value

CLT275

CLT.004.275

DIAGNOSIS-TYPE

Diagnosis Type

Mandatory

DIAGNOSISTYPE

CLT00004

CLAIM-DX-LT

X(1)

131

1. Value must be 1 character
2. Value must be in Diagnosis Type Code List
(VVL)
3. Value must be in [P,A,E,O]
4. Mandatory

CLT276

CLT.004.276

DIAGNOSISSEQUENCENUMBER

Diagnosis
Sequence
Number

Mandatory

N/A

CLT00004

CLAIM-DX-LT

9(2)

132

133

1. Value must be in [01-24]
2. Mandatory

CLT277

CLT.004.277

DIAGNOSISCODE-FLAG

Diagnosis Code
Flag

Mandatory

Flag used to idenLfy wither the associated
Diagnosis Code value is a ICD-9 or ICD-10 code.

DIAGNOSISCODE-FLAG

CLT00004

CLAIM-DX-LT

X(1)

134

1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List
(VVL)
3. Mandatory

CLT278

CLT.004.278

DIAGNOSISCODE

Diagnosis Code

Mandatory

CLT279

CLT.004.279

DIAGNOSIS-POAFLAG

Diagnosis POA
Flag

CLT280

CLT.004.280

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

CLT00004

CLAIM-DX-LT

X(7)

135

141

DIAGNOSISPOA-FLAG

CLT00004

CLAIM-DX-LT

X(1)

142

1. Value must be 1 character
2. Value must be in Diagnosis POA Flag List
(VVL)
3. CondiLonal

N/A

CLT00004

CLAIM-DX-LT

X(500)

143

642

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

CLT282

CLT.003.282

MBESCBESFORM-GROUP

MBESCBES
Form Group

MBESCBESFORM-GROUP

CLT00003

CLAIM-LINERECORD-LT

X(1)

484

T-MSIS Data Dic,onary – COT File Changes Between Versions 2.4.0 and 4.0.0

Data
Element
Number

System Data
Element
Number

Data Element

Data Element
Name Text

Data
Element
Necessity

Deﬁni,on

Valid Value List
(VVL)

File
Segment
Number

File Segment
Name

Size

Pipe
Separated
Value
Segment
Data
Element
Order

Fixed
Length
Field
Start
Posi,on

Fixed
Coding Requirements
Length
Field
Stop
Posi,on

COT001

COT.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

COT00001

FILE-HEADERRECORD-OT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "COT00001"

DATADICTIONARYVERSION

COT00001

FILE-HEADERRECORD-OT

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

SUBMISSIONTRANSACTIONTYPE

COT00001

FILE-HEADERRECORD-OT

X(1)

1.1. Value must be 1 character

COT.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

COT003

COT.001.003

SUBMISSIONTRANSACTIONTYPE

Submission
TransacLon
Type

Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

2. Value must be in Submission TransacLon
Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

COT004

COT.001.004

FILE-ENCODINGSPECIFICATION

File Encoding
SpeciﬁcaLon

Mandatory

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

COT00001

FILE-HEADERRECORD-OT

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

COT005

COT.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state
submission ﬁle. Use the version number specified

N/A

COT00001

FILE-HEADERRECORD-OT

X(9)

1. Value must be 9 characters or less
2. Mandatory

COT00001

FILE-HEADERRECORD-OT

X(8)

1. Value must equal 'CLAIM-OT'"CLAIM-OT"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

COT00001

FILE-HEADERRECORD-OT

X(2)

1.1. Value must be 2 characters

The date on which the ﬁle was created.

N/A

on the title page of the data mapping document

COT006

COT.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

COT007

COT008

COT.001.007

COT.001.008

SUBMITTINGSTATE

DATE-FILECREATED

Submieng
State

Date File
Created

Mandatory

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory
COT00001

FILE-HEADERRECORD-OT

9(8)

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory

COT009

COT.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

COT00001

FILE-HEADERRECORD-OT

9(8)

2. Value must be equal to or earlier than
associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"
COT010

COT.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

COT00001

FILE-HEADERRECORD-OT

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
COT011

COT.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

COT00001

FILE-HEADERRECORD-OT

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory

COT012

COT013

COT.001.012

COT.001.013

SSN-INDICATOR

TOT-REC-CNT

SSN Indicator

Total Record
Count

Mandatory

SSN-INDICATOR

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

COT00001

FILE-HEADERRECORD-OT

X(1)

1.1. Value must be 1 character

2. Value must be in SSN Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

COT00001

FILE-HEADERRECORD-OT

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory
COT014

COT.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

COT016

COT.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

COT00001

FILE-HEADERRECORD-OT

X(500)

582

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

COT00002

CLAIMHEADERRECORD-OT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "COT00002"

padded with leading zeros (e.g., 00001, 00002,
00003, etc.).

COT017

COT.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

COT00002

CLAIMHEADERRECORD-OT

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (COT.001.007)
COT018

COT019

COT.002.018

COT.002.019

RECORDNUMBER

ICN-ORIG

Record Number

Original ICN

Mandatory

N/A

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

COT00002

CLAIMHEADERRECORD-OT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

COT020

COT.002.020

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(50)

121

COT021

COT.002.021

SUBMITTER-ID

Submiaer ID

Mandatory

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(12)

122

133

1. Value must be 12 characters or less
2. Mandatory

COT022

COT.002.022

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

COT00002

CLAIMHEADERRECORD-OT

X(20)

134

153

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. Populated value must begin with an '&', when
Type of Claim (COT.002.037) = 4, D or X (lump
sum payment)
6.1. Value must be 20 characters or less

2. Mandatory
3. Value must match MSIS IdenLﬁcaLon
Number (ELG.021.251) and the Beginning
Date of Service (COT.002.033) must be
between Enrollment EﬀecLve Date
(ELG.021.253) and Enrollment End Date
(ELG.021.254)

COT023

COT.002.023

CROSSOVERINDICATOR

Crossover
Indicator

Conditional

Mandatory

An indicator specifying whether the claim is a
crossover claim where a porLon is paid by
Medicare.

CROSSOVERINDICATOR

COT00002

CLAIMHEADERRECORD-OT

X(1)

154

1.1. Value must be 1 character

COT024

COT025

COT.002.024

COT.002.025

1115ADEMONSTRATIO
N-IND

ADJUSTMENTIND

1115A
DemonstraLon
Indicator

Adjustment
Indicator

1115ADEMONSTRATI
ON-IND

Mandatory

ADJUSTMENTIND

Indicates the type of adjustment record.

COT00002

CLAIMHEADERRECORD-OT

X(1)

155

1.1. Value must be 1 character

2. Value must be in 1115A DemonstraLon
Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal
4. When value equals '"0'", is invalid or not

populated, then the associated 1115A
DemonstraLon Indicator (ELG.018.2233) must
equal '"0'", is invalid or not populated
COT00002

CLAIMHEADERRECORD-OT

X(1)

156

1.1. Value must be 1 character

2. Value must be in Adjustment Indicator List
(VVL)
2. If associated Type of Claim value is in [ 1, 3, 5,
A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]
3. If associated Type of Claim value is '4, D, X',
then value. Value must be in [ 5, 6 0,1,4]
4. Value must be 1 character
5. Mandatory

5. If value equals "0", then associated
Adjustment ICN must not be populated
6. Value must equal "1", when associated
Claim Status equals "686"

COT026

COT.002.026

ADJUSTMENTREASON-CODE

Adjustment
Reason Code

CondiLonal Claim adjustment reason codes communicate
why a claim was paid diﬀerently than it was
billed. If the amount paid is different from the

ADJUSTMENTREASON-CODE

COT00002

CLAIMHEADERRECORD-OT

X(3)

157

159

1.1. Value must be 3 characters or less

2. Value must be in Adjustment Reason Code
List (VVL)

amount billed you need an adjustment reason code.

2. Value must be 3 characters or less
3.3. CondiLonal
4. Value must not be populated when
associated Adjustment Indicator equals "0"the

total paid amount is diﬀerent from the total
billed amount
COT027

COT.002.027

DIAGNOSISCODE-1

Diagnosis Code 1

Conditional

DIAGNOSISCODE

COT00002

CLAIM-HEADERRECORD-OT

X(7)

160

166

1. When populated, a Diagnosis Code Flag is
required
2. If associated Diagnosis Code Flag value is "1"
(ICD-9), then value must be in ICD-9 Diagnosis
Codes List (VVL)
3. If associated Diagnosis Code Flag value is "2"
(ICD-10), then value must be in ICD-10 Diagnosis
Codes List (VVL)
4. Value must be a minimum of 3 characters
5. Value must not contain a decimal point
6. If associated Diagnosis Code Flag value is '"1"
(ICD-9), value must not exceed 5 characters
7. If associated Diagnosis Code Flag value is "2"
(ICD-10), value must not exceed 7 characters
8. When there is more than one diagnosis code on
a claim, each value must be unique
9. Conditional
10. If Type of Claim (COT.002.037) is in ("1", "3",
"A", "C", "U", "W") then Diagnosis Code 1
(COT.002.027) must be populated.

COT028

COT.002.028

DIAGNOSISCODE-FLAG-1

Diagnosis Code
Flag 1

Conditional

DIAGNOSISCODE-FLAG

COT00002

CLAIM-HEADERRECORD-OT

X(1)

167

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

COT029

COT.002.029

DIAGNOSIS-POAFLAG-1

Diagnosis POA
Flag 1

Conditional

DIAGNOSISPOA-FLAG

COT00002

CLAIM-HEADERRECORD-OT

X(1)

168

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

DIAGNOSISCODE

COT00002

CLAIM-HEADERRECORD-OT

X(7)

169

175

COT.002.030

DIAGNOSISCODE-2

Diagnosis Code 2

Conditional

10. When populated, value cannot equal
Diagnosis Code 1 (COT.002.027)
11. When Diagnosis Code 1 (COT.002.027) is not
populated, value should not be populated
COT031

COT.002.031

DIAGNOSISCODE-FLAG-2

Diagnosis Code
Flag 2

Conditional

DIAGNOSISCODE-FLAG

COT00002

CLAIM-HEADERRECORD-OT

X(1)

176

1. Value must be in Diagnosis Code Flag List (VVL)
2. Value must be 1 character
3. Conditional
4. Value should not be populated, if the
associated diagnosis code is not populated

COT032

COT.002.032

DIAGNOSIS-POAFLAG-2

Diagnosis POA
Flag 2

Conditional

DIAGNOSISPOA-FLAG

COT00002

CLAIM-HEADERRECORD-OT

X(1)

177

1. Value must be in Diagnosis POA Flag List (VVL)
2. Value must be 1 character
3. Conditional

COT033

COT.002.033

BEGINNINGDATE-OFSERVICE

Beginning Date
of Service

Mandatory

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

1812

178160

185167

2. Value must be less than or equal to
associated End of Time Period value
43. Value must be less than or equal to
associated Ending Date of Service value

capitation premium payments, the date on which the
period of coverage related to this payment began.
For financial transactions reported to the OT file,
populate with the first day of the time period
covered by this financial transaction.

5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V']
value4. Value must be less than or equal to

COT.002.034

ENDING-DATEOF-SERVICE

Ending Date of
Service

Mandatory

For services received during a single encounter
with a provider, the date the service covered by
this claim was received. For services involving
mulLple encounters on diﬀerent days, or
periods of care extending over two or more
days, the date on which the service covered by
this claim ended. For capitation premium
payments, the date on which the period of coverage
related to this payment ends/ended. For financial
transactions reported to the OT file, populate with
the first day of the time period covered by this
financial transaction.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

1913

1868

193175

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value

when populated
76. Value must be equal to or greater than
associated Date of Birth (ELG.002.024) value
87. Mandatory

COT035

COT.002.035

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

2014

194176

201183

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in(CIP.001.010)
3. Mandatory
4. Value should be on or afer associated TMSIS File Header Record
4. MandatoryAdmission Date value

COT036

COT.002.036

MEDICAID-PAIDDATE

Medicaid Paid
Date

Mandatory

The date Medicaid paid this claim or
adjustment. For Encounter Records (Type of
Claim = 3, C, W), the date the managed care
organizaLon paid the provider for the claim or
adjustment.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

2115

202184

209191

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Total Medicaid
Paid Amount
43. Mandatory

COT037

COT038

COT039

COT.002.037

COT.002.038

COT.002.039

TYPE-OF-CLAIM

TYPE-OF-BILL

CLAIM-STATUS

Type of Claim

Type of Bill

Claim Status

Mandatory

A code to indicate what type of payment is
covered in this claim. For sub-capitated
encounters from a sub-capitated enLty or subcapitated network provider, report TYPE-OFCLAIM = '3' for a Medicaid sub-capitated
encounter record or “C” for an S-CHIP subcapitated encounter record

TYPE-OF-CLAIM

CondiLonal A data element corresponding with UB-04 form
locator FL4 that classiﬁes the claim as to the
type of facility (2nd digit), type of care (3rd digit)
and the billing record's sequence in the episode
of care (4th digit). (Note that the 1st digit is
always zero.)

TYPE-OF-BILL

CondiLonal The health care claim status codes convey the
status of an enLre claim. status codes from the
277 transacLon set. Only report the claim status
for the ﬁnal, adjudicated claim.

CLAIM-STATUS

COT00002

CLAIMHEADERRECORD-OT

X(1)

CLAIMHEADERRECORD-OT

X(4)

2216

210192

1.1. Value must be 1 character

2. Value must be in Type of Claim List (VVL)
2. Value must be 1 character
3.3. Mandatory
4. When value equals 'Z', claim denied indicator
must equal '0'

2317

211193

214196

1.1. Value must be 4 characters

2. Value must be in Type of Bill List (VVL)
2. Value must be 4 characters
3.3. First character must be a '0'"0"

4. CondiLonal
COT00002

CLAIMHEADERRECORD-OT

X(3)

2418

215197

217199

1.1. Value must be 3 characters or less

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. If value in [ 26, 87, 542,585,654 ],], then
Claim Denied Indicator must be '0'"0" and

Claim Status Category must be "F2"
COT040

COT.002.040

CLAIM-STATUSCATEGORY

Claim Status
Category

Mandatory

CLAIM-STATUSCATEGORY

COT00002

CLAIMHEADERRECORD-OT

X(3)

2519

218200

2202

1.1. Value must be 3 characters or less

5. Mandatory

COT041

COT.002.041

SOURCELOCATION

Source LocaLon

Mandatory

The field denotes the claims payment system from
which the claim was extracted.The ﬁeld denotes

the claims payment system from which the
claim was extracted.

SOURCELOCATION

COT00002

CLAIMHEADERRECORD-OT

X(2)

2620

221203

222204

1.1. Value must be 2 characters

2. Value must be in Source LocaLon List (VVL)
2. Value must be 2 characters
3.3. Mandatory

COT.002.042

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(15)

2721

223205

237219

1. Value must be 15 characters or less
2. Value must have an associated Check
EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

COT043

COT.002.043

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

2822

238220

245227

Remittance Date
4. in the form "CCYYMMDD"

2. Must have an associated Check Number
53. CondiLonal
COT044

COT045

COT.002.044

COT.002.045

CLAIM-PYMTREM-CODE-1

CLAIM-PYMTREM-CODE-2

Claim
PaymentRemiaa

nce Advice
Remark Code 1

Claim
PaymentRemiaa

nce Advice
Remark Code 2

CLAIM-PYMTREM-CODE

COT00002

CLAIMHEADERRECORD-OT

X(5)

2923

246228

250232

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

Claim Payment Remark Code 1 through Claim
Payment Remark Code 4 is populated on a
claim, all values must be unique

COT00002

CLAIMHEADERRECORD-OT

X(5)

3024

251233

255237

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

and Accountably Act of 1996 (P.L.104-191,
commonly referred to as HIPAA).

COT046

COT.002.046

CLAIM-PYMTREM-CODE-3

Claim
PaymentRemiaa

nce Advice
Remark Code 3

CLAIM-PYMTREM-CODE

COT00002

CLAIMHEADERRECORD-OT

X(5)

3125

256238

260242

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

COT047

COT048

COT.002.047

COT.002.048

CLAIM-PYMTREM-CODE-4

TOT-BILLED-AMT

Claim
PaymentRemiaa

nce Advice
Remark Code 4

Total Billed
Amount

CLAIM-PYMTREM-CODE

N/A

COT00002

CLAIMHEADERRECORD-OT

X(5)

3226

261243

265247

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

3327

266248

278260

when populated and Payment Level Indicator
(COT.002.068) equals "2" value must be
greater than or equal to the sum of all claim
line Revenue Charges (COT.003.168)

COT049

COT.002.049

TOT-ALLOWEDAMT

Total Allowed
Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

3428

279261

291273

COT050

COT.002.050

TOT-MEDICAIDPAID-AMT

Total Medicaid
Paid Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

3529

292274

304286

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)
V99

305

317

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. Conditional

COT.002.051

TOT-COPAY-AMT

Total Copayment
Amount

Conditional

The total amount paid by Medicaid/CHIP enrollee
for each office or emergency department visit or
purchase of prescription drugs in addition to the
amount paid by Medicaid/CHIP.

COT052

COT.002.052

TOT-MEDICAREDEDUCTIBLEAMT

Total Medicare
DeducLble
Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

3730

318287

330299

COT053

COT.002.053

TOT-MEDICARECOINS-AMT

Total Medicare
Coinsurance
Amount

CondiLonal The total amount paid by the Medicaid/CHIP
agency or a managed care plan towards the
porLon of the Medicare allowed charges that
Medicare applied to coinsurance.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

3831

331300

343312

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value is
'0'equals "0" (not a crossover claim), then
value should not be populated.
4. CondiLonal
5. If associated Medicare Combined
DeducLble Indicator is '1',equals "1", then
value must not be populated
6. When populated, value must be less than
or equal to Total Billed Amount

COT054

COT.002.054

TOT-TPL-AMT

Total Third Party
LiabilityTPL
Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

3932

344313

3256

COT056

COT.002.056

TOT-OTHERINSURANCEAMT

Total Other
Insurance
Amount

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

4033

357326

369338

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT057

COT.002.057

OTHERINSURANCE-IND

Other Insurance
Indicator

CondiLonal The ﬁeld denotes whether the insured party is
covered under an other insurance plan other
than Medicare or Medicaid.

OTHERINSURANCEIND

COT00002

CLAIMHEADERRECORD-OT

X(1)

4134

370339

1.1. Value must be 1 character

2. Value must be in Other Insurance Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

COT058

COT.002.058

OTHER-TPLCOLLECTION

Other TPL
CollecLon

Conditional

COT059

COT.002.059

SERVICETRACKING-TYPE

Service Tracking
Type

Conditional

Mandatory

OTHER-TPLCOLLECTION

COT00002

CLAIMHEADERRECORD-OT

X(3)

4235

371340

373342

1. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. ConditionalMandatory

A code to categorize service tracking claims. A
"service tracking claim" is used to report lump sum
payments that cannot be attributed to a single
enrollee.

SERVICETRACKING-TYPE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

374

375

COT060

COT.002.060

SERVICETRACKINGPAYMENT-AMT

Service Tracking
Payment Amount

Conditional

COT061

COT.002.061

FIXED-PAYMENTIND

Fixed Payment
Indicator

COT062

COT.002.062

FUNDING-CODE

Funding Code

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)
V99

376

388

FIXEDPAYMENT-IND

COT00002

CLAIMHEADERRECORD-OT

X(1)

4536

389343

1.1. Value must be 1 character

MandatoryC

FUNDINGCODE

ondiLonal

On service tracking claims, the payment amount is
the lump sum that cannot be attributed to any one
beneficiary paid to the provider.

A code to indicate the source of non-federal
share funds.

2. Value must be in Fixed Payment Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

4637

390344

391345

1.1. Value must be 1 character

2. Value must be in Funding Code List (VVL)
2. Value must be 1 character
3. Mandatory3. If Type of Claim is not in

[3,C,W], then value must be populated
4. CondiLonal

COT063

COT064

COT.002.063

COT.002.064

FUNDINGSOURCENONFEDERALSHARE

MEDICARECOMB-DED-IND

Funding Source
Non-Federal
Share

Medicare
Combined
DeducLble
Indicator

Not
ApplicableC

ondiLonal

FUNDINGSOURCENONFEDERALSHARE

COT00002

CLAIMHEADERRECORD-OT

X(2)

4738

392346

393347

1.1. Value must be 2 characters

2. Value must be in Funding Source NonFederal Share List (VVL)
2. Value must be 2 characters
3. Required3. If Type of Claim is in [3,C,W],

then value must be populated
4. CondiLonal
MEDICARECOMB-DEDIND

COT00002

CLAIMHEADERRECORD-OT

X(1)

4839

3948

1.1. Value must be 1 character

Crossover Indicator must equals "0"
5. If value equals "1", then Crossover
Indicator must equals "1"
6. CondiLonal
COT065

COT.002.065

PROGRAM-TYPE

Program Type

Mandatory

A code to indicate special Medicaid program
under which the service was provided.

PROGRAMTYPE

COT00002

CLAIMHEADERRECORD-OT

X(2)

4940

3495

396350

1.1. Value must be 2 characters

2. Value must be in Program Type List (VVL)
2. Value must be 2 characters
3.3. Mandatory

COT066

COT.002.066

PLAN-IDNUMBER

Plan ID Number

N/A

COT00002

CLAIMHEADERRECORD-OT

X(12)

5041

397351

408362

For sub-capitated encounters from a subcapitated enLty or sub-capitated network
provider, report the PLAN-ID-NUMBER for the
MCP (MCO, PIHP, or PAHP that has a contract
with a state) that is making the payment to the
sub-capitated enLty or sub-capitated network
provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal
4. Value must match Managed Care Plan ID
(ELG.014.192)
5. Value must match State Plan ID Number
(MCR.002.019)
6. When Type of Claim (COT.002.037) in
([3,C,W, 2, B, V)] value must have a managed
care enrollment (ELG.014) for the beneﬁciary
where the Beginning DOS (COT.002.033)
occurs between the managed care plan
enrollment eﬀ/end dates (ELG.014.197/198)
7. When Type of Claim (COT.002.037) in
([3,C,W, 2, B, V)] value must have a managed
care main record (MCR.002) for the plan
where the Beginning DOS (COT.002.0337)
occurs between the managed care contract
eﬀ/end dates (MCR.002.020/021)
8. If Type of Claim (COT.002.037) does not equal
3, C, W (Encounter Record) and Type of Service
(COT.003.186) does not equal 119, 120, 121, 122
(Capitation payments) value must not be
populated

COT067

COT.002.067

NATIONALHEALTH-CAREENTITY-ID

National Health
Care Entity ID

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(10)

409

418

1. Not Applicable

COT068

COT.002.068

PAYMENT-LEVELIND

Payment Level
Indicator

Mandatory

The field denotes whether the payment amount was
determined at the claim header or line/detail
level.The ﬁeld denotes whether the payment

PAYMENTLEVEL-IND

COT00002

CLAIMHEADERRECORD-OT

X(1)

5242

419363

1.1. Value must be 1 character

2. Value must be in Payment Level Indicator
List (VVL)
2. Value must be 1 character
3.3. Mandatory

COT069

COT.002.069

MEDICAREREIM-TYPE

Medicare
Reimbursement
Type

CondiLonal A code to indicate the type of Medicare
reimbursement.

MEDICAREREIM-TYPE

COT00002

CLAIMHEADERRECORD-OT

X(2)

5343

420364

421365

1.1. Value must be 2 characters

2. Value must be in Medicare Reimbursement
Type List (VVL)
2. (Crossover Claim) if associated Crossover
Indicator value indicates a crossover claim,
value3. Value is mandatory and must be

provided
3. Value must be 2 characters

, when Crossover Indicator is equal to "1"

(Crossover Claim)
4. CondiLonal

COT070

COT.002.070

CLAIM-LINECOUNT

Claim Line
Count

Mandatory

The total number of lines on the claim.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(4)

5444

422366

425369

6. Mandatory
COT072

COT.002.072

FORCED-CLAIMIND

Forced Claim
Indicator

CondiLonal The charges for inpatient care, which are not

reimbursable by the primary payer. The non-covered
charges do not refer to charges not covered for any
other service. see US Dollar Amount
(DT.008)Indicates if the claim was processed by

FORCEDCLAIM-IND

COT00002

CLAIMHEADERRECORD-OT

X(1)

5545

426370

2. Value must be in Forced Claim Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

forcing it through a manual override process.
COT073

COT.002.073

HEALTH-CAREACQUIREDCONDITION-IND

Healthcare
Acquired
CondiLon
Indicator

CondiLonal This code indicates whether the claim has a
Health Care Acquired CondiLon. For addiLonal
coding informaLon refer to the following site :
:
haps://www.cms.gov/Medicare/Medicare-Feefor-ServicePayment/HospitalAcqCond/index.html?redirect
=/hospitalacqcond/05_Coding.asp#TopOfPage

1.1. Value must be 1 character

HEALTH-CAREACQUIREDCONDITIONIND

COT00002

CLAIMHEADERRECORD-OT

X(1)

5646

427371

1.1. Value must be 1 character

2. Value must be in Healthcare Acquired
CondiLon Indicator List (VVL).
2. Value must be 1 character

)
3. CondiLonal

COT074

COT075

COT076

COT077

COT078

COT.002.074

COT.002.075

COT.002.076

COT.002.077

COT.002.078

OCCURRENCECODE-01

OCCURRENCECODE-02

OCCURRENCECODE-03

OCCURRENCECODE-04

OCCURRENCECODE-05

Occurrence
Code 1

Occurrence
Code 2

Occurrence
Code 3

Occurrence
Code 4

Occurrence
Code 5

OCCURRENCECODE

COT00002

CLAIMHEADERRECORD-OT

X(2)

5747

428372

429373

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

5848

430374

431375

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

5949

432376

433377

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

6050

434378

435379

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

6151

436380

437381

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT079

COT080

COT081

COT082

COT083

COT.002.079

COT.002.080

COT.002.081

COT.002.082

COT.002.083

OCCURRENCECODE-06

OCCURRENCECODE-07

OCCURRENCECODE-08

OCCURRENCECODE-09

OCCURRENCECODE-10

Occurrence
Code 6

Occurrence
Code 7

Occurrence
Code 8

Occurrence
Code 9

Occurrence
Code 10

OCCURRENCECODE

COT00002

CLAIMHEADERRECORD-OT

X(2)

6252

4382

439383

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

6353

440384

441385

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

6454

442386

443387

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

6555

444388

445389

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

X(2)

6656

446390

447391

1.1. Value must be 2 characters

2. Value must be in Occurrence Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

COT084

COT.002.084

OCCURRENCECODE-EFF-DATE01

Occurrence
Code EﬀecLve
Date 1

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

6757

448392

455399

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT085

COT.002.085

OCCURRENCECODE-EFF-DATE02

Occurrence
Code EﬀecLve
Date 2

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

6858

456400

463407

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT086

COT.002.086

OCCURRENCECODE-EFF-DATE03

Occurrence
Code EﬀecLve
Date 3

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

6959

464408

4715

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

COT087

COT.002.087

OCCURRENCECODE-EFF-DATE04

Occurrence
Code EﬀecLve
Date 4

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7060

472416

479423

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT088

COT.002.088

OCCURRENCECODE-EFF-DATE05

Occurrence
Code EﬀecLve
Date 5

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7161

480424

487431

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT089

COT.002.089

OCCURRENCECODE-EFF-DATE06

Occurrence
Code EﬀecLve
Date 6

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7262

488432

4395

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

COT090

COT.002.090

OCCURRENCECODE-EFF-DATE07

Occurrence
Code EﬀecLve
Date 7

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7363

496440

503447

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT091

COT.002.091

OCCURRENCECODE-EFF-DATE08

Occurrence
Code EﬀecLve
Date 8

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7464

504448

511455

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT092

COT.002.092

OCCURRENCECODE-EFF-DATE09

Occurrence
Code EﬀecLve
Date 9

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7565

512456

519463

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date

COT093

COT.002.093

OCCURRENCECODE-EFF-DATE10

Occurrence
Code EﬀecLve
Date 10

CondiLonal The start date of the corresponding occurrence
code or occurrence span codes.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7666

520464

527471

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. When populated, value must have an
associated populated Occurrence Code
43. CondiLonal
54. Value must be less than or equal to
Occurrence Code End Date
COT094

COT.002.094

OCCURRENCECODE-ENDDATE-01

Occurrence
Code End Date
1

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7767

528472

535479

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT095

COT.002.095

OCCURRENCECODE-ENDDATE-02

Occurrence
Code End Date
2

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7868

536480

543487

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

COT096

COT.002.096

OCCURRENCECODE-ENDDATE-03

Occurrence
Code End Date
3

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

7969

544488

551495

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT097

COT.002.097

OCCURRENCECODE-ENDDATE-04

Occurrence
Code End Date
4

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8070

552496

559503

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT098

COT.002.098

OCCURRENCECODE-ENDDATE-05

Occurrence
Code End Date
5

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8171

5604

567511

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

COT099

COT.002.099

OCCURRENCECODE-ENDDATE-06

Occurrence
Code End Date
6

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8272

568512

575519

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT100

COT.002.100

OCCURRENCECODE-ENDDATE-07

Occurrence
Code End Date
7

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8373

576520

583527

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT101

COT.002.101

OCCURRENCECODE-ENDDATE-08

Occurrence
Code End Date
8

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8474

5284

591535

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal

COT102

COT.002.102

OCCURRENCECODE-ENDDATE-09

Occurrence
Code End Date
9

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8575

592536

599543

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT103

COT.002.103

OCCURRENCECODE-ENDDATE-10

Occurrence
Code End Date
10

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

8676

600544

607551

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Occurrence Code
3. Must be greater than or equal to
Occurrence Code EﬀecLve Date
4. CondiLonal
COT104

COT.002.104

PATIENTCONTROL-NUM

PaLent Control
Number

N/A

COT00002

CLAIMHEADERRECORD-OT

X(20)

8777

608552

627571

1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk
symbol
3. CondiLonal

COT105

COT.002.105

ELIGIBLE-LASTNAME

Eligible Last
Name

N/A

COT00002

CLAIMHEADERRECORD-OT

X(30)

8878

628572

657601

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

COT106

COT.002.106

ELIGIBLE-FIRSTNAME

Eligible First
Name

N/A

COT00002

CLAIMHEADERRECORD-OT

X(30)

8979

658602

687631

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

COT107

COT.002.107

ELIGIBLEMIDDLE-INIT

Eligible Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

COT00002

CLAIMHEADERRECORD-OT

X(1)

9080

688632

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
COT108

COT.002.108

DATE-OF-BIRTH

Date of Birth

Mandatory

An individual's date of birth.

N/A

COT00002

CLAIMHEADERRECORD-OT

9(8)

9181

689633

696640

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Mandatory
COT109

COT.002.109

HEALTH-HOMEPROV-IND

Health Home
Provider
Indicator

CondiLonal Indicates whether the claim is submiaed by a
provider or provider group enrolled in the
Health Home care model. to provide services for
the beneﬁciary on the claim. Health home
providers provide service for paLents with
chronic illnesses. States should not submit claim
records for an eligible individual that indicate the
claim was submitted by a provider or provider group
enrolled in a health home model if the eligible
individual is not enrolled in the health home
program. States that do not specify an eligible

individual's health home provider number, if
applicable, should not report claims that
indicate the claim is submiaed by a provider or

HEALTH-HOMEPROV-IND

COT00002

CLAIMHEADERRECORD-OT

X(1)

9282

697641

provider group enrolled in the health home
model.

COT110

COT.002.110

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which claim
is submiaed.

WAIVER-TYPE

COT00002

CLAIMHEADERRECORD-OT

X(2)

9383

698642

699643

1.1. Value must be 2 characters

2. Value must be in Waiver Type List (VVL)
2. Value must be 2 characters
3. Value must be in [ '06', '07', '08', '09', '10', '11',
'12', '13', '14', '15', '16', '17', '18', '19', '20', '33']
when associated Program Type equals "07"
4.3. Value must match Eligible Waiver Type

(ELG.012.173) for the enrollee for the same
Lme period (by date of service)
4. When populated, Waiver ID (COT.002.111)
must be populated
5. CondiLonal
6. Value must be in
[06,07,08,09,10,11,12,13,14,15,16,17,18,19,2
0,33] when associated Program Type equals
"07"

COT111

COT.002.111

WAIVER-ID

Waiver ID

N/A

COT00002

CLAIMHEADERRECORD-OT

X(20)

9484

700644

719663

1.1. Value must be 20 characters or less

2. Value must be associated with a populated
Waiver Type
2. Value must be 20 characters or less
3.3. (1115 demonstraLon waivers) If value

COT112

COT.002.112

BILLING-PROVNUM

Billing Provider
Number

N/A

COT00002

CLAIMHEADERRECORD-OT

X(30)

9585

720664

749693

then value may match (PRV.002.019)
Submieng State Provider ID or
4. When Type of Claim not in
('Z','3','C','W',"2","B","V"," 4","D","X")[3,C,W]
then value may match (PRV.005.081) Provider
IdenLﬁer where the Provider IdenLﬁer Type =
'1'(PRV.005.077) equals "1"
5. Must have an enrollment where the Ending
Date of Service (COT.003.167) may be
between Provider Aaributes EﬀecLve Date
(PRV.002.020) and Provider Aaributes End
Date (PRV.002.021) or
6. Must have an enrollment where the Ending
Date of Service (COT.003.167) may be
between Provider IdenLﬁer EﬀecLve Date
(PRV.005.079) and Provider IdenLﬁer End
Date (PRV.005.080)
6. When Type of Service (COT..003.186) is in
['119', '120', '122'] value must match Plan ID
Number (COT.002.066)).

7. Value must be reported in Provider
IdenLﬁer (PRV.005.080) with an associated
Provider IdenLﬁer Type (PRV.005.081) equal
to '1'.

COT113

COT.002.113

BILLING-PROVNPI-NUM

Billing Provider
NPI Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

COT00002

CLAIMHEADERRECORD-OT

X(10)

9686

750694

759703

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal
45. When Type of Claim (COT.002.037) not in
('3','C','W') thenpopulated, value must match
Provider IdenLﬁer (PRV.0025.081) and Facility
Group Individual Code (PRV.002.028) must
equal "01"
6. NPPES EnLty Type Code associated with
this NPI must equal "2" (OrganizaLon)

NaLonal Provider ID (NPI) of the billing enLty
responsible for billing a paLent for healthcare
services. The billing provider can also be
servicing, referring, or prescribing provider. Can
be admieng provider except for Long Term
Care. For sub-capitaLon payments, report the
naLonal provider idenLﬁer (NPI) for the subcapitated enLty if the provider has one.
COT114

COT.002.114

BILLING-PROVTAXONOMY

Billing Provider
Taxonomy

CondiLonal The taxonomy code for the provider billing for
the service.

1. Value must be 10 digits, consisting of 9

PROVTAXONOMY

COT00002

CLAIMHEADERRECORD-OT

X(12)

9787

7604

7715

1. Value must be in Provider Taxonomy List
(VVL)
2. Value must be 12 characters or less
3. CondiLonal
4. Value is in [119, 120, 121, 122 ], then value
should not be populated

COT115

COT.002.115

BILLING-PROVTYPE

Billing Provider
Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

COT00002

CLAIMHEADERRECORD-OT

X(2)

9888

772716

7173

1.1. Value must be 2 characters

2. Value must be in Provider Type Code List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
COT116

COT.002.116

BILLING-PROVSPECIALTY

Billing Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

COT00002

CLAIMHEADERRECORD-OT

X(2)

9989

774718

775719

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal

COT117

COT118

COT.002.117

COT.002.118

REFERRINGPROV-NUM

REFERRINGPROV-NPI-NUM

Referring
Provider
Number

N/A

Referring
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

COT00002

CLAIMHEADERRECORD-OT

X(30)

CLAIMHEADERRECORD-OT

X(10)

10090

776720

805749

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. CondiLonal

10191

806750

815759

1. Value must be 10 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to '2'
3. Conditional"2"
4. Value must exist in the NPPES NPI File

NaLonal Provider ID (NPI) of the provider who
recommended the servicing provider to the
paLent.
COT119

COT.002.119

REFERRINGPROV-TAXONOMY

Referring
Provider
Taxonomy

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(12)

102

816

827

1. Not Applicable

COT120

COT.002.120

REFERRINGPROV-TYPE

Referring
Provider Type

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(2)

103

828

829

1. Not Applicable

COT121

COT.002.121

REFERRINGPROV-SPECIALTY

Referring
Provider Specialty

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(2)

104

830

831

1. Not Applicable

COT122

COT.002.122

MEDICARE-HICNUM

Medicare HIC
Number

N/A

COT00002

CLAIMHEADERRECORD-OT

X(12)

10592

832760

843771

1. Conditional
2. Value must be 12 characters or less
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols
4. (Not Dual Eligible) if Dual Eligible Code
(ELG.DE.085) value =equals "00", then value
must not be populated.
5. Value must be populated when Crossover
Indicator (COT.002.023) equals '1'"1" and
Medicare Beneﬁciary IdenLﬁer (COT.002.147)
is not populated.

COT123

COT.002.123

PLACE-OFSERVICE

Place of Service

CondiLonal A data element corresponding with line 24b on
the CMS-1500 that indicates where the services
took place. This is a pass-through data element
that should not be modiﬁed or derived when
missing unless otherwise speciﬁed.

PLACE-OFSERVICE

COT00002

CLAIMHEADERRECORD-OT

X(2)

10693

844772

845773

1.1. Value must be 2 characters

2. Value must be in Place of Service Code List
(VVL)
2. Value must be 2 characters

3. CondiLonal
4. If value is populated on a non-denied claim,
then Procedure Code (COT.003.169) must be
populated.
5. When Type of Service (COT.003.186) is in [119122], Place of Service (COT.002.123) should Bill

must not be populated
COT125

COT.002.125

BMI

Body Mass Index

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(5)V
9

107

846

851

1. Not Applicable

COT126

COT.002.126

REMITTANCENUM

Remiaance
Number

Mandatory

N/A

COT00002

CLAIMHEADERRECORD-OT

X(30)

10894

852774

881803

detailed .

symbols
43. Mandatory

explanaLon of the reason for the payment
amount. The RA number is not the check number.

COT127

COT.002.127

DAILY-RATE

Daily Rate

CondiLonal The amount a policy will pay per day for a
covered service. In some cases for OT claims this
is referred to as a ﬂat rate. see US Dollar Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(5)V
99

10995

882804

888810

1. Value must be between 0.00 and 99999.99
2. CondiLonal
3. Value must be expressed as a number with
2-digit precision (e.g. 100.50)

BORDER-STATEIND

COT00002

CLAIMHEADERRECORD-OT

X(1)

11096

889811

1.1. Value must be 1 character

N/A

CondiLonal The date the beneﬁciary paid the coinsurance
amount.

N/A

(DT.008)

COT128

COT130

COT131

COT.002.128

COT.002.130

COT.002.131

BORDER-STATEIND

TOTBENEFICIARYCOINSURANCEPAID-AMOUNT

BENEFICIARYCOINSURANCEDATE-PAID

Border State
Indicator

Total
Beneﬁciary
Coinsurance
Paid Amount

Beneﬁciary
Coinsurance
Date Paid

2. Value must be in Border State Indicator List
(VVL)
2. Value must be 1 character
3.3. CondiLonal

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

11197

890812

902824

COT00002

CLAIMHEADERRECORD-OT

9(8)

11298

903825

910832

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Must in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Coinsurance Amount
43. CondiLonal

COT132

COT133

COT.002.132

COT.002.133

TOTBENEFICIARYCOPAYMENTPAID-AMOUNT

BENEFICIARYCOPAYMENTDATE-PAID

Total
Beneﬁciary
Copayment Paid
Amount

Beneﬁciary
Copayment
Date Paid

N/A

CondiLonal The date the beneﬁciary paid the copayment
amount.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

11399

911833

923845

COT00002

CLAIMHEADERRECORD-OT

9(8)

114100

924846

931853

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Must in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Copayment Amount
43. CondiLonal
COT134

COT135

COT.002.134

COT.002.135

TOTBENEFICIARYDEDUCTIBLEPAID-AMOUNT

BENEFICIARYDEDUCTIBLEDATE-PAID

Total
Beneﬁciary
DeducLble Paid
Amount

Beneﬁciary
DeducLble Date
Paid

N/A

CondiLonal The date the beneﬁciary paid the deducLble
amount.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

1015

932854

944866

COT00002

CLAIMHEADERRECORD-OT

9(8)

116102

945867

952874

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Must in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary DeducLble Date Paid
4Amount
3. CondiLonal

COT136

COT.002.136

CLAIM-DENIEDINDICATOR

Claim Denied
Indicator

Mandatory

An indicator to idenLfy a claim that the state
refused pay in its enLrety.

CLAIM-DENIEDINDICATOR

COT00002

CLAIMHEADERRECORD-OT

X(1)

117103

953875

1.1. Value must be 1 character

2. Value must be in Claim Denied Indicator
List (VVL)
23. If value is '0',equals "0", then Claim Status
Category must equal "F2"
3. Value must be 1 character
4.4. Mandatory

COT137

COT.002.137

COPAY-WAIVEDIND

Copayment
Waived
Indicator

OpSituaLo

nal

An indicator signifying that the copay was
waived by the provider.

COPAYWAIVED-IND

COT00002

CLAIMHEADERRECORD-OT

X(1)

118104

954876

1.1. Value must be 1 character

2. Value must be in Copay Waived Indicator
List (VVL)
2. Value must be 1 character
3. Optional3. SituaLonal

COT138

COT140

COT.002.138

COT.002.140

HEALTH-HOMEENTITY-NAME

Health Home
EnLty Name

N/A

THIRD-PARTYCOINSURANCEAMOUNT-PAID

Third Party
Coinsurance
Amount Paid

OpSituaLo

N/A

nal

The amount of money paid by a third party on
behalf of the beneﬁciary towards coinsurance on
the claim or claim line item.

COT00002

CLAIMHEADERRECORD-OT

X(50)

CLAIMHEADERRECORD-OT

S9(11)
V99

119105

955877

100492

1206

100592

101793

1. Value must 50 characters or less
2.1. Value must not contain a pipe or asterisk

symbols
2. Value must 50 characters or less
3. CondiLonal

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. OpSituaLonal

COT141

COT.002.141

THIRD-PARTYCOINSURANCEDATE-PAID

Third Party
Coinsurance
Date Paid

CondiLonal The date a Third Party Coinsurancethe third party
paid the coinsurance amount was paid on this

N/A

COT00002

claim or adjustment.

CLAIMHEADERRECORD-OT

9(8)

121107

101894

102594

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

2. When populated, value must have an
associated Third Party Coinsurance Amount
3. CondiLonal
COT142

COT143

COT.002.142

COT.002.143

THIRD-PARTYCOPAYMENTAMOUNT-PAID

Third Party
Copayment
Amount Paid

OpSituaLo

THIRD-PARTYCOPAYMENTDATE-PAID

Third Party
Copayment
Date Paid

OpSituaLo

nal

The amount of money paid by a third -party on
behalf of the beneﬁciary paid towards a
copayment.

N/A

The date a Third Partythe third party paid the
copayment amount was paid on a claim or
adjustment.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

122108

CLAIMHEADERRECORD-OT

9(8)

123109

102694

103896

103996

104696

2. When populated, value must have an
associated Third Party Copayment Amount
3. OpSituaLonal
COT144

COT.002.144

DATE-CAPITATEDAMOUNTREQUESTED

Date Capitated
Amount
Requested

Conditional

The date that the managed care entity submitted
the capitated payment bill to the state. see Date
(DT.001)

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

124

1047

1054

1. Value must be 8 characters in the form
"CCYYMMDD"
2. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
3. Conditional

COT145

COT.002.145

CAPITATEDPAYMENT-AMTREQUESTED

Capitated
Payment Amount
Requested

Conditional

The amount of the capitated payment bill submitted
by the managed care entity to the state.

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)
V99

125

1055

1067

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. Conditional

COT146

COT.002.146

HEALTH-HOMEPROVIDER-NPI

Health Home
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

NaLonal Provider ID (NPI) of the health home
provider.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(10)

126110

106896

107797

1. Value must be 10 digits, consisting of 9

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer, where Provider IdenLﬁer Type
equal to '2'
3. Conditional
4. When Type of Service
(COT.003.186(PRV.005.077) equals '121',
value"2"
3. Value must not be populatedexist in the

NPPES NPI data ﬁle
4. CondiLonal

COT147

COT.002.147

MEDICAREBENEFICIARYIDENTIFIER

Medicare
Beneﬁciary
IdenLﬁer

N/A

COT00002

CLAIMHEADERRECORD-OT

X(12)

127111

107897

108999

COT148

COT.002.148

UNDERDIRECTION-OFPROV-NPI

Under Direction
of Provider NPI

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(10)

128

1090

1099

1. Not Applicable

COT149

COT.002.149

UNDERDIRECTION-OFPROV-TAXONOMY

Under Direction
of Provider
Taxonomy

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(12)

129

1100

1111

1. Not Applicable

COT150

COT.002.150

UNDERSUPERVISION-OFPROV-NPI

Under
Supervision of
Provider NPI

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(10)

130

1112

1121

1. Not Applicable

COT151

COT.002.151

UNDERSUPERVISION-OFPROV-TAXONOMY

Under
Supervision of
Provider
Taxonomy

Not
Applicable

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(12)

131

1122

1133

1. Not Applicable

COT152

COT.002.152

STATE-NOTATION

State NotaLon

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(500)

1326

113415

163320

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

COT00003

CLAIM-LINERECORD-OT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "COT00003"

STATE

COT00003

CLAIM-LINERECORD-OT

X(2)

1.1. Value must be 2 characters

nal

COT154

COT.003.154

RECORD-ID

Record ID

Mandatory

COT.003.155

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (COT.001.007)

COT156

COT157

COT.003.156

COT.003.157

RECORDNUMBER

MSISIDENTIFICATIONNUM

Record Number

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

COT00003

CLAIM-LINERECORD-OT

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

COT00003

CLAIM-LINERECORD-OT

X(20)

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. When Type of Claim (COT.002.037) equals 4, D
or X (lump sum payment) value must begin with
an '&'1. Value must be 20 characters or less

2. Mandatory

COT158

COT.003.158

ICN-ORIG

Original ICN

Mandatory

COT159

COT.003.159

ICN-ADJ

Adjustment ICN

COT160

COT.003.160

LINE-NUM-ORIG

Original Line
Number

COT161

COT.003.161

LINE-NUM-ADJ

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

COT00003

CLAIM-LINERECORD-OT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

COT00003

CLAIM-LINERECORD-OT

X(50)

141

Mandatory

A unique number to idenLfy the transacLon line
number that is being reported on the original
claim.

N/A

COT00003

CLAIM-LINERECORD-OT

X(3)

142

144

1. Value must be 3 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory
4. When populated, valueValue must be one or
greater

Adjustment Line CondiLonal A unique number to idenLfy the transacLon line
Number
number that idenLﬁes the line number on the
adjustment claim.

N/A

COT00003

CLAIM-LINERECORD-OT

X(3)

145

147

COT162

COT.003.162

LINEADJUSTMENTIND

Line Adjustment CondiLonal A code to indicate the type of adjustment record
Indicator
claim/encounter represents at claim detail level.

LINEADJUSTMENTIND

COT00003

CLAIM-LINERECORD-OT

X(1)

148

1.1. Value must be 1 character

2. Value must be in Line Adjustment Indicator
List (VVL)
2. If associated Type of Claim value is in [ 1, 3, 5,
A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]
3. If associated Type of Claim value is in [ 4, D, X ],
then value. Value must be in [5, 6]
4. Value must be 1 character
5.0,1,4]

4. CondiLonal
65. If associated Line Adjustment Number is
populated, then value must be populated
COT163

COT.003.163

LINEADJUSTMENTREASON-CODE

Line Adjustment CondiLonal Claim adjustment reason codes communicate
Reason Code
why a service line was paid diﬀerently than it
was billed.

LINEADJUSTMENTREASON-CODE

COT00003

CLAIM-LINERECORD-OT

X(3)

149

151

1.1. Value must be 3 characters or less

2. Value must be in Line Adjustment Reason
Code List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. When populated, Line Adjustment
IndicatorValue must be populated when the

total paid amount is diﬀerent from the total
billed amount
COT164

COT.003.164

SUBMITTER-ID

Submiaer ID

Mandatory

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

COT165

COT.003.165

CLAIM-LINESTATUS

Claim Line
Status

N/A

COT00003

CLAIM-LINERECORD-OT

X(12)

152

163

1. Value must be 12 characters or less
2. Mandatory

CLAIM-STATUS

COT00003

CLAIM-LINERECORD-OT

X(3)

164

166

1.1. Value must be 3 characters or less

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal

4. If value in [545,585,654], then Claim
Denied Indicator must be "0" and Claim
Status Category must be"F2"

COT166

COT.003.166

BEGINNINGDATE-OFSERVICE

Beginning Date
of Service

Mandatory

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

167

174

2. Value must be less than or equal to
associated End of Time Period value
43. Value must be less than or equal to
associated Ending Date of Service value

5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V']
value4. Value must be less than or equal to

COT.003.167

ENDING-DATEOF-SERVICE

Ending Date of
Service

Mandatory

For services received during a single encounter
with a provider, the date the service covered by
this claim was received. For services involving
mulLple encounters on diﬀerent days, or
periods of care extending over two or more
days, the date on which the service covered by
this claim ended. For capitation premium
payments, the date on which the period of coverage
related to this payment ends/ended. For financial
transactions reported to the OT file, populate with
the first day of the time period covered by this
financial transaction.

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

175

182

associated AdjudicaLon Date value
65. Value must be less than or equal to
associated Date of Death (ELG.002.025) value

when populated
76. Value must be equal to or greater than
associated Date of Birth (ELG.002.024) value
87. Mandatory

COT168

COT.003.168

REVENUE-CODE

Revenue Code

CondiLonal A code which idenLﬁes a speciﬁc
accommodaLon, ancillary service or billing
calculaLon (as deﬁned by UB-04 Billing Manual).
Revenue Code should be passed through to TMSIS exactly as it was billed by the provider on
the provider's 837I or UB-04 claim. It is only
required on InpaLent, Long-Term Care and
Other Fee for Service claims and managed care
encounters that have a valid Type of Bill value.
It's not required on ﬁnancial transacLons or
non-insLtuLonal claims.

REVENUECODE

COT00003

CLAIM-LINERECORD-OT

X(4)

183

186

1.1. Value must be 4 characters or less

2. Value must be in Revenue Code List (VVL)
23. A Revenue Code value requires an
associated Revenue Charge
3. Value must be 4 characters or less
4.4. CondiLonal

COT169

COT.003.169

PROCEDURECODE

Procedure Code

CondiLonal A ﬁeld to capture the CPT or HCPCS code that
describes a service or good rendered by the
provider to an enrollee on the speciﬁed date of
service.

PROCEDURECODE

COT00003

CLAIM-LINERECORD-OT

X(8)

187

194

1.1. Value must be 8 characters or less

2. Value must be in Procedure Code List (VVL)
3. When populated, there must be a
corresponding Procedure Code Flag
24. If associated Procedure Code Flag List
(VVL) value indicates an CPT-4 encoding '"01'",
then value must be a valid CPT-4 procedure
code
35. If associated Procedure Code Flag List
(VVL) value indicates an "Other" encoding '1087',"10-87", then State must provide T-MSIS
system with State-speciﬁc procedure code
list, and value must be a valid State-speciﬁc
procedure code
46. If associated Procedure Code Flag List
(VVL) value indicates an HCPCS encoding
'"06'", then value must be a valid HCPCS code
5. Value must be 8 characters or less
6.7. CondiLonal

COT170

COT.003.170

PROCEDURECODE-DATE

Procedure Code
Date

CondiLonal The date upon which a reported medical
procedure was performed.

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

195

202

9. Value must be populated when Procedure Code
(COT.003.169) is populated

COT171

COT.003.171

PROCEDURECODE-FLAG

Procedure Code
Flag

CondiLonal A ﬂag that idenLﬁes the coding system used for
an associated procedure code.

PROCEDURECODE-FLAG

COT00003

CLAIM-LINERECORD-OT

X(2)

203

204

1. Value must be 2 characters
2. Value must be in Procedure Code Flag List
(VVL)
3. When populated, there must be a
corresponding Procedure Code
2. Value must be in Procedure Code Flag List (VVL)
3. Value must be 2 characters
4.4. CondiLonal

COT172

COT.003.172

PROCEDURECODE-MOD-1

Procedure Code
Modiﬁer 1

CondiLonal The procedure code modiﬁer used with an
associated procedure code. For example, some
states use modiﬁers to indicate assistance in
surgery or anesthesia services.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

205

206

1.1. Value must be 2 characters

2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
2. Value must be 2 characters
3.4. CondiLonal

COT173

COT.003.173

IMMUNIZATIONTYPE

Immunization
Type

Not
Applicable

N/A

COT00003

CLAIM-LINERECORD-OT

X(2)

207

208

1. Not Applicable

COT174

COT.003.174

BILLED-AMT

Billed Amount

CondiLonal The amount billed at the claim detail level as
submiaed by the provider. For encounter
records, Type of Claim = 3, C, or W, this ﬁeld
should be populated with the amount that the
provider billed the managed care plan. For subcapitated encounters from a sub-capitated
enLty that is not a sub-capitated network
provider, report the amount that the provider
billed the sub-capitated enLty at the claim line
detail level. Report a null value in this ﬁeld if the
provider is a sub-capitated network provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2120

2097

2219

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT175

COT.003.175

ALLOWED-AMT

Allowed
Amount

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2221

2220

2342

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2322

2353

2475

1. Value must be 5 digits or less left of the
decimal i.e. 99999between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT.003.176

COPAYAMTBENEFICIAR

Y-COPAYMENTPAID-AMOUNT

Beneﬁciary
Copayment Paid
Amount

CondiLonal The copayment amount paid by an enrollee for the

service, which does not include the amount paid by
the insurance company.The amount the

beneﬁciary or his or her representaLve (e.g.,
their guardian) paid towards their copayment
for the covered services on a claim line. Do not
include copayment payments made by a third
party/ies on behalf of the beneﬁciary. This is a
copayment paid for a service in the
corresponding claim line for OT and RX claim
ﬁles. The Beneﬁciary Copayment Paid Amount is
an opLonal line level data element reported for
OT and RX claim ﬁle types, only. If the
beneﬁciary copayment paid amount is not
available at the claim line level, report the total

N/A

copayment paid amount in the header level
copayment data element.

COT177

COT.003.177

TPL-AMT

Third Party
LiabilityTPL

Amount

COT178

COT.003.178

MEDICAID-PAIDAMT

Medicaid Paid
Amount

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2423

2486

260258

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CondiLonal The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For claims

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2524

261259

2731

capitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

COT179

COT.003.179

MEDICAID-FFSEQUIVALENTAMT

Medicaid FFS
Equivalent
Amount

CondiLonal The amount that would have been paid had the
services been provided on a Fee for Service
basis.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2625

2742

2864

COT182

COT.003.182

MEDICARE-PAIDAMT

Medicare Paid
Amount

CondiLonal The amount paid by Medicare on this claim. For
claims where Medicare payment is only
available at the header level, report the enLre
payment amount on the T-MSIS claim line with
the highest charge or adjustmentthe 1st nondenied line. Zero ﬁll Medicare Paid Amount on
all other claim lines.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

2726

2875

2997

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value
isequals "0", then the Medicare Paid Amount
value must not be populated.
4. CondiLonal
5. If value is populated, Crossover Indicator
must be equal to "1"

COT183

COT.003.183

OT-RXCLAIMSERVICE-

OT RX
ClaimService

QUANTITYACTUAL

QuanLty Actual

Conditional

Mandatory

The quanLty of a drug, service, or product that is
rendered/dispensed for a prescription, speciﬁc
date of service, or billing Lme span. This field is
only applicable when as reported by revenue code
or procedure code on the service being billed can

N/A

COT00003

CLAIM-LINERECORD-OT

S9(68)
V999

2827

300298

308

1. Value may include up to 68 digits to the
lef of the decimal point, and 3 digits to the
right e.g. 123456.78912345678.999
2. Conditional
3. If Type of Claim is in [1, 3, A, C, U, W], then this
value must be reported.
4. When populated, corresponding Unit of
Measure must be populatedMandatory

be quantified in discrete units, e.g., a number of
visits or the number of units of a prescription/refill
that were filled.claim/encounter line. For
prescriptions/refills, use the Medicaid Drug Rebate
definition of a unit, which is the smallest unit by
which the drug is normally measured; e.g. tablet,
capsule, milliliter, etc. use with CLAIMOT claims.
For drugs not identifiable or dispensed by a normal
unit, e.g. powder filled vialsCLAIMRX
claims/encounters, use 1 as the number of
unitsthe PrescripLon QuanLty Actual ﬁeld. For

CLAIMIP and CLAIMLT claims/encounters, use
the Revenue Center QuanLty Actual ﬁeld.
COT184

COT.003.184

OT-RXCLAIMSERVICE-

OT RX
ClaimService

QUANTITYALLOWED

QuanLty
Allowed

CondiLonal The maximum allowable quantity of a drug or service
that may be dispensed per prescription per date of
service or per month. Quantity limits are applied to
medications when the majority of appropriate
clinical utilizations will be addressed within the
quantity allowed.The maximum allowable

quanLty of a service that may be rendered per
date of service or per month. For use with
CLAIMOT claims/encounters. For CLAIMIP and
CLAIMLT claims/encounters, use the Revenue
Center QuanLty Allowed ﬁeld. NOTE: One
prescripLon for 100 250 milligram tablets results
in Service QuanLty Allowed = 100. This ﬁeld is
only applicable when the service being billed
can be quanLﬁed in discrete units, e.g., a
number of visits or the number of units of a
prescripLon/reﬁll that were ﬁlled. For
prescripLons/reﬁlls, use the Medicaid Drug
Rebate deﬁniLon of a unit, which is the smallest

N/A

COT00003

CLAIM-LINERECORD-OT

S9(68)
V999

2928

309

3179

1. Value may include up to 68 digits to the lef
of the decimal point, and 3 digits to the right
e.g. 123456.78912345678.999
2. CondiLonal
3. If Type of Claim is in [1, 3, A, C, U, W], then this
value must be reported.

unit by which the drug is normally measured;
e.g. tablet, capsule, milliliter, etc. For drugs not
idenLﬁable or dispensed by a normal unit, e.g.
powder ﬁlled vials, use 1 as the number of units.

COT186

COT.003.186

TYPE-OFSERVICE

Type of Service

Mandatory

A code to categorize the services provided to a
Medicaid or CHIP enrollee.

TYPE-OFSERVICE-OT

COT00003

CLAIM-LINERECORD-OT

X(3)

3029

318320

3202

1. Value must be in Dual Eligible Code List (VVL)
2. If value is "05", then Eligibility Group
(ELG.005.087) must be "24"
3. If value is "06", then Eligibility Group
(ELG.005.087) must be "26"
4. If Dual Eligible Code (ELG.005.085) is "01", "02",
"03", 04", 05", "06", "08", "09", or "10", then
Primary Eligibility Group Indicator (ELG.005.086)
must be "1" (Yes)
5. Conditional
6. A partial dual eligible (values="01', "03", "05"
or "06") then Restricted Benefits Code
(ELG.005.097) must be "3"
7. (Not Dual Eligible) if value = "00", then
associated Medicare Beneficiary Identifier
(ELG.003.051) value must not be populated.
8. Value must be 2 characters
9. If value is in ["08", "10"] then Restricted
Benefits Code (ELG.005.097) must be "1"
10. If value is "09", then Eligibility Group
(ELG.005.087) and Restricted Benefits Code

(ELG.005.097) must not be populated
11. If value equals "10", then CHIP Code
(ELG.003.054) must be "03" (S-CHIP) and
Medicare Beneficiary Identifier (ELG.003.051)
must be populated
12. If value is "01", then Eligibility Group
(ELG.005.087) must be "23"
13. If value is "03", then Eligibility Group
(ELG.005.087) must be "25"1. Value must be 3

characters.
2. Mandatory
3. Value must be in Type of Service OT List
(VVL)
4. When value is not in [025,085], Sex
(ELG.002.023) equals "M"
COT187

COT.003.187

HCBS-SERVICECODE

HCBS Service
Code

CondiLonal A code to indicate that the service represents a
long-term care home and community based
service or support for an individual with chronic
medical and/or mental condiLons. The codes
help to delineate between acute care and longterm care provided in the home and community
seeng (e.g. 1915(c), 1915(i), 1915(j), and
1915(k) services).

HCBS-SERVICECODE

COT00003

CLAIM-LINERECORD-OT

X(1)

3130

3213

1.1. Value must be 1 character

2. Value must be in HCBS Service Code List
(VVL).
2. Value must be 1 character

)
3. If value is in [1-7,], then HCBS Taxonomy
must be populated.
4. CondiLonal

COT188

COT.003.188

HCBSTAXONOMY

HCBS Taxonomy

CondiLonal A code to classify the home and community based
services listed on the claim into the HCBS
taxonomy.A code to classify the home and

community based services listed on the claim
into the HCBS taxonomy. The HCBS Taxonomic
classiﬁcaLon system was adopted by CMS in
August 2012.
To acknowledge state variaLon, services and
categories are deﬁned based on the minimum
deﬁniLon necessary to establish mutually
disLnct categories and services. Some services
are deﬁned in part by characterisLcs that are
NOT in that service. For example, the diﬀerence
between companion services and personal care
is that companion services do not include
assistance with acLviLes of daily living (ADLs)
such as bathing, dressing, eaLng, and toileLng.
Some of the services reﬂected by the HCBS
Taxonomy including, but not limited to personal
care, case management, home health aide, and
physician services, may (and in some case, must)
also be covered under the Medicaid State Plan.
The deﬁniLons below only deﬁne these services
for purposes of SecLon 1915(c) Waivers and the
State Plan Home and Community-Based Services
beneﬁt authorized by SecLon 1915(i). States
interested in reﬂecLng services as “extended
state plan” services must oﬀer them in
accordance with state plan service deﬁniLons.
Consult with the CMS Division of Beneﬁts and
Coverage in those instances to ensure deﬁniLon
alignment.
The services and categories are arranged in
order of consideraLon for placing a parLcular

HCBSTAXONOMY

COT00003

CLAIM-LINERECORD-OT

X(5)

3231

3224

3268

1.1. Value must be 5 characters or less

2. Value must be in HCBS Taxonomy Code List
(VVL).
2. Value must be 5 characters or less

)
3. CondiLonal

state service in the taxonomy. If one is not sure
how to map a state’s service to the taxonomy,
one should ﬁrst consider Case Management,
then Round-the-Clock Services, then Supported
Employment, etc.
DocumentaLon of the HCBS Taxonomy from the
CMS Waiver Management System can be found
here: haps://wmsmmdl.cms.gov/WMS/help/TaxonomyCategoryD
eﬁniLons.pdf.

COT189

COT.003.189

SERVICINGPROV-NUM

Servicing
Provider
Number

N/A

COT00003

CLAIM-LINERECORD-OT

X(30)

3332

3279

3568

then value may match (PRV.005.081) Provider
IdenLﬁer or

4. When Type of Claim not in
('Z','3','C','W',"2","B","V"," 4","D","X") [3,C,W],

then value may match (PRV.002.019)
Submieng State Provider ID

COT190

COT.003.190

SERVICINGPROV-NPI-NUM

Servicing
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

3433

3579

3668

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. CondiLonal
4. WhenIf Type of Claim (COT.002.037) not in
('3','C','W')[3,C,W], then value must match
Provider IdenLﬁer (PRV.005.081)
5. Value must exist in the NPPES NPI data ﬁle

the health care professional who delivers or
completes a parLcular medical service or nonsurgical procedure. The SERVICING-PROV-NPINUM is required when rendering provider is
diﬀerent than the aaending provider and state
or federal regulatory requirements call for a
"combined claim" (i.e., a claim that includes
both facility and professional components).
Examples are Medicaid clinic bills or criLcal
access hospital claims.
COT191

COT.003.191

SERVICINGPROVTAXONOMY

Servicing
Provider
Taxonomy

Not
ApplicableC

ondiLonal

N/APROV-

COT00003

TAXONOMY

CLAIM-LINERECORD-OT

X(12)

CLAIM-LINERECORD-OT

X(2)

3534

3679

3780

COT.003.192

SERVICINGPROV-TYPE

Servicing
Provider Type

CondiLonal A code to describe the type of entity billing for the PROV-TYPE
serviceprovider being reported.

COT00003

1. Not Applicable1. Value must be 12

characters or less
2. Value must be in Provider Taxonomy List
(VVL)
3. CondiLonal

provider who treated the recipient.
COT192

1. Value must be 10 digits, consisting of 9

3635

379381

3802

1.1. Value must be 2 characters

2. Value must be in Provider Type Code List
(VVL).
2. Value must be 2 characters
3.3. CondiLonal

COT193

COT.003.193

SERVICINGPROV-SPECIALTY

Servicing
Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

COT00003

CLAIM-LINERECORD-OT

X(2)

3736

3813

3824

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
COT194

COT195

COT.003.194

COT.003.195

OTHER-TPLCOLLECTION

TOOTHDESIGNATIONSYSTEM

Other TPL
CollecLon

Tooth
DesignaLon
System

Conditional

Mandatory

OTHER-TPLCOLLECTION

COT00003

CLAIM-LINERECORD-OT

X(3)

3837

3835

3857

1.1. Value must be 3 characters

2. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

CondiLonal A code to idenLfy the tooth numbering system is TOOTHbeing used.
DESIGNATIONSYSTEM

COT00003

CLAIM-LINERECORD-OT

X(2)

3938

3868

3879

1.1. Value must be 2 characters

2. Value must be in Tooth DesignaLon System
List (VVL)
23. Value must not contain a pipe symbol
3. Value must be 2 characters

4. CondiLonal
COT196

COT.003.196

TOOTH-NUM

Tooth Number

CondiLonal The tooth number serviced based on the tooth
numbering system idenLﬁed in the TOOTHDESIGNATION-SYSTEM ﬁeld. see Tooth Number
List (VVL.171)

TOOTH-NUM

COT00003

CLAIM-LINERECORD-OT

X(2)

4039

388390

3891

1.1. Value must be 2 characters or less

2. Value must be in Tooth Number List (VVL)
23. If Tooth DesignaLon System
(COT.003.195) is '"JP'" value must be found in
[1..32][51-82][A..T]or [AS..KS]
34. If Tooth DesignaLon System
(COT.003.195) is '"JO'" value must have 1 digit
before and afer the decimal (N.N)
45. If Tooth DesignaLon System
(COT.003.195) is '"JO'" value must be a ﬁrst
digit of 1-4 and the decimal must be between
1-8
5. Value must be 2 characters or less
6.6. CondiLonal
7. When value is in ['A'-'T'A-T], the diﬀerence

between Ending Date of Service

(COT.002.034) and Date of Birth
(COT.002.108) is less than 15 years

COT197

COT.003.197

TOOTH-QUADCODE

Tooth Quad
Code

CondiLonal The area of the oral cavity is designated by a
two-digit code.

TOOTH-QUADCODE

COT00003

CLAIM-LINERECORD-OT

X(2)

4140

3902

3913

1.1. Value must be 2 characters

2. Value must be in Tooth Quad Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

4. When populated, associated type of
service value must be in [013,029,035]
COT198

COT.003.198

TOOTHSURFACE-CODE

Tooth Surface
Code

CondiLonal A code to idenLfy the tooth's surface on which
the service was performed.

TOOTHSURFACE-CODE

COT00003

CLAIM-LINERECORD-OT

X(1)

4241

3924

1.1. Value must be 1 character

2. Value must be in Tooth Surface Code List
(VVL)
2. Value must be 1 character
3.3. CondiLonal

4. When populated, associated type of
service value must be in [013,029,035]

COT199

COT.003.199

ORIGINATIONADDR-LN1

OriginaLon
Address Line 1

CondiLonal The street address of the originaLon point from
which a paLent is transported either from home
or Long term care facility to a health care
provider for healthcare services or vice versa.
For transportaLon claims, this is only required if
state has captured this informaLon, otherwise it
is condiLonal.

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

4342

3935

4524

1. Value must be 60 characters or less
2. Value must not be equal to associated
Address Line 2 or Address Line 3 value(s)
3. Value must not contain a pipe or asterisk
symbols
4. When populated, the associated Address Type
is required
5. CondiLonal

COT200

COT.003.200

ORIGINATIONADDR-LN2

OriginaLon
Address Line 2

CondiLonal The second line of the street address of the
ordesLginaLon point fromto which a paLent is
transported either from home or Long term care
facility to a health care provider for healthcare
services or vice versa. For transportaLon claims,
this is only required if state has captured this
informaLon, otherwise it is condiLonal.

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

4443

4535

5124

1. Value must be 60 characters or less
2. Value must not be equal to associated
Address Line 1 or Address Line 3 value(s)
3. There must be an Address Line 1 in order
to have an Address Line 2
4. Value must not contain a pipe or asterisk
symbols
5. CondiLonal

COT201

COT.003.201

ORIGINATIONCITY

OriginaLon City

CondiLonal The name of the originaLon city from which a
paLent is transported either from home or a
long term care facility to a health care provider
for healthcare services or vice versa. For
transportaLon claims, this is only required if
state has captured this informaLon, otherwise it
is condiLonal.

N/A

COT00003

CLAIM-LINERECORD-OT

X(28)

4544

5135

5402

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

COT202

COT.003.202

ORIGINATIONSTATE

OriginaLon
State

CondiLonal The ANSI numeric code of the originaLon state
in which a paLent is transported either from
home or a long term care facility to a health
care provider to a health care provider for
healthcare services or vice versa.

STATE

COT00003

CLAIM-LINERECORD-OT

X(2)

4645

5413

5424

1.1. Value must be 2 characters

CondiLonal U.S. Zip Code component of an address associated

ZIP-CODE

COT203

COT.003.203

ORIGINATIONZIP-CODE

OriginaLon
ZipZIP Code

with a given entity (e.g. person, organization, agency,
etc.)The zip code of the originaLon city from

which a paLent is transported either from home

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. CondiLonal
4. (transportation claim) value is mandatory and
must be provided for all transportation claims

COT00003

CLAIM-LINERECORD-OT

X(9)

4746

5435

5513

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. CondiLonal

or long term care facility to a health care
provider for healthcare services or vice versa.

COT204

COT.003.204

DESTINATIONADDR-LN1

DesLnaLon
Address Line 1

CondiLonal The street address of the desLnaLon point to
which a paLent is transported either from home
or Long term care facility to a health care
provider for healthcare services or vice versa.
For transportaLon claims only. Required if state
has captured this informaLon, otherwise it is
condiLonal.

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

4847

5524

6113

COT205

COT.003.205

DESTINATIONADDR-LN2

DesLnaLon
Address Line 2

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

4948

6124

6713

COT206

COT.003.206

DESTINATIONCITY

DesLnaLon City

CondiLonal The name of the desLnaLon city to which a
paLent is transported either from home or a
long term care facility to a health care provider
for healthcare services or vice versa. For
transportaLon claims only. Required if state has
captured this informaLon, otherwise it is
condiLonal.

N/A

COT00003

CLAIM-LINERECORD-OT

X(28)

5049

6724

699701

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

COT207

COT208

COT.003.207

COT.003.208

DESTINATIONSTATE

DESTINATIONZIP-CODE

DesLnaLon
State

DesLnaLon
ZipZIP Code

CondiLonal The ANSI state numeric code for the U.S. state,
Territory, or the District of Columbia code of the
desLnaLon state in which a paLent is
transported either from home or a long term
care facility to a health care provider for
healthcare services or vice versa. For
transportaLon claims only. Required if state has
captured this informaLon, otherwise it is
condiLonal.

STATE

CondiLonal U.S. Zip Code component of an address associated

ZIP-CODE

COT00003

CLAIM-LINERECORD-OT

X(9)

5251

7024

7102

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. CondiLonal

BENEFIT-TYPE

COT00003

CLAIM-LINERECORD-OT

X(3)

711

713

1. Value must be in Benefit Type Code List (VVL)
2. Value must be 3 characters
3. Mandatory

with a given entity (e.g. person, organization, agency,
etc.)The zip code of the desLnaLon city to which

COT00003

CLAIM-LINERECORD-OT

X(2)

5150

7002

7013

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3. (transportation claim) value is mandatory and
must be provided for all transportation claims
4. CondiLonal

a paLent is transported either from home or
long term care facility to a health care provider
for healthcare services or vice versa. For
transportaLon claims only. Required if state has
captured this informaLon, otherwise it is
condiLonal.
COT209

COT.003.209

BENEFIT-TYPE

Benefit Type

Mandatory

1.1. Value must be 2 characters

COT210

COT.003.210

CMS-64-

CATEGORY-FORFEDERALREIMBURSEMEN
T

CMS 64 Category

for Federal
Reimbursement

CondiLonal A code to indicate the Federal funding source
for the payment.

CMS-64-

CATEGORYFOR-FEDERALREIMBURSEME
NT

COT00003

CLAIM-LINERECORD-OT

X(2)

5452

7143

7154

COT.003.211

XIX-MBESCBESCATEGORY-OFSERVICE

XIX MBESCBES
Category of
Service

Conditional

XIX-MBESCBESCATEGORY-OFSERVICE

COT00003

CLAIM-LINERECORD-OT

X(4)

716

719

COT212

COT.003.212

XXI-MBESCBESCATEGORY-OFSERVICE

XXI MBESCBES
Category of
Service

Conditional

XXI-MBESCBESCATEGORY-OFSERVICE

COT00003

CLAIM-LINERECORD-OT

X(3)

720

722

4. If XIX MBESCBES Category of Service is
populated then value must not be populated
5. Value must be 3 characters or less

COT213

COT.003.213

OTHERINSURANCEAMT

Other Insurance
Amount

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

5753

723715

735727

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT214

COT.003.214

STATE-NOTATION

State NotaLon

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

COT00003

CLAIM-LINERECORD-OT

X(500)

5888

736126

123765

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

N/A

FILE-HEADERRECORD-OT

X(4)

1.1. Value must be 4 characters or less

nal

COT216

COT217

COT218

COT.001.216

COT.003.217

COT.003.218

SEQUENCENUMBER

Sequence
Number

Mandatory

COT00001

5. Mandatory

NATIONALDRUG-CODE

NaLonal Drug
Code

CondiLonal A code following the NaLonal Drug Code format
indicaLng the drug, device, or medical supply
covered by this claim.

N/A

PROCEDURECODE-MOD-3

Procedure Code
Modiﬁer 3

CondiLonal The procedure code modiﬁer used with an
associated procedure code. For example, some
states use modiﬁers to indicate assistance in
surgery or anesthesia services.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(12)

CLAIM-LINERECORD-OT

X(2)

5954

6156

123672

124773

125074

125174

1.1. Value must be 2 characters

2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code

2. Value must be 2 characters
3.4. CondiLonal

COT219

COT.003.219

PROCEDURECODE-MOD-4

Procedure Code
Modiﬁer 4

CondiLonal The procedure code modiﬁer used with an
associated procedure code. For example, some
states use modiﬁers to indicate assistance in
surgery or anesthesia services.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

6257

125274

125374

1.1. Value must be 2 characters

2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
2. Value must be 2 characters
3.4. CondiLonal

COT220

COT.003.220

HCPCS-RATE

HCPCS Rate

Not
Applicable

N/A

COT00003

CLAIM-LINERECORD-OT

X(14)

1254

1267

1. Not Applicable

COT221

COT.003.221

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

6458

126874

12753

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in(COT.001.010)
3. Mandatory
4. Value should be on or afer associated TMSIS File Header Record
4. MandatoryAdmission Date value

COT222

COT.003.222

SELF-DIRECTIONTYPE

Self DirecLon
Type

Conditional

Mandatory

A data element to idenLfy how the beneﬁciary
self-directed the service, i.e. hiring authority
(the beneﬁciary has decision-making authority
to recruit, hire, train and supervise the
individuals who furnish his/her services), budget
authority (The beneﬁciary has decision-making
authority over how the Medicaid funds in a

SELFDIRECTIONTYPE

COT00003

CLAIM-LINERECORD-OT

X(3)

6559

127675

127875

1.1. Value must be 3 characters

2. Value must be in Self DirecLon Type List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

budget are spent), or both hiring and budget
authority.

COT223

COT224

COT.003.223

COT.003.224

PREAUTHORIZATION
-NUM

PreauthorizaLo
n Number

N/A

NDC-UNIT-OFMEASURE

NDC Unit of
Measure

CondiLonal A code to indicate the basis by which the
quanLty of the NaLonal Drug Code is expressed.

NDC-UNIT-OFMEASURE

COT00003

CLAIM-LINERECORD-OT

X(18)

CLAIM-LINERECORD-OT

X(2)

6660

6761

127975

129677

1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

129777

129877

1.1. Value must be 2 characters

2. Value must be in NDC Unit of Measure List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
COT225

COT.003.225

NDC-QUANTITY

NDC QuanLty

CondiLonal This ﬁeld is to capture the actual quanLty of the
NaLonal Drug Code being prescribed on the
claim/encounters.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(6)V9
999)V(
9)

6862

129977

130779

1. Value may include up to 69 digits to the lef
of the decimal point, and 39 digits to the right
e.g. 123456.789123456789.123456789
2. CondiLonal

COT226

COT227

COT.002.226

COT.003.227

PROV-LOCATION- Provider
ID
LocaLon ID

PROCEDURECODE-MOD-2

Procedure Code
Modiﬁer 2

Mandatory

CondiLonal The procedure code modiﬁer used with an
associated procedure code. For example, some
states use modiﬁers to indicate assistance in
surgery or anesthesia services.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(5)

133112

163499

163899

1.1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
2. Value must be 5 characters or less
3.3. Mandatory

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

6055

124874

124974

1.1. Value must be 2 characters

2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
2. Value must be 2 characters
3.4. CondiLonal

COT230

COT.002.230

TOTBENEFICIARYCOPAYMENTLIABLE-AMOUNT

Total
Beneﬁciary
Copayment
Liable Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

113

996

1008

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT231

COT.002.231

TOTBENEFICIARYCOINSURANCELIABLE-AMOUNT

Total
Beneﬁciary
Coinsurance
Liable Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

114

1009

1021

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT232

COT.002.232

TOTBENEFICIARYDEDUCTIBLELIABLE-AMOUNT

Total
Beneﬁciary
DeducLble
Liable Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

115

1022

1034

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT233

COT.002.233

COMBINEDBENE-COSTSHARING-PAIDAMOUNT

Combined
Beneﬁciary Cost
Sharing Paid
Amount

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

116

1035

1047

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT234

COT.003.234

IHS-SERVICE-IND

IHS Service
Indicator

Mandatory

COT00003

CLAIM-LINERECORD-OT

X(1)

795

1. Value must be 1 character
2. Value must be in the IHS Service Indicator
List (VVL)
3. Mandatory

IHS-SERVICEIND

COT235

COT.002.235

LTC-RCP-LIABAMT

LTC RCP Liability
Amount

CondiLonal The total amount paid by the paLent for
services where they are required to use their
personal funds to cover part of their care before
Medicaid funds can be uLlized.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

117

1048

1060

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT236

COT.002.236

BILLING-PROVADDR-LN-1

Billing Provider
Address Line 1

Mandatory

Billing provider address line 1 from X12 837I,
837P, and 837D loop 2010AA.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(60)

118

1061

1120

1. Value must not be more than 60 characters
long
2. Mandatory
3. Value must not contain a pipe or asterisk
symbols

COT237

COT.002.237

BILLING-PROVADDR-LN-2

Billing Provider
Address Line 2

CondiLonal Billing provider address line 2 from X12 837I,
837P, and 837D loop 2010AA.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(60)

119

1121

1180

COT238

COT.002.238

BILLING-PROVCITY

Billing Provider
City

Mandatory

Billing provider address city name from X12
837I, 837P, and 837D loop 2010AA.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(28)

120

1181

1208

1. Value must not be more than 28 characters
long
2. Mandatory

COT239

COT.002.239

BILLING-PROVSTATE

Billing Provider
State Code

Mandatory

Billing provider address state code from X12
837I, 837P, and 837D loop 2010AA.

STATE

COT00002

CLAIMHEADERRECORD-OT

X(2)

121

1209

1210

1. Value must not be more than 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

COT240

COT.002.240

BILLING-PROVZIP-CODE

Billing Provider
ZIP Code

Mandatory

Billing provider address ZIP code from X12 837I,
837P, and 837D loop 2010AA.

ZIP-CODE

COT00002

CLAIMHEADERRECORD-OT

X(9)

122

1211

1219

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. Mandatory

COT241

COT.002.241

SERVICEFACILITYLOCATION-ORGNPI

Service Facility
LocaLon
OrganizaLon
NPI

CondiLonal Service facility locaLon organizaLon NPI from
X12 837I loop 2310E or 837P and 837D loop
2310C.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(10)

123

1220

1229

COT242

COT.002.242

SERVICEFACILITYLOCATIONADDR-LN-1

Service Facility
LocaLon
Address Line 1

CondiLonal Service facility locaLon address line 1 from X12
837I loop 2310E or 837P and 837D loop 2310C.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(60)

124

1230

1289

1. Value must not be more than 60 characters
long
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols

COT243

COT.002.243

SERVICEFACILITYLOCATIONADDR-LN-2

Service Facility
LocaLon
Address Line 2

CondiLonal Service facility locaLon address line 2 from X12
837I loop 2310E or 837P and 837D loop 2310C.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(60)

125

1290

1349

COT244

COT.002.244

SERVICEFACILITYLOCATION-CITY

Service Facility
LocaLon City

CondiLonal Service facility locaLon address city name from
X12 837I loop 2310E or 837P and 837D loop
2310C.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(28)

126

1350

1377

1. Value must not be more than 28 characters
long
2. CondiLonal

COT245

COT.002.245

SERVICEFACILITYLOCATION-STATE

Service Facility
LocaLon State

CondiLonal Service facility locaLon address state code from
X12 837I loop 2310E or 837P and 837D loop
2310C.

STATE

COT00002

CLAIMHEADERRECORD-OT

X(2)

127

1378

1379

1. Value must not be more than 2 characters
2. Value must be in State Code list (VVL)
3. CondiLonal

COT246

COT.002.246

SERVICEFACILITYLOCATION-ZIPCODE

Service Facility
LocaLon ZIP
Code

CondiLonal Service facility locaLon address ZIP code from
X12 837I loop 2310E or 837P and 837D loop
2310C.

ZIP-CODE

COT00002

CLAIMHEADERRECORD-OT

X(9)

128

1380

1388

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. CondiLonal

COT247

COT.002.247

PROVIDERCLAIM-FORMCODE

Provider Claim
Form Code

Mandatory

PROVIDERCLAIM-FORMCODE

COT00002

CLAIMHEADERRECORD-OT

X(2)

129

1389

1390

1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code
List (VVL)
3. Mandatory

COT248

COT.002.248

PROVIDERCLAIM-FORMOTHER-TEXT

Provider Claim
Form Other Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the "other" claim form used by the provider to
submit their claim. Required when "Other" is
reported to Provider Claim Form Code.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(50)

130

1391

1440

1. Value must not be more than 50 characters
long
2. CondiLonal
3. Value must be provided when
corresponding Provider Claim Form Code is
"Other"

COT249

COT.002.249

TOT-GMEAMOUNT-PAID

Total GME
Amount Paid

CondiLonal The amount included in the Total Medicaid
Amount (COT.002.050) that is aaributable to a
Graduate Medical EducaLon (GME) payment,
when the state makes GME payments by claim.

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

131

1441

1453

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT250

COT.002.250

REFERRINGPROV-NUM-2

Referring
Provider
Number 2

N/A

COT00002

CLAIMHEADERRECORD-OT

X(30)

132

1454

1483

1. Value must be 30 characters or less
2. CondiLonal
3. Value must not be populated when
Referring Provider Number is not populated.
4. Value must not equal Referring Provider
Number

A code indicaLng the format in which the
provider submiaed their claim. Very few if any
claims should be classiﬁed as "Other".

COT251

COT.002.251

REFERRINGPROV-NPI-NUM2

Referring
Provider NPI
Number 2

CondiLonal The NaLonal Provider ID (NPI) of the provider
who recommended the servicing provider to the
paLent. This is only applicable when a provider
reports a second referral at the header of their
claim.

N/A

COT00002

CLAIMHEADERRECORD-OT

X(10)

133

1484

1493

1. Value must be 10 digits
2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to "2"
4. Value must exist in the NPPES NPI File
5. Value must not be populated when
Referring Provider NPI Number is not
populated
6. Value must not equal Referring Provider
NPI Number

COT252

COT.002.252

TOT-SDPALLOWED-AMT

Total State
Directed
Payment
Allowed
Amount

N/A

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

134

1494

1506

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT253

COT.002.253

TOT-SDP-PAIDAMT

Total State
Directed
Payment Paid
Amount

COT00002

CLAIMHEADERRECORD-OT

S9(11)
V99

135

1507

1519

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT254

COT.003.254

DIAGNOSISCODE-POINTER1

Diagnosis Code
Pointer 1

Mandatory

A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

796

797

1. Value must be numeric
2. Value must be 2 digits or less
3. Value must be between 1 and 12
4. Mandatory

COT255

COT.003.255

UNIQUE-DEVICEIDENTIFIER

Unique Device
IdenLﬁer

CondiLonal An unique idenLﬁer assigned to every medical
device that meets the requirements of 21 CFR
801 and 830.

N/A

COT00003

CLAIM-LINERECORD-OT

X(76)

804

879

1. Value must not be more than 76 characters
long
2. CondiLonal

COT256

COT.003.256

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

COT00003

CLAIM-LINERECORD-OT

X(5)

931

935

COT257

COT.003.257

MBESCBESFORM

MBESCBES
Form

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

COT00003

CLAIM-LINERECORD-OT

X(50)

881

930

COT258

COT.003.258

SERVICEFACILITYLOCATION-ORGNPI

Service Facility
LocaLon
OrganizaLon
NPI

CondiLonal Service facility locaLon organizaLon NPI from
X12 837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

936

945

COT259

COT.003.259

SERVICEFACILITYLOCATIONADDR-LN-1

Service Facility
LocaLon
Address Line 1

CondiLonal Service facility locaLon address line 1 from X12
837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

946

1005

1. Value must not be more than 60 characters
long
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols

COT260

COT.003.260

SERVICEFACILITYLOCATIONADDR-LN-2

Service Facility
LocaLon
Address Line 2

CondiLonal Service facility locaLon address line 2 from X12
837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

1006

1065

COT261

COT.003.261

SERVICEFACILITYLOCATION-CITY

Service Facility
LocaLon City

CondiLonal Service facility locaLon address city name from
X12 837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(28)

1066

1093

1. Value must not be more than 28 characters
long
2. CondiLonal

COT262

COT.003.262

SERVICEFACILITYLOCATION-STATE

Service Facility
LocaLon State

CondiLonal Service facility locaLon address state code from
X12 837P loop 2420C and 837D loop 2420D.

STATE

COT00003

CLAIM-LINERECORD-OT

X(2)

1094

1095

1. Value must not be more than 2 characters
2. Value must be in State Code list (VVL)
3. CondiLonal

COT263

COT.003.263

SERVICEFACILITYLOCATION-ZIPCODE

Service Facility
LocaLon ZIP
Code

CondiLonal Service facility locaLon address ZIP code from
X12 837P loop 2420C and 837D loop 2420D.

ZIP-CODE

COT00003

CLAIM-LINERECORD-OT

X(9)

1096

1104

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. CondiLonal

COT264

COT.003.264

PLACE-OFSERVICE

Place of Service

CondiLonal PLACE-OF-SERVICE is a pass-through data
element meaning that the state should report
the ﬁeld in T-MSIS as reported by the provider
on the claims form (i.e., 837P, CMS-1500, or
837D). If the claim is submiaed on the 837p
electronic claims form and the Facility Code
Qualiﬁer is reported with any value other than
“B”, then the PLACE-OF-SERVICE value should be
blank or space-ﬁlled. If the claim is submiaed on
the CMS 1450 (UB04) insLtuLonal claims form,
the PLACE-OF-SERVICE ﬁeld should be blank or
space-ﬁlled. Otherwise, if the claim is submiaed
with the place of service populated with any
value other than the valid values listed in T-MSIS
Data Guide for PLACE-OF-SERVICE values, that
value should sLll be reported in the PLACE-OFSERVICE data element. If the claim is submiaed
by a provider with the place of service ﬁelds
blank, then the PLACE-OF-SERVICE on the TMSIS OT claims ﬁle should be blank or spaceﬁlled.

PLACE-OFSERVICE

COT00003

CLAIM-LINERECORD-OT

X(2)

1105

1106

1. Value must not be more than 2 characters
2. Value must be in Place of Service Code List
(VVL)
3. CondiLonal
4. if value is populated, then Revenue Code
must be null

COT265

COT.003.265

GME-AMOUNTPAID

GME Amount
Paid

CondiLonal The amount included in the Medicaid Amount
(COT.003.178) that is aaributable to a Graduate
Medical EducaLon (GME) payment, when the
state makes GME payments by claim.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

1107

1119

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT266

COT.003.266

REFERRINGPROV-NUM

Referring
Provider
Number

N/A

COT00003

CLAIM-LINERECORD-OT

X(30)

1120

1149

1. Value must be 30 characters or less
2. CondiLonal

COT267

COT.003.267

REFERRINGPROV-NPI-NUM

Referring
Provider NPI
Number

CondiLonal The NaLonal Provider ID (NPI) of the provider
who recommended the servicing provider to the
paLent.

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

1150

1159

1. Value must be 10 digits
2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to "2"
4. Value must exist in the NPPES NPI File

COT268

COT.003.268

REFERRINGPROV-NUM-2

Referring
Provider
Number 2

N/A

COT00003

CLAIM-LINERECORD-OT

X(30)

1160

1189

1. Value must be 30 characters or less
2. CondiLonal

COT269

COT.003.269

REFERRINGPROV-NPI-NUM2

Referring
Provider NPI
Number 2

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

1190

1199

1. Value must be 10 digits
2. CondiLonal
3. Value must have an associated Provider
IdenLﬁer Type equal to "2"
4. Value must exist in the NPPES NPI File
5. Value must not be populated when
Referring Provider NPI Number is not
populated.
6. Value must not equal Referring Provider
NPI Number

COT270

COT.003.270

ORDERINGPROV-NUM

Ordering
Provider
Number

CondiLonal The Medicaid provider ID of the Ordering
Provider is the individual who requested the
services or items being reported on this service
line. Examples include, but are not limited to,
provider ordering diagnosLc tests and medical
equipment or supplies.

N/A

COT00003

CLAIM-LINERECORD-OT

X(30)

1200

1229

1. Value must be 30 characters or less
2. CondiLonal

COT271

COT.003.271

ORDERINGPROV-NPI-NUM

order Provider
NPI Number

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

1230

1239

1. Value must be 10 digits
2. Value must have an associated Provider
IdenLﬁer Type equal to "2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

COT272

COT.003.272

SDP-ALLOWEDAMT

State Directed
Payment
Allowed
Amount

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

1240

1252

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT273

COT.003.273

SDP-PAID-AMT

State Directed
Payment Paid
Amount

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)
V99

1253

1265

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

COT274

COT.004.274

RECORD-ID

Record ID

Mandatory

RECORD-ID

COT00004

CLAIM-DX-OT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "COT00004"

COT275

COT.004.275

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

COT00004

CLAIM-DX-OT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
4. Value must be the same as Submieng
State (COT.001.007)

COT276

COT.004.276

RECORDNUMBER

Record Number

Mandatory

N/A

COT00004

CLAIM-DX-OT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

COT277

COT.004.277

ICN-ORIG

Original ICN

Mandatory

COT278

COT.004.278

ICN-ADJ

Adjustment ICN

COT279

COT.004.279

ADJUSTMENTIND

COT280

COT.004.280

ADJUDICATIONDATE

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

COT00004

CLAIM-DX-OT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

COT00004

CLAIM-DX-OT

X(50)

121

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

COT00004

CLAIM-DX-OT

X(1)

122

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

COT00004

CLAIM-DX-OT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value should be on or before End of Time
Period (COT.001.010)
3. Mandatory
4. Value should be on or afer associated
Admission Date value

COT281

COT.004.281

DIAGNOSIS-TYPE

Diagnosis Type

Mandatory

Indicates the context of the diagnosis code from
the provider's claim (i.e., an 837I claim can have
one principal diagnosis code, up to 12 external
cause of injury diagnosis codes, and up to 24
other diagnosis codes; a UB-04 claim can have
one principal diagnosis code, one admieng
diagnosis code, and up to 17 other diagnosis
codes; an 837P or CMS-1500 claim can have up
to 12 diagnosis codes; an 837D or ADA claim can
have up to 4 diagnosis codes). The type of
diagnosis code (e.g., principal, external cause of
injury, or other) is captured here. The order in
which the diagnosis code was reported is
captured in the Diagnosis Sequence Number.

DIAGNOSISTYPE

COT00004

CLAIM-DX-OT

X(1)

131

1. Value must be 1 character
2. Value must be in Diagnosis Type Code List
(VVL)
3. Value must be in [P,A,E,O]
4. Mandatory

COT282

COT.004.282

DIAGNOSISSEQUENCENUMBER

Diagnosis
Sequence
Number

Mandatory

The order in which the diagnosis occurred on
the provider's claim for a given type of diagnosis
code (e.g., an 837P claim can have up to 12
external cause of injury diagnosis codes and up
to 24 other diagnosis codes).

N/A

COT00004

CLAIM-DX-OT

9(2)

132

133

1. Value must be in [01-24]
2. Mandatory

COT283

COT.004.283

DIAGNOSISCODE-FLAG

Diagnosis Code
Flag

Mandatory

Flag used to idenLfy wither the associated
Diagnosis Code value is a ICD-9 or ICD-10 code.

DIAGNOSISCODE-FLAG

COT00004

CLAIM-DX-OT

X(1)

134

1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List
(VVL)
3. Mandatory

COT284

COT.004.284

DIAGNOSISCODE

Diagnosis Code

Mandatory

COT00004

CLAIM-DX-OT

X(7)

135

141

COT285

COT.004.285

STATE-NOTATION

State NotaLon

SituaLonal

COT287

COT.003.287

DIAGNOSISCODE-POINTER2

Diagnosis Code
Pointer 2

COT288

COT.003.288

DIAGNOSISCODE-POINTER3

COT289

COT.003.289

COT290

COT.003.290

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

COT00004

CLAIM-DX-OT

X(500)

142

641

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

CondiLonal A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

798

799

1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. CondiLonal

Diagnosis Code
Pointer 3

CondiLonal A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

800

801

1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. CondiLonal

DIAGNOSISCODE-POINTER4

Diagnosis Code
Pointer 4

CondiLonal A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

802

803

1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. CondiLonal

MBESCBESFORM-GROUP

MBESCBES
Form Group

MBESCBESFORM-GROUP

COT00003

CLAIM-LINERECORD-OT

X(1)

880

T-MSIS Data Dic,onary – CRX File Changes Between Versions 2.4.0 and 4.0.0

CRX001

CRX.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

CRX00001

FILE-HEADERRECORD-RX

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CRX00001"

DATADICTIONARYVERSION

CRX00001

FILE-HEADERRECORD-RX

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

CRX00001

FILE-HEADERRECORD-RX

X(1)

1.1. Value must be 1 character

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

CRX.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

CRX003

CRX004

CRX.001.003

CRX.001.004

SUBMISSIONTRANSACTIONTYPE

FILE-ENCODINGSPECIFICATION

Submission
TransacLon
Type

File Encoding
SpeciﬁcaLon

Mandatory

2. Value must be in Submission TransacLon
Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

CRX00001

FILE-HEADERRECORD-RX

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

CRX005

CRX.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state

N/A

CRX00001

FILE-HEADERRECORD-RX

X(9)

1. Value must be 9 characters or less
2. Mandatory

submission ﬁle. Use the version number specified
on the title page of the data mapping document.

CRX006

CRX.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

CRX007

CRX008

CRX.001.007

CRX.001.008

SUBMITTINGSTATE

DATE-FILECREATED

Submieng
State

Date File
Created

Mandatory

CRX00001

FILE-HEADERRECORD-RX

X(8)

1. Value must equal 'CLAIM-RX'"CLAIM-RX"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CRX00001

FILE-HEADERRECORD-RX

X(2)

1.1. Value must be 2 characters

The date on which the ﬁle was created.

N/A

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory
CRX00001

FILE-HEADERRECORD-RX

9(8)

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory
CRX009

CRX.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

CRX00001

FILE-HEADERRECORD-RX

9(8)

2. Value must be equal to or earlier than

associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"

CRX010

CRX.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

CRX00001

FILE-HEADERRECORD-RX

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
CRX011

CRX.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

CRX00001

FILE-HEADERRECORD-RX

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
CRX012

CRX.001.012

SSN-INDICATOR

SSN Indicator

Mandatory

SSN-INDICATOR

CRX00001

FILE-HEADERRECORD-RX

X(1)

1.1. Value must be 1 character

2. Value must be in SSN Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

CRX013

CRX.001.013

TOT-REC-CNT

Total Record
Count

Mandatory

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

CRX00001

FILE-HEADERRECORD-RX

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory
CRX014

CRX.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

CRX016

CRX.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CRX00001

FILE-HEADERRECORD-RX

X(500)

582

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

CRX00002

CLAIMHEADERRECORD-RX

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CRX00002"

CRX017

CRX.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CRX00002

CLAIMHEADERRECORD-RX

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (CRX.001.007)
CRX018

CRX.002.018

RECORDNUMBER

Record Number

Mandatory

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(11)

1.1. Value must be 11 digits or less

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

CRX019

CRX.002.019

ICN-ORIG

Original ICN

Mandatory

CRX020

CRX.002.020

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(50)

121

CRX021

CRX.002.021

SUBMITTER-ID

Submiaer ID

Mandatory

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(12)

122

133

1. Value must be 12 characters or less
2. Mandatory

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

CRX022

CRX023

CRX.002.022

CRX.002.023

MSISIDENTIFICATIONNUM

CROSSOVERINDICATOR

MSIS
IdenLﬁcaLon
Number

Crossover
Indicator

Mandatory

Conditional

Mandatory

N/A

An indicator specifying whether the claim is a
crossover claim where a porLon is paid by
Medicare.

CROSSOVERINDICATOR

CRX00002

CLAIMHEADERRECORD-RX

X(20)

134

153

3. The PrescripLon Fill Date (CRX.002.085) on
the claim must fall between Enrollment
Timespan EﬀecLve Date (ELG.021.253) and
Enrollment Timespan End Date (ELG.021.253)

CRX00002

CLAIMHEADERRECORD-RX

X(1)

154

1.1. Value must be 1 character

CRX024

CRX025

CRX.002.024

CRX.002.025

1115ADEMONSTRATIO
N-IND

ADJUSTMENTIND

1115A
DemonstraLon
Indicator

Adjustment
Indicator

1115ADEMONSTRATI
ON-IND

Mandatory

ADJUSTMENTIND

Indicates the type of adjustment record.

CRX00002

CLAIMHEADERRECORD-RX

X(1)

155

1.1. Value must be 1 character

2. Value must be in 1115A DemonstraLon
Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal
4. When value equals '"0'", is invalid or not

populated, then the associated 1115A
DemonstraLon Indicator (ELG.018.2233) must
equal '"0'", is invalid or not populated
CRX00002

CLAIMHEADERRECORD-RX

X(1)

156

1.1. Value must be 1 character

5. If value equals "0", then associated
Adjustment ICN must not be populated
6. Value must equal "1", when associated
Claim Status equals "686"
CRX026

CRX.002.026

ADJUSTMENTREASON-CODE

Adjustment
Reason Code

CondiLonal Claim adjustment reason codes communicate
why a claim was paid diﬀerently than it was
billed. If the amount paid is different from the
amount billed you need an adjustment reason code.

ADJUSTMENTREASON-CODE

CRX00002

CLAIMHEADERRECORD-RX

X(3)

157

159

1.1. Value must be 3 characters or less

2. Value must be in Adjustment Reason Code
List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. Value must not be populated when
associated Adjustment Indicator equals "0"the

total paid amount is diﬀerent from the total
billed amount

CRX027

CRX.002.027

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

160

167

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in(CIP.001.010)
3. Mandatory
4. Value should be on or afer associated TMSIS File Header Record
4. MandatoryAdmission Date value

CRX028

CRX.002.028

MEDICAID-PAIDDATE

Medicaid Paid
Date

Mandatory

The date Medicaid paid this claim or
adjustment. For Encounter Records (Type of
Claim = 3, C, W), the date the managed care
organizaLon paid the provider for the claim or
adjustment.

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

168

175

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Must have an associated Total Medicaid
Paid Amount
43. Mandatory
CRX029

CRX030

CRX.002.029

CRX.002.030

TYPE-OF-CLAIM

CLAIM-STATUS

Type of Claim

Claim Status

Mandatory

A code to indicate what type of payment is
covered in this claim. For sub-capitated
encounters from a sub-capitated enLty or subcapitated network provider, report TYPE-OFCLAIM = '3' for a Medicaid sub-capitated
encounter record or “C” for an S-CHIP subcapitated encounter record.

CondiLonal The health care claim status codes convey the
status of an enLre claim. status codes from the
277 transacLon set. Only report the claim status
for the ﬁnal, adjudicated claim.

TYPE-OF-CLAIM

CLAIM-STATUS

CRX00002

CLAIMHEADERRECORD-RX

X(1)

CLAIMHEADERRECORD-RX

X(3)

176

1.1. Value must be 1 character

2. Value must be in Type of Claim List (VVL)
2. Value must be 1 character
3.3. Mandatory
4. When value equals 'Z', claim denied indicator
must equal '0'

177

179

1.1. Value must be 3 characters or less

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. If value in [ 26, 87, 542,585,654 ],], then
Claim Denied Indicator must be '0'"0" and

Claim Status Category must be "F2"

CRX031

CRX.002.031

CLAIM-STATUSCATEGORY

Claim Status
Category

Mandatory

CLAIM-STATUSCATEGORY

CRX00002

CLAIMHEADERRECORD-RX

X(3)

180

182

1.1. Value must be 3 characters or less

5. Mandatory
CRX032

CRX.002.032

SOURCELOCATION

Source LocaLon

Mandatory

The field denotes the claims payment system from
which the claim was extracted.The ﬁeld denotes

SOURCELOCATION

CRX00002

CLAIMHEADERRECORD-RX

X(2)

183

184

1.1. Value must be 2 characters

2. Value must be in Source LocaLon List (VVL)
2. Value must be 2 characters
3.3. Mandatory

CRX033

CRX.002.033

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(15)

185

199

1. Value must be 15 characters or less
2. Value must have an associated Check
EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

CRX034

CRX.002.034

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

200

207

2. Must have an associated Check Number
53. CondiLonal
CRX035

CRX.002.035

CLAIM-PYMTREM-CODE-1

Claim
PaymentRemiaa

nce Advice
Remark Code 1

CLAIM-PYMTREM-CODE

CRX00002

CLAIMHEADERRECORD-RX

X(5)

208

212

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

Claim Payment Remark Code 1 through Claim
Payment Remark Code 4 is populated on a
claim, all values must be unique

CRX036

CRX037

CRX.002.036

CRX.002.037

CLAIM-PYMTREM-CODE-2

CLAIM-PYMTREM-CODE-3

Claim
PaymentRemiaa

nce Advice
Remark Code 2

Claim
PaymentRemiaa

nce Advice
Remark Code 3

CLAIM-PYMTREM-CODE

CRX00002

CLAIMHEADERRECORD-RX

X(5)

213

217

1.1. Value must be 5 characters or less

2. Value must be in Claim Payment
Remiaance Code List (VVL)
2. Value must be 5 characters or less
3.3. CondiLonal
4. When more than one codeoccurrence of

CRX00002

CLAIMHEADERRECORD-RX

X(5)

218

222

CRX038

CRX039

CRX.002.038

CRX.002.039

CLAIM-PYMTREM-CODE-4

Claim
PaymentRemiaa

TOT-BILLED-AMT

Total Billed
Amount

nce Advice
Remark Code 4

CLAIM-PYMTREM-CODE

CRX00002

CLAIMHEADERRECORD-RX

X(5)

223

227

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

228

240

CRX040

CRX.002.040

TOT-ALLOWEDAMT

Total Allowed
Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

241

253

CRX041

CRX.002.041

TOT-MEDICAIDPAID-AMT

Total Medicaid
Paid Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

254

266

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Must have an associated Medicaid Paid
Date
4. If Total Medicare Coinsurance Amount and
Total Medicare DeducLble Amount is
reported it must equal Total Medicaid Paid
Amount
5. When Payment Level Indicator equals '"2'",
value must equal the sum of line level
Medicaid Paid Amounts.
6. CondiLonal
7. Value must be populated, when Type of
Claim is in [1,A]
8. Value must not be populated or equal to
"0.00" when associated Claim Status is in
[542,585,654]
9. Value must not be greater than Total
Allowed Amount (CRX.002.040)

N/A

CRX00002

CLAIM-HEADERRECORD-RX

S9(11)
V99

267

279

1. Value must be between -99999999999.99 and
99999999999.99
2. Value must be expressed as a number with 2digit precision (e.g. 100.50 )
3. Conditional

CRX042

CRX.002.042

TOT-COPAY-AMT

Total Copayment
Amount

Conditional

The total amount paid by Medicaid/CHIP enrollee
for each office or emergency department visit or
purchase of prescription drugs in addition to the
amount paid by Medicaid/CHIP.

CRX043

CRX.002.043

TOT-MEDICAREDEDUCTIBLEAMT

Total Medicare
DeducLble
Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

2827

280267

2792

CRX044

CRX.002.044

TOT-MEDICARECOINS-AMT

Total Medicare
Coinsurance
Amount

CondiLonal The total amount paid by the Medicaid/CHIP
agency or a managed care plan towards the
porLon of the Medicare allowed charges that
Medicare applied to coinsurance.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

2928

293280

305292

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value is
'0'equals "0" (not a crossover claim), then
value should not be populated.
4. CondiLonal
5. If associated Medicare Combined
DeducLble Indicator is '1',equals "1", then
value must not be populated
6. When populated, value must be less than
or equal to Total Billed Amount

CRX045

CRX.002.045

TOT-TPL-AMT

Total Third Party
LiabilityTPL
Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

3029

306293

318305

CRX047

CRX.002.047

TOT-OTHERINSURANCEAMT

Total Other
Insurance
Amount

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

3130

319306

3318

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX048

CRX.002.048

OTHERINSURANCE-IND

Other Insurance
Indicator

CondiLonal The ﬁeld denotes whether the insured party is
covered under an other insurance plan other
than Medicare or Medicaid.

OTHERINSURANCEIND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

3231

332319

1.1. Value must be 1 character

2. Value must be in Other Insurance Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CRX049

CRX.002.049

OTHER-TPLCOLLECTION

Other TPL
CollecLon

Conditional

CRX050

CRX.002.050

SERVICETRACKING-TYPE

Service Tracking
Type

Conditional

Mandatory

OTHER-TPLCOLLECTION

CRX00002

CLAIMHEADERRECORD-RX

X(3)

3332

333320

335322

1. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. ConditionalMandatory

A code to categorize service tracking claims. A
"service tracking claim" is used to report lump sum
payments that cannot be attributed to a single
enrollee.

SERVICETRACKING-TYPE

CRX00002

CLAIM-HEADERRECORD-RX

X(2)

336

337

CRX051

CRX.002.051

SERVICETRACKINGPAYMENT-AMT

Service Tracking
Payment Amount

Conditional

CRX052

CRX.002.052

FIXED-PAYMENTIND

Fixed Payment
Indicator

CRX053

CRX.002.053

FUNDING-CODE

Funding Code

N/A

CRX00002

CLAIM-HEADERRECORD-RX

S9(11)
V99

338

350

CondiLonal This indicator indicates that the reimbursement
amount included on the claim is for a ﬁxed
payment. Fixed payments are made by the state
to insurers or providers for premiums or eligible
coverage, not for a parLcular service. For
example, some states have Primary Care Case
Management programs where the state pays
providers a monthly paLent management fee of
$3.50 for each eligible parLcipant under their
care. This fee is considered a ﬁxed payment. It is
very important for states to correctly idenLfy
ﬁxed payments. Fixed payments do not have a
deﬁned "medical record".'medical record'
associated with the payment; therefore, ﬁxed
payments are not subject to medical record
request and medical record review.

FIXEDPAYMENT-IND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

3633

351323

1.1. Value must be 1 character

MandatoryC

FUNDINGCODE

ondiLonal

On service tracking claims, the payment amount is
the lump sum that cannot be attributed to any one
beneficiary paid to the provider.

A code to indicate the source of non-federal
share funds.

2. Value must be in Fixed Payment Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CRX00002

CLAIMHEADERRECORD-RX

X(2)

3734

3524

3253

1.1. Value must be 1 character

2. Value must be in Funding Code List (VVL)
2.3. If Type of Claim is not in [3,C,W], then
value must be 1 character
3. Mandatorypopulated
4. CondiLonal

CRX054

CRX055

CRX.002.054

CRX.002.055

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Non-Federal
Share

Not
ApplicableC

PROGRAM-TYPE

Program Type

Mandatory

ondiLonal

FUNDINGSOURCENONFEDERALSHARE

CRX00002

A code to indicate special Medicaid program
under which the service was provided.

PROGRAMTYPE

CRX00002

CLAIMHEADERRECORD-RX

X(2)

CLAIMHEADERRECORD-RX

X(2)

3835

354326

355327

1.1. Value must be 2 characters

2. Value must be in Funding Source NonFederal Share List (VVL)
2.3. If Type of Claim is in [3,C,W], then value
must be 2 characters
3. Requiredpopulated
4. CondiLonal
3936

356328

357329

1.1. Value must be 2 characters

2. Value must be in Program Type List (VVL)
2. Value must be 2 characters
3.3. Mandatory

CRX056

CRX.002.056

PLAN-IDNUMBER

Plan ID Number

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(12)

4037

358330

369341

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal
4. Value must match Managed Care Plan ID
(ELG.014.192)
5. Value must match State Plan ID Number
(MCR.002.019)
6. Value should be populated when Type of
Claim (CRX.002.029) is in [3,C,W, 2, B, V]
7. When Type of Claim (CRX.002.029) in
([3,C,W, 2, B, V)] value must have a Managed
Care Enrollment (ELG.014) for the beneﬁciary
where the PrescripLon Fill Date
(CRX.002.085) occurs between the managed
care plan enrollment eﬀ/end dates
(ELG.014.197/198)
8. When Type of Claim (CRX.002.029) in
([3,C,W, 2, B, V)] value must have a Managed
Care Main Record (MCR.002) for the plan
where the PrescripLon Fill Date
(CRX.002.085) occurs between the managed
care contract eﬀ/end dates
(MCR.002.020/021)

CRX057

CRX.002.057

NATIONALHEALTH-CAREENTITY-ID

National Health
Care Entity ID

Not
Applicable

N/A

CRX00002

CLAIM-HEADERRECORD-RX

X(10)

370

379

1. Not Applicable

CRX058

CRX.002.058

PAYMENT-LEVELIND

Payment Level
Indicator

Mandatory

The field denotes whether the payment amount was
determined at the claim header or line/detail
level.The ﬁeld denotes whether the payment

PAYMENTLEVEL-IND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

4238

380342

1.1. Value must be 1 character

2. Value must be in Payment Level Indicator
List (VVL)
2. Value must be 1 character
3.3. Mandatory

CRX059

CRX.002.059

MEDICAREREIM-TYPE

Medicare
Reimbursement
Type

CondiLonal A code to indicate the type of Medicare
reimbursement.

MEDICAREREIM-TYPE

CRX00002

CLAIMHEADERRECORD-RX

X(2)

4339

381343

382344

1.1. Value must be 2 characters

2. Value must be in Medicare Reimbursement
Type List (VVL)
2. (Crossover Claim) if associated Crossover
Indicator value indicates a crossover claim,3.

Value is mandatory and must be provided
3. Value must be 2 characters

, when Crossover Indicator is equal to "1"

(Crossover Claim)
4. CondiLonal

CRX060

CRX.002.060

CLAIM-LINECOUNT

Claim Line
Count

Mandatory

The total number of lines on the claim.

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(4)

4440

383345

3486

6. Mandatory
CRX061

CRX.002.061

FORCED-CLAIMIND

Forced Claim
Indicator

CondiLonal Indicates if the claim was processed by forcing it
through a manual override process.

FORCEDCLAIM-IND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

4541

387349

1.1. Value must be 1 character

2. Value must be in Forced Claim Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CRX062

CRX.002.062

PATIENTCONTROL-NUM

PaLent Control
Number

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(20)

4642

388350

407369

1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk
symbol
3. CondiLonal

CRX063

CRX.002.063

ELIGIBLE-LASTNAME

Eligible Last
Name

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(30)

4743

408370

437399

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CRX064

CRX.002.064

ELIGIBLE-FIRSTNAME

Eligible First
Name

CondiLonal The ﬁrst name of the individual to whom the
services were provided.(The paLents name
should be captured as it appears on the claim
record, it does not need to be the same as it
appears on the eligibility ﬁle. The MSIS
IdenLﬁcaLon Number will be used to associate
a claim record with the appropriate eligibility
data.)

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(30)

4844

438400

467429

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CRX065

CRX.002.065

ELIGIBLEMIDDLE-INIT

Eligible Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(1)

4945

468430

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
CRX066

CRX.002.066

DATE-OF-BIRTH

Date of Birth

Mandatory

An individual's date of birth.

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

5046

469431

476438

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Mandatory

CRX067

CRX.002.067

HEALTH-HOMEPROV-IND

Health Home
Provider
Indicator

HEALTH-HOMEPROV-IND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

5147

477439

individual's health home provider number, if
applicable, should not report claims that
indicate the claim is submiaed by a provider or
provider group enrolled in the health home
model.
CRX068

CRX.002.068

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which claim
is submiaed.

WAIVER-TYPE

CRX00002

CLAIMHEADERRECORD-RX

X(2)

5248

478440

479441

1.1. Value must be 2 characters

(ELG.012.173) for the enrollee for the same
Lme period (by date of service)
4. Value must have a corresponding value in
Waiver ID (CRX.002.069)
5. CondiLonal
6. Value must be in
[06,07,08,09,10,11,12,13,14,15,16,17,18,19,2
0,33] when associated Program Type equals
"07"

CRX069

CRX070

CRX.002.069

CRX.002.070

WAIVER-ID

BILLING-PROVNUM

Waiver ID

Billing Provider
Number

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(20)

5349

480442

499461

1.1. Value must be 20 characters or less

2. Value must be associated with a populated
Waiver Type
2. Value must be 20 characters or less
3.3. (1115 demonstraLon waivers) If value

CLAIMHEADERRECORD-RX

X(30)

5450

500462

529491

Date (PRV.002.021) or
Prescription Fill6. Discharge Date
(CRXCIP.002.085096) may be between
Provider IdenLﬁer EﬀecLve Date
(PRV.005.079) and Provider IdenLﬁer End
Date (PRV.005.080)

CRX071

CRX.002.071

BILLING-PROVNPI-NUM

Billing Provider
NPI Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(10)

5551

530492

539501

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal
45. When Type of Claim not in ('3','C','W')
thenpopulated, value must match Provider
IdenLﬁer (PRV.005.081) and Facility Group
Individual Code (PRV.002.081)028) must equal
"01"
6. NPPES EnLty Type Code associated with
this NPI must equal "2" (OrganizaLon)

NaLonal Provider ID (NPI) of the billing provider
responsible for billing for the service on the
claim. The billing provider can also be servicing,
referring, or prescribing provider; can be
admieng provider except for Long Term Care.

CRX072

CRX.002.072

BILLING-PROVTAXONOMY

Billing Provider
Taxonomy

CondiLonal The taxonomy code for the provider billing for
the service.

1. Value must be 10 digits, consisting of 9

PROVTAXONOMY

CRX00002

CLAIMHEADERRECORD-RX

X(12)

5652

5402

5513

1.1. Value must be 12 characters or less

2. Value must be in Provider Taxonomy List
(VVL)
2. Value must be 12 characters or less
3.3. CondiLonal

CRX073

CRX.002.073

BILLING-PROVSPECIALTY

Billing Provider
Specialty

CondiLonal This code describes the area of specialty for the
provider being reported.

PROVSPECIALTY

CRX00002

CLAIMHEADERRECORD-RX

X(2)

5753

552514

5153

1.1. Value must be 2 characters

2. Value must be in Provider Specialty List
(VVL).
2. Value must be 2 characters

)
3. CondiLonal
CRX074

CRX075

CRX.002.074

CRX.002.075

PRESCRIBINGPROV-NUM

PRESCRIBINGPROV-NPI-NUM

Prescribing
Provider
Number

Mandatory

Prescribing
Provider NPI
Number

Mandatory

A unique idenLﬁcaLon number assigned by the
state to the provider who prescribed the drug,
device, or supply. This must be the individual's
ID number, not a group idenLﬁcaLon number. If
the prescribing physician provider ID is not
available, but the physician's Drug Enforcement
Agency (DEA) ID is on the state ﬁle, then the
State should use the DEA ID for this data
element

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(30)

CLAIMHEADERRECORD-RX

X(10)

5854

554516

583545

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. Mandatory

5955

5846

593555

1. Value must be 10 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type equal to '2'"2"
3. Mandatory
4. Value must exist in the NPPES NPI data ﬁle
5. NPPES EnLty Type Code associate with this
NPI must equal ‘1’ (Individual)

NaLonal Provider ID (NPI) of the provider who
prescribed a medicaLon to a paLent.

CRX076

CRX.002.076

PRESCRIBINGPROV-TAXONOMY

Prescribing
Provider
Taxonomy

Not
Applicable

N/A

CRX00002

CLAIM-HEADERRECORD-RX

X(12)

594

605

1. Not Applicable

CRX077

CRX.002.077

PRESCRIBINGPROV-TYPE

Prescribing
Provider Type

Not
Applicable

PRESCRIPTIONORIGIN-CODE

CRX00002

CLAIM-HEADERRECORD-RX

X(2)

606

607

1. Not Applicable

CRX078

CRX.002.078

PRESCRIBINGPROV-SPECIALTY

Prescribing
Provider Specialty

Not
Applicable

CRX079

CRX.002.079

MEDICARE-HICNUM

Medicare HIC
Number

CRX081

CRX.002.081

REMITTANCENUM

Remiaance
Number

N/A

CRX00002

CLAIM-HEADERRECORD-RX

X(2)

608

609

1. Not Applicable

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(12)

6356

610556

621567

1. Conditional
2. Value must be 12 characters or less
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols
4. (Not Dual Eligible) if Dual Eligible Code
(ELG.DE.085) value =equals "00", then value
must not be populated.
5. Value must be populated when Crossover
Indicator (CRX.002.023) equals '1'"1" and
Medicare Beneﬁciary IdenLﬁer (CRX.002.105)
mustis not be populated.

Mandatory

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(30)

6457

622568

651597

1. Value must be 30 characters or less
2. First five (5) characters of the value must be a

Julian date express in the form YYDDD (e.g.
19095, 95th day of 20(19))
3. Value must not contain a pipe or asterisk

symbols
43. Mandatory

number.

CRX082

CRX.002.082

BORDER-STATEIND

Border State
Indicator

BORDER-STATEIND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

6558

652598

1.1. Value must be 1 character

2. Value must be in Border State Indicator List
(VVL)
2. Value must be 1 character
3.3. CondiLonal

CRX084

CRX085

CRX.002.084

CRX.002.085

DATEPRESCRIBED

PRESCRIPTIONFILL-DATE

Date Prescribed

PrescripLon Fill
Date

Mandatory

The date the drug, device, or supply was
prescribed by the physician or other
pracLLoner. This should not be confused with
the PrescripLon-FILL- Fill Date, which represents
the date the prescripLon was actually ﬁlled by
the provider.

N/A

Date the drug, device, or supply was dispensed
by the provider. see Date (DT.001)

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

6659

653599

6606

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be on or afer associated
eligible party's Date of Birth (ELG.002.024)
43. Value must be on or before associated
PrescripLon Fill Date (CRX.002.085)
54. Value must be on or before associated
AdjudicaLon Date (CRX.002.027)
65. Value must be on or before associated
eligible party's Date of Death (ELG.002.025)
76. Mandatory
87. Value should be on or before End of Time
Period (CRX.001.010)
CRX00002

CLAIMHEADERRECORD-RX

9(8)

6760

661607

668614

1. Value must be 8 characters in the form
"CCYYMMDD"
2.1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. Value must be on or before associated End
of Time Period (CRX.001.010)
43. Value must be on or afer associated Start
of Time Period (CRX.001.009)
54. Value must be on or afer associated Date
Prescribed (CRX.002.084)
65. Value must be on or afer associated
eligible party's Date of Birth (ELG.002.024)
76. Value must be on or before associated
eligible party's Date of Death (ELG.002.025)
87. Value must be populated when
Adjustment Indicator (CRX.002.025) does not
equal '1' and Type of Claim (CRX.002.029) does
not equal 'Z'

9."1"

8. Mandatory

CRX086

CRX.002.086

COMPOUNDDRUG-IND

Compound
Drug Indicator

CondiLonal Indicator to specify if the drug is compound or
not. see Compound Drug Indicator List (VVL.038)

COMPOUNDDRUG-IND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

6861

669615

1.1. Value must be 1 character

2. Value must be in Compound Drug Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CRX087

CRX088

CRX.002.087

CRX.002.088

TOTBENEFICIARYCOINSURANCEPAID-AMOUNT

BENEFICIARYCOINSURANCEDATE-PAID

Total
Beneﬁciary
Coinsurance
Paid Amount

Beneﬁciary
Coinsurance
Date Paid

N/A

CondiLonal The date the beneﬁciary paid the coinsurance
amount.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

6962

670616

6828

CRX00002

CLAIMHEADERRECORD-RX

9(8)

7263

704629

711636

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Coinsurance Amount
43. CondiLonal

CRX089

CRX090

CRX.002.089

CRX.002.090

TOTBENEFICIARYCOPAYMENTPAID-AMOUNT

BENEFICIARYCOPAYMENTDATE-PAID

Total
Beneﬁciary
Copayment Paid
Amount

Beneﬁciary
Copayment
Date Paid

N/A

CondiLonal The date the beneﬁciary paid the copayment
amount.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

7064

6837

6495

CRX00002

CLAIMHEADERRECORD-RX

9(8)

7165

696650

703657

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. When populated, value must have an
associated Beneﬁciary Copayment Amount
43. CondiLonal
CRX092

CRX093

CRX.002.092

CRX.002.093

TOTBENEFICIARYDEDUCTIBLEPAID-AMOUNT

BENEFICIARYDEDUCTIBLEDATE-PAID

Total
Beneﬁciary
DeducLble Paid
Amount

Beneﬁciary
DeducLble Date
Paid

N/A

CondiLonal The date the beneﬁciary paid the deducLble
amount.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

7366

712658

724670

CRX00002

CLAIMHEADERRECORD-RX

9(8)

7467

725671

732678

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. When populated, value must have an

associated Beneﬁciary DeducLble Date Paid
4Amount
3. CondiLonal

CRX094

CRX.002.094

CLAIM-DENIEDINDICATOR

Claim Denied
Indicator

Mandatory

An indicator to idenLfy a claim that the state
refused pay in its enLrety.

CLAIM-DENIEDINDICATOR

CRX00002

CLAIMHEADERRECORD-RX

X(1)

7568

733679

1.1. Value must be 1 character

2. Value must be in Claim Denied Indicator
List (VVL)
23. If value is '0',equals "0", then Claim Status
Category must equal "F2"
3. Value must be 1 character
4.4. Mandatory

CRX095

CRX096

CRX.002.095

CRX.002.096

COPAY-WAIVEDIND

HEALTH-HOMEENTITY-NAME

Copayment
Waived
Indicator

Health Home
EnLty Name

OpSituaLo

nal

COPAYWAIVED-IND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

7669

734680

1.1. Value must be 1 character

2. Value must be in Copay Waived Indicator
List (VVL)
2. Value must be 1 character
3. Optional3. SituaLonal

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(50)

7770

735681

784730

1. Value must 50 characters or less
2.1. Value must not contain a pipe or asterisk

symbols
2. Value must 50 characters or less
3. CondiLonal

CRX098

CRX099

CRX.002.098

CRX.002.099

THIRD-PARTYCOINSURANCEAMOUNT-PAID

Third Party
Coinsurance
Amount Paid

CondSituaL

THIRD-PARTYCOINSURANCEDATE-PAID

Third Party
Coinsurance
Date Paid

CondiLonal The date a Third Partythe third party paid the
coinsurance amount was paid on this claim or

onal

The amount of money paid by a third party on
behalf of the beneﬁciary towards coinsurance.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

7871

785731

797743

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondSituaLonal

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

7972

798744

805751

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

adjustment.

2. When populated, value must have an
associated Third Party Coinsurance Amount
3. CondiLonal
CRX100

CRX101

CRX.002.100

CRX.002.101

THIRD-PARTYCOPAYMENTAMOUNT-PAID

Third Party
Copayment
Amount Paid

OpSituaLo

THIRD-PARTYCOPAYMENTDATE-PAID

Third Party
Copayment
Date Paid

OpSituaLo

nal

The amount of money paid by a third -party on
behalf of the beneﬁciary paid towards a
copayment.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

8073

806752

818764

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. OpSituaLonal

The date a Third Partythe third party paid the
copayment amount was paid on a claim or
adjustment.

N/A

CRX00002

CLAIMHEADERRECORD-RX

9(8)

8174

819765

826772

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

2. When populated, value must have an
associated Third Party Copayment Amount
3. OpSituaLonal

CRX102

CRX.002.102

DISPENSINGPRESCRIPTIONDRUG-PROV-NPI

Dispensing
PrescripLon
Drug Provider
NPI Number

Mandatory

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(10)

8275

827773

836782

1. Value must be 10 digits, consisting of 9
numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer Type (PRV.005.007) equal to '2'
3. When Type of Claim not in
('3','C','W')[3,C,W], then value must match
Provider IdenLﬁer (PRV.005.081)
4. Mandatory
5. Value must exist in the NPPES NPI data ﬁle
6. NPPES EnLty Type Code associate with this
NPI must equal "1" (Individual)

NaLonal Provider ID (NPI) of the provider
responsible for dispensing the prescripLon drug.

CRX103

CRX.002.103

DISPENSINGPRESCRIPTIONDRUG-PROVTAXONOMY

Dispensing
Prescription Drug
Provider
Taxonomy

Not
Applicable

N/A

CRX00002

CLAIM-HEADERRECORD-RX

X(12)

837

848

1. Not Applicable

CRX104

CRX.002.104

HEALTH-HOMEPROVIDER-NPI

Health Home
Provider NPI
Number

CondiLonal A National Provider Identifier (NPI) is a unique 10-

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(10)

8476

849783

858792

1. Value must be 10 digits, consisting of 9

NaLonal Provider ID (NPI) of the health home
provider.

numeric digits followed by one check digit
calculated using the Luhn formula (algorithm)
2.

2. Value must have an associated Provider
IdenLﬁer, where Provider IdenLﬁer Type
equal to '2'(PRV.005.077) equals "2"
3. Value must exist in the NPPES NPI data ﬁle
4. CondiLonal

CRX105

CRX.002.105

MEDICAREBENEFICIARYIDENTIFIER

Medicare
Beneﬁciary
IdenLﬁer

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(12)

8577

859793

8704

CRX106

CRX.002.106

STATE-NOTATION

State NotaLon

OpSituaLo

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(500)

8692

871998

134970

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

CRX108

CRX.003.108

RECORD-ID

Record ID

Mandatory

RECORD-ID

CRX00003

CLAIM-LINERECORD-RX

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "CRX00003"

STATE

CRX00003

CLAIM-LINERECORD-RX

X(2)

1.1. Value must be 2 characters

CRX.003.109

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (CRX.001.007)
CRX110

CRX.003.110

RECORDNUMBER

Record Number

Mandatory

N/A

CRX00003

CLAIM-LINERECORD-RX

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

CRX111

CRX.003.111

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CRX00003

CLAIM-LINERECORD-RX

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

N/A

CRX00003

CLAIM-LINERECORD-RX

X(50)

141

CRX112

CRX.003.112

ICN-ORIG

Original ICN

Mandatory

CRX113

CRX.003.113

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

CRX00003

CLAIM-LINERECORD-RX

X(20)

1. Mandatory
2. For SSN States (i.e. SSN Indicator = 1), value
must be equal to eligible individual's SSN
3. For Non-SSN States (i.e. SSN Indicator = 0),
value must not be equal to eligible individual's
SSN
4. Value must be 20 characters or less
5. When TYPE-OF-CLAIM = 4, D or X (lump sum
payment), value must begin with an '&'1. Value

must be 20 characters or less
2. Mandatory

CRX114

CRX.003.114

LINE-NUM-ORIG

Original Line
Number

Mandatory

A unique number to idenLfy the transacLon line
number that is being reported on the original
claim.

N/A

CRX00003

CLAIM-LINERECORD-RX

X(3)

142

144

1. Value must be 3 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory
4. When populated, Value must be one or
greater

CRX115

CRX.003.115

LINE-NUM-ADJ

Adjustment Line
Number

CondiLonal A unique number to idenLfy the transacLon line
number that idenLﬁes the line number on the
adjustment claim.

N/A

CRX00003

CLAIM-LINERECORD-RX

X(3)

145

147

1. Value of the CC component must be "20"3
characters or less
2. If associated Line Adjustment Indicator
value equals "0", then value must not be 8
characters in the form "CCYYMMDD"
3. The datepopulated

3. If associated Line Adjustment Indicator
value equals "1", then value is mandatory
and must be a valid calendar date (i.e. Feb 29th
only on the leap year, never April 31st or Sept
31st)provided

4. CondiLonal
5. When populated, value must be equal
toone or after the value of associated End of
Time Period
5. Mandatorygreater

CRX116

CRX.003.116

LINEADJUSTMENTIND

Line Adjustment
Indicator

CondiLonal A code to indicate the type of adjustment record
claim/encounter represents at claim detail level.

LINEADJUSTMENTIND

CRX00003

CLAIM-LINERECORD-RX

X(1)

148

1.1. Value must be 1 character

4. CondiLonal
65. If associated Line Adjustment Number is
populated, then value must be populated

CRX117

CRX.003.117

LINEADJUSTMENTREASON-CODE

Line Adjustment CondiLonal Claim adjustment reason codes communicate
Reason Code
why a service line was paid diﬀerently than it
was billed.

LINEADJUSTMENTREASON-CODE

CRX00003

CLAIM-LINERECORD-RX

X(3)

149

151

1.1. Value must be 3 characters or less

2. Value must be in Line Adjustment Reason
Code List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal
4. When populated, Line Adjustment
IndicatorValue must be populated when the

total paid amount is diﬀerent from the total
billed amount
CRX118

CRX.003.118

SUBMITTER-ID

Submiaer ID

Mandatory

CRX119

CRX.003.119

CLAIM-LINESTATUS

Claim Line
Status

CRX120

CRX.003.120

NATIONALDRUG-CODE

NaLonal Drug
Code

The Submiaer IdenLﬁcaLon number is the value
that idenLﬁes the provider/trading
partner/clearing house organizaLon to the
state's claim adjudicaLon system.

N/A

CRX00003

CLAIM-LINERECORD-RX

X(12)

152

163

1. Value must be 12 characters or less
2. Mandatory

CLAIM-STATUS

CRX00003

CLAIM-LINERECORD-RX

X(3)

164

166

1.1. Value must be 3 characters or less

Mandatory

N/A

A code following the NaLonal Drug Code format
indicaLng the drug, device, or medical supply
covered by this claim.

2. Value must be in Claim Status List (VVL)
2. Value must be 3 characters or less
3.3. CondiLonal

4. If value in [545,585,654], then Claim
Denied Indicator must be "0" and Claim
Status Category must be"F2"
CRX00003

CLAIM-LINERECORD-RX

X(12)

167

178

Decimal QuanLty (CRX.003.144)
85. Value must have an associated Unit of
Measure (CRX.003.133)

CRX121

CRX.003.121

BILLED-AMT

Billed Amount

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

179

191

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX122

CRX.003.122

ALLOWED-AMT

Allowed
Amount

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

192

204

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX00003

CLAIM-LINERECORD-RX

S9(5)V
99

205

211

1. Value must be 5 digits or less left of the
decimal i.e. 99999between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX.003.123

COPAYAMTBENEFICIAR

Y-COPAYMENTPAID-AMOUNT

Beneﬁciary
Copayment Paid
Amount

CondiLonal The copayment amount paid by an enrollee for the

service, which does not include the amount paid by
the insurance company.The amount the

N/A

copayment paid amount in the header level
copayment data element.

CRX124

CRX.003.124

TPL-AMT

Third Party
CondiLonal Third-party liability refers to the legal obligaLon
Liability Amount
of third parLes, i.e., certain individuals, enLLes,
or programs, to pay all or part of the
expenditures for medical assistance furnished
under a state plan. This is the total amount
denoted at the claim detail level paid by the
third party.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

212

224

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX125

CRX.003.125

MEDICAID-PAIDAMT

Medicaid Paid
Amount

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

225

237

CondiLonal The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For claims
where Medicaid payment is only available at the
header level, report the entire payment amount on
the T-MSIS record corresponding to the line item
with the highest charge or the 1st detail. Zero fill
Medicaid Amount Paid on all other MSIS records
created from the original claim.For sub-capitated

capitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report a
null value in this ﬁeld.

CRX126

CRX.003.126

MEDICAID-FFSEQUIVALENTAMT

Medicaid FFS
Equivalent
Amount

CondiLonal The amount that would have been paid had the
services been provided on a Fee for Service
basis.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

238

250

CRX127

CRX.003.127

MEDICAREDEDUCTIBLEAMT

Medicare
DeducLble
Amount

CondiLonal The amount paid by Medicaid/CHIP on this
claim at the claim line level toward the
beneﬁciary's Medicare deducLble. If the
Medicare deducLble amount can be idenLﬁed
separately from Medicare coinsurance
payments, code that amount in this ﬁeld. If the
Medicare coinsurance and deducLble payments
cannot be separated, ﬁll this ﬁeld with the
combined payment amount and MedicareCOINSURANCE- Coinsurance Payment is not
required.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

251

263

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50 )
3. Conditional)
3. CondiLonal
4. Value should not be populated if
associated Crossover Indicator value equals
"0" (not a crossover claim)
5. If value is greater than "0", then Crossover
Indicator must be "1"

CRX128

CRX.003.128

MEDICARECOINS-AMT

Medicare
Coinsurance
Amount

CondiLonal The amount paid by Medicaid/CHIP on this
claim toward the recipient's Medicare
coinsurance at the claim detail level. If the
Medicare coinsurance amount can be idenLﬁed
separately from Medicare deducLble payments,
code that amount in this ﬁeld. If Medicare
coinsurance and deducLble payments cannot be
separated, populate the Medicare-DEDUCTIBLEAMT. See US Dollar DeducLble Amount (DT).

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

264

276

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. (payments can't be separated)If associated
Medicare Combined DeducLble Indicator
equals "1", then value must not be populated
(or must be 99998 is an exception to the US
Dollar)
4. Value must not be populated if Medicare
DeducLble Amount requirements
4. is not populated
5. CondiLonal

CRX129

CRX.003.129

MEDICARE-PAIDAMT

Medicare Paid
Amount

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

277

289

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value
isequals "0", then the Medicare Paid Amount
value must not be populated.
4. CondiLonal
5. If value is populated, Crossover Indicator
must be equal to "1"

CRX131

CRX.003.131

OT-RXCLAIMPRESCRIPT

OT RX
ClaimPrescripLo

N/A

CRX00003

S9(6)V9
999)V(
9)

290

298307

n QuanLty
Allowed

CLAIM-LINERECORD-RX

ION-QUANTITYALLOWED

CondiLonal The maximum allowable quanLty of a drug or
service that may be dispensed per prescripLon
per date of service or per month. QuanLty limits
are applied to medicaLons when the majority of
appropriate clinical uLlizaLons will be addressed
within the quanLty allowed. For use with
CLAIMRX claims/encounters. For CLAIMOT
claims/encounters, use the Service QuanLty
Allowed ﬁeld. For CLAIMIP and CLAIMLT
claims/encounters, use the Revenue Center
QuanLty Actual ﬁeld. One prescripLon for 100

1. Value may include up to 69 digits to the lef
of the decimal point, and 39 digits to the right
e.g. 123456.789123456789.123456789
2. CondiLonal
3. If Type of Claim is in [1, 3, A, C, U, W], then this
value must be reported.

250 milligram tablets results in PrescripLon
QuanLty Allowed =100.

CRX132

CRX.003.132

OT-RXCLAIMPRESCRIPT

OT RX
ClaimPrescripLo

ION-QUANTITYACTUAL

n QuanLty
Actual

Conditional

Mandatory

The quantity of a drug, service, or product that is
rendered/dispensed for a prescription, specific date
of service, or billing time span. This field is only
applicable when the service being billed can be
quantified in discrete units, e.g., a number of visits or
the number of units of a prescription/refill that were
filled. For prescriptions/refills, use the Medicaid Drug
Rebate definition of a unit, which is the smallest unit
by which the drug is normally measured; e.g. tablet,
capsule, milliliter, etc. For drugs not identifiable or
dispensed by a normal unit, e.g. powder filled vials,
use 1 as the number of units.The quanLty of a

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(6)V9
999)V(
9)

299308

307325

1. Value may include up to 69 digits to the
lef of the decimal point, and 39 digits to the
right e.g. 123456.789123456789.123456789
2. Conditional
3. If Type of Claim is in [1, 3, A, C, U, W], then this
value must be reported.
4. When populated, corresponding Unit of
Measure must be populatedMandatory

drug that is dispensed for a prescripLon as
reported by NaLonal Drug Code on the claim
line. For use with CLAIMRX claims/encounters.
For CLAIMOT claims/encounters, use the Service
QuanLty Actual ﬁeld. For CLAIMIP and CLAIMLT
claims/encounter records, use the Revenue
Center QuanLty Actual ﬁeld.
CRX133

CRX.003.133

UNIT-OFMEASURE

Unit of Measure

Conditional

Mandatory

A code to indicate the basis by which the
quanLty of the drug or supply is expressed.

NDC-UNIT-OFMEASURE

CRX00003

CLAIM-LINERECORD-RX

X(2)

308326

309327

1. Value must be 2 characters
2. Value must be in NDC Unit of Measure List
(VVL).
2. Value must be 2 characters

)
3. ConditionalMandatory
CRX134

CRX.003.134

TYPE-OFSERVICE

Type of Service

Mandatory

A code to categorize the services provided to a
Medicaid or CHIP enrollee.

CRX135

CRX.003.135

HCBS-SERVICECODE

HCBS Service
Code

TYPE-OFSERVICE-RX

CRX00003

CLAIM-LINERECORD-RX

X(3)

310328

312330

1. Value must be 3 characters
2. Mandatory
3. Value must satisfy the requirements ofbe in
Type of Service (RX Claim) List (VVL)

HCBS-SERVICECODE

CRX00003

CLAIM-LINERECORD-RX

X(1)

3131

1.1. Value must be 1 character

2. Value must be in HCBS Service Code List
(VVL).
2. Value must be 1 character

)
3. If value is in [1-7,], then HCBS Taxonomy
must be populated.
4. CondiLonal

CRX136

CRX.003.136

HCBSTAXONOMY

HCBS Taxonomy

CondiLonal A code to classify the home and community based
services listed on the claim into the HCBS
taxonomy.A code to classify the home and

HCBSTAXONOMY

CRX00003

CLAIM-LINERECORD-RX

X(5)

314332

318336

1.1. Value must be 5 characters or less

2. Value must be in HCBS Taxonomy Code List
(VVL).
2. Value must be 5 characters or less

)
3. CondiLonal

CRX137

CRX.003.137

OTHER-TPLCOLLECTION

Other TPL
CollecLon

Conditional

Mandatory

OTHER-TPLCOLLECTION

CRX00003

CLAIM-LINERECORD-RX

X(3)

319337

321339

1.1. Value must be 3 characters

2. Value must be in Other TPL CollecLon List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

CRX138

CRX.003.138

DAYS-SUPPLY

Days Supply

Mandatory

Number of days supply dispensed.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(5)

322340

326344

1. Value must be 5 digits or less
2. Mandatory
3. Value should be between -365 and 365

CRX139

CRX.003.139

NEW-REFILL-IND

New Reﬁll
Indicator

Mandatory

Indicator showing whether the prescripLon
being ﬁlled was a new prescripLon or a reﬁll. If
it is a reﬁll, the indicator will indicate the
number of reﬁlls.

NEW-REFILLIND

CRX00003

CLAIM-LINERECORD-RX

X(2)

327345

328346

1.1. Value must be 2 characters

2. Value must be in New Reﬁll Indicator List
(VVL)
2. Value must be 2 characters
3.3. Mandatory

CRX140

CRX.003.140

BRANDGENERIC-IND

Brand Generic
Indicator

Mandatory

Indicates whether the drug is a brand name,
generic, single-source, or mulL-source drug.

BRANDGENERIC-IND

CRX00003

CLAIM-LINERECORD-RX

X(1)

329347

1. Value must be 1 character
2. Value must be in Brand Generic Indicator
List (VVL)
3. Mandatory

CRX141

CRX.003.141

DISPENSE-FEESUBMITTED

Dispense Fee
Submiaed

Mandatory

The charge to cover the cost of dispensing the
prescription. Dispensing costs include overhead,
supplies, and labor, etc. to fill the prescription.
Dispense Fee reflects the amount billed by the
provider towards the professional dispensing fee.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(6)V
99

330348

337355

1.1. Value must be between -

CLAIM-LINERECORD-RX

X(12)

99999999999.99 and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Value may include up to 6 digits to the lef
of the decimal point, and 32 digits to the right
e.g. 123456.789
278
4. Mandatory

If the provider does not break out the professional
dispensing fee on the NCPDP transaction, this field
should be left blank in T-MSIS.
There is currently no specific field in T-MSIS to
capture either the professional dispensing fee
amount paid, or the amount billed or paid towards
ingredient costs.The charge to cover the cost of

the professional dispensing fee for the
prescripLon.
CRX142

CRX.003.142

PRESCRIPTIONNUM

PrescripLon
Number

Mandatory

The unique idenLﬁcaLon number assigned by
the pharmacy or supplier to the prescripLon.

N/A

CRX00003

338356

349367

1.1. Value must be 12 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 12 characters or less
3.3. Mandatory

CRX143

CRX.003.143

DRUGUTILIZATIONCODE

Drug ULlizaLon
Code

Mandatory

A code indicaLng the conﬂict, intervenLon and
outcome of a prescripLon presented for
fulﬁllment. The T-MSIS Drug ULlizaLon Code
data element is composite ﬁeld comprised of
three disLnct NCPDP data elements: "'Reason
for Service Code"' (439-E4); "'Professional
Service Code" (44Code' (440-E5); and "'Result of
Service Code"' (441-E6). All 3 of these NCPDP
ﬁelds are situaLonally required and
independent of one another. Pharmacists may
report none, one, two or all three. NCPDP
situaLonal rules call for one or more of these
values in situaLons where the ﬁeld(s) could
result in diﬀerent coverage, pricing, paLent
ﬁnancial responsibility, drug uLlizaLon review
outcome, or if the informaLon aﬀects payment
for, or documentaLon of, professional pharmacy
service. The NCPDP "Results'Reasons of Service
Code"' (bytes 1 &and 2 of the T-MSIS DRUG
Utilization -UTILIZATION-CODE) explains whether
the pharmacist ﬁlled the prescripLon, ﬁlled part
of the prescripLon, etc. The NCPDP
"'Professional Service Code"' (bytes 3 &and 4 of
the T-MSIS Drug ULlizaLon Code) describes
what the pharmacist did for the paLent. The
NCPDP "'Result of Service Code"' (bytes 5 &and
6 of the T-MSIS Drug ULlizaLon Code) describes
the acLon the pharmacist took in response to a
conﬂict or the result of a pharmacist's
professional service. Because the T-MSIS Drug
ULlizaLon Code data element is a composite
ﬁeld, it is necessary for the state to populate all
six bytes if any of the three NCPDP ﬁelds has a
value. In such situaLons, use 'spaces' as
placeholders for not applicable codes.
see Drug Utilization Professional Service Code List

DRUGUTILIZATIONCODE-E4,
DRUGUTILIZATIONCODE-E5,
DRUGUTILIZATIONCODE-E6

CRX00003

CLAIM-LINERECORD-RX

X(6)

350368

355373

1. Value must be 6 characters or less
2. Characters 1 and 2 (2-character string)
maymust be in Drug ULlizaLon Result
ofReason for Service Code List (VVL), or spaces
in cases where code is unused or not available
3.)

3. Characters 3 and 4 (2-character string)
maymust be in Drug ULlizaLon Professional
Service Code List (VVL), or spaces in cases
where code is unused or not available
4.)

4. Characters 5 and 6 (2-character string)
maymust be in Drug ULlizaLon Reason
ForResult of Service Code List (VVL), or not
populated in cases where code is unused or not
available)

5. Mandatory

(VVL.044)
see Drug Utilization Reason For Service Code List
(VVL.045)
see Drug Utilization Result of Service Code List
(VVL.046)

CRX144

CRX.003.144

DTL-METRICDEC-QTY

Metric Decimal
QuanLty

CondiLonal Metric decimal quanLty of the product with the
appropriate unit of measure (each, gram, or
milliliter).

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(7)V
999

356374

365383

1. Value must be numeric
2. Value may include up to 7 digits to the lef
of the decimal point, and 3 digits to the right,
e.g. 1234567.890
3. Value must be populated when Compound
Drug Indicator (CRX.002.086) equals "1"
4. CondiLonal

CRX145

CRX.003.145

COMPOUNDDOSAGE-FORM

Compound
Dosage Form

CondiLonal The physical form of a dose of medicaLon, such
as a capsule or injecLon. see Compound Dosage

COMPOUNDDOSAGE-FORM

CRX00003

CLAIM-LINERECORD-RX

X(2)

366384

367385

1.1. Value must be 2 characters

2. Value must be in Compound Dosage Form
List (VVL)

Form List (VVL.037)

2. Value must be 2 characters
3.3. CondiLonal

CRX146

CRX.003.146

REBATEELIGIBLEINDICATOR

Rebate Eligible
Indicator

CondiLonal An indicator to idenLfy claim lines with an NDC
that is eligible for the drug rebate program.

REBATEELIGIBLEINDICATOR

CRX00003

CLAIM-LINERECORD-RX

X(1)

3686

1.1. Value must be 1 character

2. Value must be in Rebate Eligible Indicator
List (VVL)
2. Value must be 1 character
3.3. CondiLonal

CRX147

CRX.003.147

IMMUNIZATIONTYPE

Immunization
Type

Not
Applicable

N/A

CRX00003

CLAIM-LINERECORD-RX

X(2)

369

370

1. Not Applicable

CRX148

CRX.003.148

BENEFIT-TYPE

Benefit Type

Mandatory

BENEFIT-TYPE

CRX00003

CLAIM-LINERECORD-RX

X(3)

371

373

1. Value must be in Benefit Type Code List (VVL)
2. Value must be 3 characters
3. Mandatory

CRX149

CRX.003.149

CMS-64-

CMS 64 Category

CondiLonal A code to indicate the Federal funding source
for the payment.

CMS-64-

CRX00003

CLAIM-LINERECORD-RX

X(2)

4139

3874

375388

1. Value must be 2 characters
2. Value must be in CMS 64 Category for
Federal Reimbursement List (VVL)

CATEGORY-FORFEDERALREIMBURSEMEN
T

for Federal
Reimbursement

CATEGORYFOR-FEDERALREIMBURSEME
NT

2. Value must be 2 characters
3.3. (Federal Funding under Title XXI) if value
equals '"02'", then the eligible's CHIP Code
(ELG.003.054) must be in ['2', '3'2,3]

corresponding claim header, then value must
be reported.
7. If Type of Claim is in ['4','D'] and the Service
Tracking Payment Amount on the relevant record
is populated, then value must be reported.

CRX150

CRX.003.150

XIX-MBESCBESCATEGORY-OFSERVICE

XIX MBESCBES
Category of
Service

Conditional

XIX-MBESCBESCATEGORY-OFSERVICE

CRX00003

CLAIM-LINERECORD-RX

X(4)

376

379

CRX151

CRX.003.151

XXI-MBESCBESCATEGORY-OFSERVICE

XXI MBESCBES
Category of
Service

Conditional

XXI-MBESCBESCATEGORY-OFSERVICE

CRX00003

CLAIM-LINERECORD-RX

X(3)

380

382

CRX152

CRX.003.152

OTHERINSURANCEAMT

Other Insurance
Amount

CondiLonal The amount paid by insurance other than
Medicare or Medicaid on this claim.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

4440

3839

395401

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX153

CRX.003.153

STATE-NOTATION

State NotaLon

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CRX00003

CLAIM-LINERECORD-RX

X(500)

4568

396694

895119

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

N/A

FILE-HEADERRECORD-RX

X(4)

The state-speciﬁc provider id of the provider
who actually dispensed the prescripLon
medicaLon.

N/A

nal

CRX155

CRX156

CRX.001.155

CRX.002.156

SEQUENCENUMBER

DISPENSINGPRESCRIPTIONDRUG-PROVNUM

Sequence
Number

Dispensing
PrescripLon
Drug Provider
Number

Mandatory

CRX00001

1.1. Value must be 4 characters or less

5. Mandatory
CRX00002

CLAIMHEADERRECORD-RX

X(30)

8778

137180

140083

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
When Type of Claim not in [3. When Type of
Claim not in ('Z','3','C','W',"2","B","V","
4","D","X"),C,W] then value may match

Submieng State Provider ID (PRV.002.019) or
3. When Type of Claim not in
('Z','3','C','W',"2","B","V"," 4","D","X")[3,C,W]
then value may match Provider IdenLﬁer
(PRV.005.081) where the Provider IdenLﬁer
Type (PRV.005.077) = '1'
equals "1"
4. Mandatory

CRX157

CRX.003.157

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CRX00003

CLAIM-LINERECORD-RX

9(8)

4641

896402

903409

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value should be on or before End of Time
Period value found in(CIP.001.010)
3. Mandatory
4. Value should be on or afer associated TMSIS File Header Record
4. MandatoryAdmission Date value

CRX158

CRX.003.158

SELF-DIRECTIONTYPE

Self DirecLon
Type

Conditional

Mandatory

This data element is not applicable to this ﬁle
type.

SELFDIRECTIONTYPE

CRX00003

CLAIM-LINERECORD-RX

X(3)

4742

904410

906412

1.1. Value must be 3 characters

2. Value must be in Self DirecLon Type List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

CRX159

CRX.003.159

PREAUTHORIZATION
-NUM

PreauthorizaLo
n Number

N/A

CRX00003

CLAIM-LINERECORD-RX

X(18)

4843

907413

924430

1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

CRX160

CRX.002.160

MEDICARECOMB-DED-IND

Medicare
Combined
DeducLble
Indicator

MEDICARECOMB-DEDIND

CRX00002

CLAIMHEADERRECORD-RX

X(1)

8879

140183

1.1. Value must be 1 character

Crossover Indicator must equals "0"
5. If value equals "1", then Crossover

Indicator must equals "1"
6. CondiLonal

CRX161

CRX162

CRX.002.161

CRX.002.162

PROV-LOCATION- Provider
ID
LocaLon ID

PRESCRIPTIONORIGIN-CODE

PrescripLon
Origin Code

Mandatory

CondiLonal How the prescripLon was sent to the pharmacy.

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(5)

8980

140283

18406

1.1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
2. Value must be 5 characters or less
3.3. Mandatory

PRESCRIPTIONORIGIN-CODE

CRX00002

CLAIMHEADERRECORD-RX

X(1)

841

1. Value must be one digit
2. Value must be in PrescripLon Origin Code
List (VVL)
3. CondiLonal

CRX163

CRX.002.163

TOTBENEFICIARYCOPAYMENTLIABLE-AMOUNT

Total
Beneﬁciary
Copayment
Liable Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

842

854

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX164

CRX.002.164

TOTBENEFICIARYCOINSURANCELIABLE-AMOUNT

Total
Beneﬁciary
Coinsurance
Liable Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

855

867

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX165

CRX.002.165

TOTBENEFICIARYDEDUCTIBLELIABLE-AMOUNT

Total
Beneﬁciary
DeducLble
Liable Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

868

880

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX166

CRX.002.166

COMBINEDBENE-COSTSHARING-PAIDAMOUNT

Combined
Beneﬁciary Cost
Sharing Paid
Amount

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

881

893

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX167

CRX.003.167

INGREDIENTCOSTSUBMITTED

Ingredient Cost
Submiaed

CondiLonal The charge to cover the cost of ingredients for
the prescripLon or drug.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

431

443

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX168

CRX.003.168

INGREDIENTCOST-PAID-AMT

Ingredient Cost
Paid Amount

CondiLonal The amount paid by Medicaid or the managed
care plan on this claim or adjustment at the
claim detail level towards the cost of ingredients
for the prescripLon or drug.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

444

456

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX169

CRX.003.169

DISPENSE-FEEPAID-AMT

Dispense Fee
Paid Amount

CondiLonal The amount paid by Medicaid or the managed
care plan on this claim or adjustment towards
the cost of the pharmacy's professional
dispensing fee for the prescripLon.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

457

469

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX170

CRX.003.170

PROFESSIONALSERVICE-FEESUBMITTED

Professional
Service Fee
Submiaed

CondiLonal The charge to cover the clinical services, not
otherwise covered under the professional
dispensing fee. (Example - not ﬁlling a
prescripLon because of therapeuLc
duplicaLon).

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

470

482

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX171

CRX.003.171

PROFESSIONALSERVICE-FEEPAID-AMT

Professional
Service Fee Paid
Amount

CondiLonal The amount paid by Medicaid or the managed
care plan on this claim or adjustment towards
the costs of clinical services not otherwise
covered under the professional dispensing fee.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

483

495

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX172

CRX.003.172

IHS-SERVICE-IND

IHS Service
Indicator

Mandatory

CRX173

CRX.002.173

LTC-RCP-LIABAMT

LTC RCP Liability
Amount

CRX174

CRX.002.174

PROVIDERCLAIM-FORMCODE

CRX175

CRX.002.175

CRX176

CRX.002.176

IHS-SERVICEIND

CRX00003

CLAIM-LINERECORD-RX

X(1)

496

1. Value must be 1 character
2. Value must be in the IHS Service Indicator
List (VVL)
3. Mandatory

CondiLonal The total amount paid by the paLent for
services where they are required to use their
personal funds to cover part of their care before
Medicaid funds can be uLlized.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

894

906

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

Provider Claim
Form Code

Mandatory

PROVIDERCLAIM-FORMCODE

CRX00002

CLAIMHEADERRECORD-RX

X(2)

907

908

1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code
List (VVL)
3. Mandatory

PROVIDERCLAIM-FORMOTHER-TEXT

Provider Claim
Form Other Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the "other" claim form used by the provider to
submit their claim. Required when "Other" is
reported to Provider Claim Form Code.

N/A

CRX00002

CLAIMHEADERRECORD-RX

X(50)

909

958

1. Value must not be more than 50 characters
long
2. CondiLonal
3. Value must be provided when
corresponding Provider Claim Form Code is
"Other"

TOT-GMEAMOUNT-PAID

Total GME
Amount Paid

CondiLonal The amount included in the Total Medicaid
Amount (CRX.002.041) that is aaributable to a
Graduate Medical EducaLon (GME) payment,
when the state makes GME payments by claim.

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

959

971

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

A code indicaLng the format in which the
provider submiaed their claim. Very few if any
claims should be classiﬁed as "Other".

CRX177

CRX.002.177

TOT-SDPALLOWED-AMT

Total State
Directed
Payment
Allowed
Amount

N/A

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

972

984

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX178

CRX.002.178

TOT-SDP-PAIDAMT

Total State
Directed
Payment Paid
Amount

CRX00002

CLAIMHEADERRECORD-RX

S9(11)
V99

985

997

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX179

CRX.003.179

UNIQUE-DEVICEIDENTIFIER

Unique Device
IdenLﬁer

CondiLonal An unique idenLﬁer assigned to every medical
device that meets the requirements of 21 CFR
801 and 830.

CRX00003

CLAIM-LINERECORD-RX

X(76)

497

572

1. Value must not be more than 76 characters
long
2. CondiLonal

N/A

CRX180

CRX.003.180

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

CRX00003

CLAIM-LINERECORD-RX

X(5)

624

628

CRX181

CRX.003.181

MBESCBESFORM

MBESCBES
Form

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

CRX00003

CLAIM-LINERECORD-RX

X(50)

574

623

CRX182

CRX.003.182

PROCEDURECODE

Procedure Code

CondiLonal The procedure code (e.g., CPT, HCPCS, or other
procedure code that is not an NDC or UDI)
reported by a pharmacy on their NCPDP
transacLon.

PROCEDURECODE

CRX00003

CLAIM-LINERECORD-RX

X(6)

629

634

1. Value must not be more than 6 characters
2. Value must be in Procedure Code List (VVL)
3. CondiLonal

CRX183

CRX.003.183

PROCEDURECODE-MOD-1

Procedure Code
Modiﬁer 1

CondiLonal The ﬁrst modiﬁer associated with the procedure
code (or if procedure code is missing, then the
modiﬁer may be associated with an NDC or
Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

635

636

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX184

CRX.003.184

PROCEDURECODE-MOD-2

Procedure Code
Modiﬁer 2

CondiLonal The second modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

637

638

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX185

CRX.003.185

PROCEDURECODE-MOD-3

Procedure Code
Modiﬁer 3

CondiLonal The third modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

639

640

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX186

CRX.003.186

PROCEDURECODE-MOD-4

Procedure Code
Modiﬁer 4

CondiLonal The fourth modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

641

642

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX187

CRX.003.187

PROCEDURECODE-MOD-5

Procedure Code
Modiﬁer 5

CondiLonal The ﬁfh modiﬁer associated with the procedure
code (or if procedure code is missing, then the
modiﬁer may be associated with an NDC or
Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

643

644

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX188

CRX.003.188

PROCEDURECODE-MOD-6

Procedure Code
Modiﬁer 6

CondiLonal The sixth modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

645

646

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX189

CRX.003.189

PROCEDURECODE-MOD-7

Procedure Code
Modiﬁer 7

CondiLonal The seventh modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

647

648

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX190

CRX.003.190

PROCEDURECODE-MOD-8

Procedure Code
Modiﬁer 8

CondiLonal The eighth modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

649

650

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX191

CRX.003.191

PROCEDURECODE-MOD-9

Procedure Code
Modiﬁer 9

CondiLonal The ninth modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

651

652

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX192

CRX.003.192

PROCEDURECODE-MOD-10

Procedure Code
Modiﬁer 10

CondiLonal The tenth modiﬁer associated with the
procedure code (or if procedure code is missing,
then the modiﬁer may be associated with an
NDC or Unique Device IdenLﬁer).

PROCEDURECODE-MOD

CRX00003

CLAIM-LINERECORD-RX

X(2)

653

654

1. Value must be 2 characters
2. Value must be in Procedure Code Mod List
(VVL)
3. Must be associated with a Procedure Code
4. CondiLonal

CRX193

CRX.003.193

GME-AMOUNTPAID

GME Amount
Paid

CondiLonal The amount included in the Medicaid Amount
(CRX.003.125) that is aaributable to a Graduate
Medical EducaLon (GME) payment, when the
state makes GME payments by claim.

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

655

667

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX194

CRX.003.194

SDP-ALLOWEDAMT

State Directed
Payment
Allowed
Amount

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

668

680

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX195

CRX.003.195

SDP-PAID-AMT

State Directed
Payment Paid
Amount

N/A

CRX00003

CLAIM-LINERECORD-RX

S9(11)
V99

681

693

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

CRX196

CRX.004.196

RECORD-ID

Record ID

Mandatory

RECORD-ID

CRX00004

CLAIM-DX-RX

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "CRX00004"

CRX197

CRX.004.197

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

CRX00004

CLAIM-DX-RX

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
4. Value must be the same as Submieng
State (CRX.001.007)

CRX198

CRX.004.198

RECORDNUMBER

Record Number

Mandatory

N/A

CRX00004

CLAIM-DX-RX

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

CRX199

CRX.004.199

ICN-ORIG

Original ICN

Mandatory

A unique number assigned by the state's
payment system that idenLﬁes an original or
adjustment claim.

N/A

CRX00004

CLAIM-DX-RX

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

CRX200

CRX.004.200

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim number assigned by the state's
payment system that idenLﬁes the adjustment
claim for an original transacLon.

N/A

CRX00004

CLAIM-DX-RX

X(50)

121

CRX201

CRX.004.201

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

CRX00004

CLAIM-DX-RX

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Value must be in [0,1,4]
4. Mandatory
5. If value equals "0", then associated
Adjustment ICN must not be populated
6. If value is in [4,1] then Adjustment ICN
must be populated
7. Value must equal "1", when associated
Claim Status equals "686"
8. Value must match the adjustment indicator
in the header (CRX.002.025)

CRX202

CRX.004.202

ADJUDICATIONDATE

AdjudicaLon
Date

Mandatory

The date on which the payment status of the
claim was ﬁnally adjudicated by the state. For
Encounter Records (Type of Claim = 3, C, W), use
date the encounter was processed by the state.

N/A

CRX00004

CLAIM-DX-RX

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value should be on or before End of Time
Period (CRX.001.010)
3. Mandatory
4. Value should be on or afer associated
Admission Date value

CRX203

CRX.004.203

DIAGNOSIS-TYPE

Diagnosis Type

Mandatory

Indicates the context of the diagnosis code from
the provider's claim (i.e., an NCPDP claim can
have up to 5 diagnosis codes). The type of
diagnosis code (e.g., principal, admieng,
external cause of injury, or other) is captured
here. The order in which the diagnosis code was
reported is captured in the Diagnosis Sequence
Number.

DIAGNOSISTYPE

CRX00004

CLAIM-DX-RX

X(1)

131

1. Value must be 1 character
2. Value must be in Diagnosis Type Code List
(VVL)
3. Value must be "D"
4. Mandatory

CRX204

CRX.004.204

DIAGNOSISSEQUENCENUMBER

Diagnosis
Sequence
Number

Mandatory

The order in which the diagnosis occurred on
the provider's claim for a given type of diagnosis
code (e.g., an NCPDP claim can have up to 5
diagnosis codes).

N/A

CRX00004

CLAIM-DX-RX

9(2)

132

133

1. Value must be in [01-24]
2. Mandatory

CRX205

CRX.004.205

DIAGNOSISCODE-FLAG

Diagnosis Code
Flag

Mandatory

Flag used to idenLfy wither the associated
Diagnosis Code value is a ICD-9 or ICD-10 code.

DIAGNOSISCODE-FLAG

CRX00004

CLAIM-DX-RX

X(1)

134

1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List
(VVL)
3. Mandatory

CRX206

CRX.004.206

DIAGNOSISCODE

Diagnosis Code

Mandatory

CRX00004

CLAIM-DX-RX

X(7)

135

141

CRX207

CRX.004.207

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

CRX00004

CLAIM-DX-RX

X(500)

142

641

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

N/A

CRX209

CRX.003.209

MBESCBESFORM-GROUP

MBESCBES
Form Group

MBESCBESFORM-GROUP

CRX00003

CLAIM-LINERECORD-RX

X(1)

573

T-MSIS Data Dic,onary – ELG File Changes Between Versions 2.4.0 and 4.0.0

ELG001

ELG.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00001"

DATADICTIONARYVERSION

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(1)

1.1. Value must be 1 characters

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

ELG.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

ELG003

ELG004

ELG.001.003

ELG.001.004

SUBMISSIONTRANSACTIONTYPE

FILE-ENCODINGSPECIFICATION

Submission
TransacLon
Type

File Encoding
SpeciﬁcaLon

Mandatory

2. Value must be in Submission TransacLon
Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

ELG005

ELG.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(9)

1. Value must be 9 characters or less
2. Mandatory

submission ﬁle. Use the version number specified
on the title page of the data mapping document

ELG006

ELG.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

ELG007

ELG.001.007

SUBMITTINGSTATE

Submieng
State

Mandatory

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(8)

1. Value must equal 'ELIGIBLE'"ELIGIBLE"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(2)

1.1. Value must be 2 characters

STATE

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same for all records
ELG008

ELG.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the ﬁle was created.

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

9(8)

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory
ELG009

ELG.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

9(8)

2. Value must be equal to or earlier than
associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"

ELG010

ELG.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
ELG011

ELG.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
ELG012

ELG.001.012

SSN-INDICATOR

SSN Indicator

Mandatory

SSN-INDICATOR

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(1)

1.1. Value must be 1 character

2. Value must be in SSN Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

ELG013

ELG.001.013

TOT-REC-CNT

Total Record
Count

Mandatory

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory
ELG014

ELG.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG016

ELG.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

RECORD-ID

ELG00002

STATE

ELG00002

X(500)

1516

8385

5824

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

PRIMARYX(8)
DEMOGRAPHIC
S-ELIGIBILITY

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00002"

PRIMARYX(2)
DEMOGRAPHIC
S-ELIGIBILITY

1.1. Value must be 2 characters

ELG.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)

ELG018

ELG019

ELG.002.018

ELG.002.019

RECORDNUMBER

MSISIDENTIFICATIONNUM

Record Number

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00002

PRIMARY9(11)
DEMOGRAPHIC
S-ELIGIBILITY

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG00002

PRIMARYX(20)
DEMOGRAPHIC
S-ELIGIBILITY

2. Mandatory

ELG020

ELG.002.020

ELIGIBLE-FIRSTNAME

Eligible First
Name

Mandatory

Individual's ﬁrst name; ﬁrst name component of
full name (e.g. First Name, Middle IniLal, Last
Name).

N/A

ELG00002

PRIMARYX(30)
DEMOGRAPHIC
S-ELIGIBILITY

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

ELG021

ELG.002.021

ELIGIBLE-LASTNAME

Eligible Last
Name

Mandatory

Individual's last name; last name component of
full name (e.g. First Name, Middle IniLal, Last
Name).

N/A

ELG00002

PRIMARYX(30)
DEMOGRAPHIC
S-ELIGIBILITY

101

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

ELG022

ELG.002.022

ELIGIBLEMIDDLE-INIT

Eligible Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

ELG00002

PRIMARYX(1)
DEMOGRAPHIC
S-ELIGIBILITY

102

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
ELG023

ELG.002.023

SEX

Sex

Mandatory

Either individual's biological sex or their selfidenLﬁed sex.

SEX

ELG00002

PRIMARYX(1)
DEMOGRAPHIC
S-ELIGIBILITY

103

1.1. Value must be 1 character

2. Value must be in Sex List (VVL)
2. Value must be 1 character
3.3. (Pregnancy) if value equals "M", then

associated Pregnancy Indicator (ELG.003.049)
value must not equal '1'"1"
4. Mandatory
ELG024

ELG.002.024

DATE-OF-BIRTH

Date of Birth

Mandatory

An individual's date of birth.

N/A

ELG00002

PRIMARY9(8)
DEMOGRAPHIC
S-ELIGIBILITY

104

111

1. Value must be 8 characters in the form
"CCYYMMDD"
2.1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3.in the form "CCYYMMDD"

2. Children enrolled in the Separate CHIP
prenatal program opLon should have a date
of birth missing or a date of birth equal to the
pregnant mother's date of birth
43. When ConcepLon to Birth Indicator
(ELG.005.094) does not equal '1'"1" and
Eligibility Group (ELG.005.087) does not equal
'"64'" value must be less than or equal to
associated End of Time Period value
54. Value must be less than or equal to
associated Date File Created (ELG.001.008)
value
65. Mandatory
76. When ConcepLon to Birth Indicator
(ELG.005.094) does not equal '1'"1" and
Eligibility Group (ELG.005.087) does not equal

'"64'" value minus Start of Time Period

(ELG.001.10) must be less than 125 years

ELG025

ELG.002.025

DATE-OF-DEATH

Date of Death

CondiLonal The date an individual died on.

DATE-OFDEATHN/A

ELG00002

PRIMARY9(8)
DEMOGRAPHIC
S-ELIGIBILITY

112

119

1. Value must be in Eligibility Group List (VVL)
2. If value is "26", then Dual Eligible Code value
must be "06"
3. Conditional
4. Value is mandatory and must be provided
when associated Eligibility Determinant Effective
Date value is on or after 1 January, 2014.
5. If value is in [ "72", "73", "74", "75" ], then
associated Restricted Benefits Code value must
equal "7" and State Plan Option Type must equal
"06"
6. If associated CHIP Code value is "2", then value
must be in [ "07", 31", "61" ]
7. If associated CHIP Code value is "3", then value
must be in [ "61", "62", "63", "64", "65", "66",
"67", "68" ]
8. Value must be 2 characters
9. If value is "23", then Dual Eligible Code value
must be in ["01", "02"]
10. If value is "25", then Dual Eligible Code value
must be in ["03", "04"]
11. If value is "24", then Dual Eligible Code value
must be "05"
12. Value must be in Level of Care Status List
(VVL)1. The date must be a valid calendar

date in the form "CCYYMMDD"
2. CondiLonal
3. If populated, value must be on or afer
individual's Date of Birth
4. Value must be less than or equal to
associated Date File Created (ELG.001.008)
value
5. There must never be more than one Date
of Death value reported across Primary
Demographic segments that have the same
MSIS IdenLﬁcaLon number
6. When populated, Procedure Code Dates on
a claim must be less than or equal to this
value

7. When populated, Admission Date on a
claim must be less than or equal to this value
8. When populated, Discharge Date on a
claim must be less than or equal to this value
9. When populated, Ending Date of Service
on a claim must be less than or equal to this
value
10. When populated, value must be less than
or equal to Enrollment End Date
(ELG.021.254)
11. When populated, value minus Date of
Birth (ELG.002.024) is less than or equal to
125 years

ELG026

ELG.002.026

PRIMARYDEMOGRAPHICELEMENT-EFFDATE

Primary
Demographic
Element
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00002

PRIMARY9(8)
DEMOGRAPHIC
S-ELIGIBILITY

120

127

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]

ELG027

ELG.002.027

PRIMARYDEMOGRAPHICELEMENT-ENDDATE

Primary
Demographic
Element End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00002

PRIMARY9(8)
DEMOGRAPHIC
S-ELIGIBILITY

128

135

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG028

ELG.002.028

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG030

ELG.003.030

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00002

PRIMARYX(500)
DEMOGRAPHIC
S-ELIGIBILITY

136

635

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00003

VARIABLEX(8)
DEMOGRAPHIC
S-ELIGIBILITY

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00003"

ELG031

ELG.003.031

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

ELG00003

VARIABLEX(2)
DEMOGRAPHIC
S-ELIGIBILITY

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG032

ELG033

ELG.003.032

ELG.003.033

RECORDNUMBER

MSISIDENTIFICATIONNUM

Record Number

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00003

VARIABLE9(11)
DEMOGRAPHIC
S-ELIGIBILITY

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG00003

VARIABLEX(20)
DEMOGRAPHIC
S-ELIGIBILITY

2. Mandatory

ELG034

ELG.003.034

MARITAL-STATUS

Marital Status

MandatoryC

ondiLonal

A code to classify eligible individual's
marital/domesLc-relaLonship status. An eligible

MARITALSTATUS

ELG00003

individual who is younger than 12 years should have
a marital status of never married or unknown. This

VARIABLEX(2)
DEMOGRAPHIC
S-ELIGIBILITY

VARIABLEX(50)
DEMOGRAPHIC
S-ELIGIBILITY

1.1. Value must be 2 characters

2. Value must be in Marital Status List (VVL)
2. Value must be 2 characters
3. Mandatory3. CondiLonal

element should be reported by the state when
the informaLon is material to eligibility (i.e.,
insLtuLonalizaLon).
Because there is no speciﬁc statutory or
regulatory basis for deﬁning marital status
codes, they are being deﬁned in a way that is as
ﬂexible for states and data users as possible.
States can report at whatever level of
granularity is available to them in their system
and a data user can choose to use them as-is or
roll the values up in broader categories
depending on whichever approach best meets
their needs. CMS periodically reviews the values
reported to MARITAL-STATUS-OTHEREXPLANATION to determine if states are
appropriately using it only when there is no
exisLng MARITAL-STATUS value that reﬂects the
state’s marital status descripLon for an
individual AND to determine whether it is
necessary to add addiLonal T-MSIS MARITALSTATUS values to reﬂect commonly used state
marLal status descripLons for which there is no
exisLng T-MSIS MARITAL-STATUS value.
ELG035

ELG.003.035

MARITALSTATUS-OTHEREXPLANATION

Marital Status
Other
ExplanaLon

CondiLonal A free-text ﬁeld to capture the descripLon of
the marital/domesLc-relaLonship status when
Marital Status =14 (Other) is selected.

N/A

ELG00003

1. If associated Marital Status (ELG.003.035)
equals '"14'" (Other), then value is mandatory
and must be provided
2. Value must be 50 characters or less
3. Value must not contain a pipe or asterisk
symbol
4. CondiLonal

ELG036

ELG.003.036

SSN

CondiLonal The eligible individual's social security number.
For newborns when value is unknown it is not
required. For SSN states, in instances where the
social security number is not known and a
temporary MSIS IdenLﬁcaLon Number is used,
the MSIS IdenLﬁcaLon Number ﬁeld should be
populated with the temporary MSIS
IdenLﬁcaLon Number and the SSN ﬁeld should
be space-ﬁlled, or blank. When the SSN
becomes known, the MSIS IdenLﬁcaLon
Number ﬁeld should conLnue to be populated
with the temporary MSIS IdenLﬁcaLon Number
and the SSN ﬁeld should be populated with the
newly acquired SSN for at least one monthly
submission of the Eligible File so that T-MSIS can
associated the temporary MSIS IdenLﬁcaLon
Number and the social security number.

N/A

ELG00003

VARIABLEX(9)
DEMOGRAPHIC
S-ELIGIBILITY

102

1. Value must be 9-digit number
2. For any individual, the value must be the
same over all segment eﬀecLve and end
dates
3. (SSN State) if associated SSN Indicator
(ELG.001.012) value is coded as "1", then
value must equal MSIS IdenLﬁcaLon Number
(ELG.002.019) value
4. Value can only be reported with one MSIS
IdenLﬁcaLon Number (ELG.002.019)
5. CondiLonal
6. (Non-SSN State) if associated SSN Indicator
(ELG.001.012) value is coded as "0", then
value must not equal MSIS IdenLﬁcaLon
Number (ELG.002.019)

ELG037

ELG.003.037

SSNVERIFICATIONFLAG

SSN VeriﬁcaLon
Flag

Mandatory

SSNVERIFICATIONFLAG

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

103

1.1. Value must be 1 character

A code describing whether the state has veriﬁed
the social security number (SSN) with the Social
Security AdministraLon (SSA).

2. Value must be in SSN VeriﬁcaLon Flag List
(VVL)
2. Value must be 1 character
3.3. Mandatory

ELG038

ELG.003.038

INCOME-CODE

Income Code

MandatoryC

A code indicating the family income level.A code

ondiLonal

indicaLng the federal poverty level range in
which the family income falls. If the
beneﬁciary's income was assessed using
mulLple methodologies (MAGI and Non-MAGI),
report the income that applies to their primary
eligibility group.

INCOME-CODE

ELG00003

VARIABLEX(2)
DEMOGRAPHIC
S-ELIGIBILITY

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

104

105

1.1. Value must be 2 characters

2. Value must be in Income Code List (VVL)
2. Value must be 2 characters
3. Mandatory3. CondiLonal

A beneﬁciary’s income is applicable unless it is
not required by the eligibility group for which
they were determined eligible. For example, the
eligibility groups for children with adopLon
assistance, foster care, or guardianship care
under Ltle IV-E and opLonal eligibility for
individuals needing treatment for breast or
cervical cancer do not have a Medicaid income
test. AddiLonally, for individuals receiving SSI,
states with secLon 1634 agreements with the
Social Security AdministraLon (SSA) and states
that use SSI ﬁnancial methodologies for
Medicaid determinaLons do not conduct
separate Medicaid ﬁnancial eligibility for this
group.
ELG039

ELG.003.039

VETERAN-IND

Veteran
Indicator

CondiLonal A ﬂag indicaLng if a non-ciLzen is exempt from
the 5-year bar on beneﬁts because they are a
veteran or an acLve member of the military,
naval or air service.

VETERAN-IND

ELG00003

106

1.1. Value must be 1 character

2. Value must be in Veteran Indicator List
(VVL)
2. Value must be 1 character
3.3. CondiLonal

4. Value must be populated when
ImmigraLon Status (ELG.003.042) is in ['1', '2',
'3'1,2,3]

ELG040

ELG.003.040

CITIZENSHIP-IND

CiLzenship
Indicator

Mandatory

Indicates if the individual is idenLﬁed as a U.S.
CiLzen.

CITIZENSHIPIND

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

107

1.1. Value must be 1 character

2. Value must be in [0,1,2]
3. Value must be in CiLzenship Indicator List
(VVL)
24. If value is coded as '0',equals "0", then
associated ImmigraLon Status (ELG.003.042)
value must be in [1,2, 3 ]
3]
5. If value is coded as '"1'", then associated
ImmigraLon Status (ELG.003.042) value must
equal '8'
4. Value must be 1 character
5. "8"

6. Mandatory
ELG041

ELG.003.041

CITIZENSHIPVERIFICATIONFLAG

CiLzenship
VeriﬁcaLon Flag

CondiLonal Indicates the individual is enrolled in Medicaid
pending ciLzenship veriﬁcaLon.

CITIZENSHIPVERIFICATIONFLAG

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

108

1.1. Value must be 1 character

2. Value must be in CiLzenship VeriﬁcaLon
Flag List (VVL)
2. Value must be 1 character
3.3. Value must be populated when

CiLzenship Indicator (ELG.003.040) equals '1'
(Yes"1" (US CiLzen)
4. CondiLonal
ELG042

ELG.003.042

IMMIGRATIONSTATUS

ImmigraLon
Status

Mandatory

The immigraLon status of the individual.

IMMIGRATIONSTATUS

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

109

1.1. Value must be 1 character

2. Value must be in ImmigraLon Status List
(VVL)
23. If associated CiLzenship Indicator
(ELG.003.040) value is coded as '0',equals "0",
then value must be in [1,2, 3 ]
3]
4. If associated CiLzenship Indicator
(ELG.003.040) value is coded as '1',equals "1",
then value must equal '8'
4. Value must be 1 character

"8"
5. Mandatory

ELG043

ELG.003.043

IMMIGRATIONVERIFICATIONFLAG

ImmigraLon
VeriﬁcaLon Flag

CondiLonal Indicates the individual is enrolled in Medicaid
pending immigraLon veriﬁcaLon.

IMMIGRATIONVERIFICATIONFLAG

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

110

1.1. Value must be 1 character

2. Value must be in ImmigraLon VeriﬁcaLon
Flag List (VVL)
2. Value must be 1 character
3.3. CondiLonal

ELG044

ELG045

ELG.003.044

ELG.003.045

IMMIGRATIONSTATUS-FIVEYEAR-BAR-ENDDATE

PRIMARYLANGUAGE-ENGL-

PROF-CODE

ELG046

ELG.003.046

PRIMARYPREFER

RED-LANGUAGECODE

ELG047

ELG.003.047

HOUSEHOLDSIZE

ImmigraLon
Status Five Year
Bar End Date

Primary Language

English
Proﬁciency
Code
Primary
Language Code

Household Size

CondiLonal The date the ﬁve-year bar for an individual ends.
SecLon 403 of the Personal Responsibility and
Work Opportunity ReconciliaLon Act of 1996
(PRWORA) provides that certain immigrants
who enter the United States on or afer August
22, 1996 are not eligible to receive federallyfunded beneﬁts, including Medicaid and the
State Children's Health Insurance Program
(Separate CHIP), for ﬁve years from the date
they enter the country with a status as a
"qualiﬁed alien."

N/A

CondiLonal A code indicaLng the level of spoken English
proﬁciency by the individual.

PRIMARYLANGUAGE-

CondiLonal A code indicaLng the language that is the
individual speaks other than English at
homeindividuals' preferred spoken or wriaen

Mandatory

ELG00003

VARIABLE9(8)
DEMOGRAPHIC
S-ELIGIBILITY

111

118

1. (U.S. Citizen) if associated Citizenship Indicator
(ELG.003.040) value is '1', then value should not
be populatedThe date must be a valid calendar

date in the form "CCYYMMDD"
2. (Non U.S. Citizen) if associated Citizenship
Indicator (ELG.003.040) value is '0', then value
should be populated
3. CondiLonal
4. (U.S. Citizen) value should not be populated
when3. If ImmigraLon Status (ELG.003.042)
equals '8'"8" (U.S. CiLzen), then value should

not be populated
ELG00003

ENGL-PROFCODE
PRIMARYPREFE

language.

RREDLANGUAGECODE

Household Size used in the Medicaid or CHIP
eligibility determinaLon process.

HOUSEHOLDSIZE

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

119

1.1. Value must be 1 character

2. Value must be in Primary Language English
Proﬁciency Code List (VVL)
2. Value must be 1 character
3.3. CondiLonal

ELG00003

VARIABLEX(3)
DEMOGRAPHIC
S-ELIGIBILITY

120

122

1.1. Value must be 3 characters

2. Value must be in Primary Language Code
List (VVL)
2. Value must be 3 characters
3.3. CondiLonal

ELG00003

VARIABLEX(2)
DEMOGRAPHIC
S-ELIGIBILITY

123

124

1.1. Value must be 2 characters

2. Value must be in Household Size List (VVL)
2. Value must be 2 characters
3.3. Mandatory

ELG049

ELG.003.049

PREGNANCY-IND

Pregnancy
Indicator

CondiLonal A ﬂag indicaLng the individual is pregnant at the
Lme of applicaLon based on self-aaestaLon.

PREGNANCYIND

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

125

1.1. Value must be 1 character

2. Value must be in Pregnancy Indicator List
(VVL)
2. If value equals '1', then Sex (ELG.002.023) value
must equal 'F"
3. Value must be 1 character
4.3. CondiLonal

ELG050

ELG.003.050

MEDICARE-HICNUM

Medicare HIC
Number

N/A

ELG00003

VARIABLEX(12)
DEMOGRAPHIC
S-ELIGIBILITY

126

137

1. Conditional
2. Value must be 12 characters or less
2. CondiLonal
3. Value must not contain a pipe or asterisk
symbols
4. (Not Dual Eligible) if Dual Eligible Code
(ELG.DE.085) value =is "00", then value must
not be populated.
5. (Medicare Enrolled) if associated Dual
Eligible Code (ELG.005.085) value is in [ "01",
",02", ",03", ",04", ",05", ",06", ",08", ",09", or
",10" ], then value for either HICN or MBI is
mandatory and must be provided

ELG051

ELG.003.051

MEDICAREBENEFICIARYIDENTIFIER

Medicare
Beneﬁciary
IdenLﬁer

N/A

ELG00003

VARIABLEX(12)
DEMOGRAPHIC
S-ELIGIBILITY

138

149

1. CondiLonal
2. Value must be an 11-character string
3. Character 1 must be numeric values 1 thru
9
4. Character 2 must be alphabeLc values A
thru Z (minus S,L,O,I,B,Z)
5. Character 3 must be alphanumeric values 0
thru 9 or A thru Z (minus S,L,O,I,B,Z)
6. Character 4 must be numeric values 0 thru
9
7. Character 5 must be alphabeLc values A
thru Z (minus S,L,O,I,B,Z)
8. Character 6 must be alphanumeric values 0
thru 9 or A thru Z (minus S,L,O,I,B,Z)
9. Character 7 must be numeric values 0 thru
9
10. Character 8 must be alphabeLc values A
thru Z (minus S,L,O,I,B,Z)
11. Character 9 must be alphabeLc values A
thru Z (minus S,L,O,I,B,Z)
12. Character 10 must be numeric values 0
thru 9
13. Character 11 must be numeric values 0
thru 9
14. Value must not contain a pipe or asterisk
symbols
15. When Dual Eligible Code (ELG.005.085)
equals '"00'" and End of Time Period
(ELG.001.010) greater than or equal to
'"2015-11-01'", value should not be
populated
16. (Medicare Enrolled) if associated Dual
Eligible Code value (ELG.005.085) is in [ "01",
",02", ",03", ",04", ",05", ",06", ",08", ",09", or
",10" ], then the value for either HICN or MBI
is mandatory and must be provided

ELG054

ELG.003.054

CHIP-CODE

CHIP Code

Mandatory

A code used to disLnguish among Medicaid,
Medicaid Expansion CHIP, and Separate CHIP
populaLons.

CHIP-CODE

ELG00003

VARIABLEX(1)
DEMOGRAPHIC
S-ELIGIBILITY

150

1. Value must be in CHIP Code List (VVL)
2. If value is in [2,3], then associated Eligibility
Group (ELG.005.087) value must be in [ "07",
",31", ",61", ,62", ",63", ",64", ",65", ",66",
",67", or ",68" ]
3. If value isequals "1", then associated
Eligibility Group (ELG.005.087) value must not
be in [ "61", ,62", ",63", ",64", ",65", ",66",
",67", or ",68" ]
4. Value must be 1 character
5. Mandatory

ELG057

ELG.003.057

VARIABLEDEMOGRAPHICELEMENT-EFFDATE

Variable
Demographic
Element
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00003

VARIABLE9(8)
DEMOGRAPHIC
S-ELIGIBILITY

151

158

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20']19,20,99]\
ELG058

ELG.003.058

VARIABLEDEMOGRAPHICELEMENT-ENDDATE

Variable
Demographic
Element End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00003

VARIABLE9(8)
DEMOGRAPHIC
S-ELIGIBILITY

159

166

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]

ELG059

ELG.003.059

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG061

ELG.004.061

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00003

VARIABLEX(500)
DEMOGRAPHIC
S-ELIGIBILITY

2527

1678

666677

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00004

ELIGIBLECONTACTINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00004"

STATE

ELG00004

ELIGIBLECONTACTINFORMATION

X(2)

1.1. Value must be 2 characters

ELG.004.062

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG063

ELG.004.063

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG064

ELG065

ELG.004.064

ELG.004.065

MSISIDENTIFICATIONNUM

ELIGIBLE-ADDRTYPE

MSIS
IdenLﬁcaLon
Number

Eligible Address
Type

Mandatory

N/A

The type of address and contact informaLon for
the eligible submiaed in the record segment.

ELIGIBLEADDR-TYPE

ELG00004

ELIGIBLECONTACTINFORMATION

X(20)

2. Mandatory

ELG00004

ELIGIBLECONTACTINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in Eligible Address Type List
(VVL)
2. Value must be 2 characters
3.3. Mandatory

ELG066

ELG.004.066

ELIGIBLE-ADDRLN1

Eligible Address
Line 1

Mandatory

The ﬁrst line of a potenLally mulL-line physical
street or mailing address for a given enLty (e.g.
person, organizaLon, agency, etc.).

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(60)

103

ELG067

ELG.004.067

ELIGIBLE-ADDRLN2

Eligible Address
Line 2

CondiLonal The second line of a mulL-line physical street or
mailing address for a given enLty (e.g. person,
organizaLon, agency, etc.).

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(60)

104

163

ELG068

ELG.004.068

ELIGIBLE-ADDRLN3

Eligible Address
Line 3

CondiLonal The third line of a mulL-line physical street or
mailing address for a given enLty (e.g. person,
organizaLon, agency, etc.).

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(60)

164

223

1. Value must be 60 characters or less
2. Value must not be equal to associated
Address Line 1 or Address Line 2 value(s)
3. If Address Line 2 is not populated, then
value should not be populated
4. Value must not contain a pipe or asterisk
symbols
5. CondiLonal

ELG069

ELG.004.069

ELIGIBLE-CITY

Eligible City

Mandatory

The city component of an address associated
with a given enLty (e.g. person, organizaLon,
agency, etc.).

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(28)

224

251

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

ELG070

ELG.004.070

ELIGIBLE-STATE

Eligible State

Mandatory

The ANSI state numeric code for the U.S. state,
Territory, or the District of Columbia code for
where the individual eligible to receive
healthcare services resides. (The state for the
type of address indicated in Address Type.)

STATE

ELG00004

ELIGIBLECONTACTINFORMATION

X(2)

252

253

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory

ELG071

ELG.004.071

ELIGIBLE-ZIPCODE

Eligible ZIP
Code

Mandatory

U.S. ZIP Code component of an address
associated with a given enLty (e.g. person,
organizaLon, agency, etc.)

ZIP-CODE

ELG00004

ELIGIBLECONTACTINFORMATION

X(9)

254

262

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. Mandatory

ELG072

ELG.004.072

ELIGIBLECOUNTY-CODE

Eligible County
Code

Mandatory

Standard ANSI code used to idenLfy a speciﬁc
U.S. County.

COUNTY

ELG00004

ELIGIBLECONTACTINFORMATION

X(3)

263

265

1.1. Value must be 3 characters

2. Value must be in US County Code List (VVL)
2. Value must be 3 characters
3.3. Mandatory

ELG073

ELG074

ELG.004.073

ELG.004.074

ELIGIBLEPHONE-NUM

Eligible Phone
Number

OpCondiLo

TYPE-OF-LIVINGARRANGEMENT

Type Of Living
Arrangement

CondiLonal A free-form text ﬁeld to describe the type of
living arrangement used for the eligibility
determinaLon process. The field will remain a

nal

Phone number for a given enLty (e.g. person,
organizaLon, agency).

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(10)

266

275

1. Value must be 10 characters, digits (0-9) onlydigit number
2. OpCondiLonal

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(100)

276

375

1. Value must not contain a pipe or asterisk
symbol
2. Value must be 100 characters or less
3. CondiLonal

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

9(8)

376

383

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

free-form text data element until MACPro develops a
list of valid values. When it becomes available, TMSIS will align with MACPro valid value lists.

ELG075

ELG.004.075

ELIGIBLE-ADDREFF-DATE

Eligible Address
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG076

ELG.004.076

ELIGIBLE-ADDREND-DATE

Eligible Address
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

9(8)

384

391

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on in the form "CCYYMMDD"
2. Value must be afer or the leap year, never
April 31st or Sept 31st)
3. Value must be greater than or equal to same

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG077

ELG.004.077

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00004

ELIGIBLECONTACTINFORMATION

X(500)

392

891

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk

symbols
3. OpSituaLonal
ELG079

ELG.005.079

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00005

ELIGIBILITYDETERMINANT
S

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00005"

STATE

ELG00005

ELIGIBILITYDETERMINANT
S

X(2)

1.1. Value must be 2 characters

ELG.005.080

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG081

ELG.005.081

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG082

ELG083

ELG084

ELG.005.082

ELG.005.083

ELG.005.084

MSISIDENTIFICATIONNUM

MSIS-CASE-NUM

MEDICAID-BASISOF-ELIGIBILITY

MSIS
IdenLﬁcaLon
Number

MSIS Case Num

Medicaid Basis
Of Eligibility

Mandatory

Not
Applicable

N/A

The state-assigned number which uniquely
idenLﬁes the Medicaid case to which the
enrollee belongs. The deﬁniLon of a case varies.
There are single-person cases (mostly aged and
blind/disabled) and mulL-person cases (mostly
TANF) in which all members of the case have the
same case number, but a unique idenLﬁcaLon
number. A warning for longitudinal research
eﬀorts: a case numbers associated with an
individual may change over Lme.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(20)

2. Mandatory

ELG00005

ELIGIBILITYDETERMINANT
S

X(12)

ELIGIBILITYDETERMINANTS

X(2)

1.1. Value must be 12 characters or less

2. Value must not contain a pipe symbol
2. Value must be 12 characters or less

3. Mandatory

1. Not Applicable

ELG085

ELG.005.085

DUAL-ELIGIBLECODE

Dual Eligible
Code

Conditional

Mandatory

Indicates coverage for individuals enLtled to
Medicare (Part A and/or B beneﬁts) and eligible
for some category of Medicaid beneﬁts.

DUAL-ELIGIBLECODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(2)

5654

5755

1. Mandatory
2. Value must be 8 characters in the form
"CCYYMMDD"
3. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
4. Value must be before or the same as the
associated Segment End Date value
5. Mandatory
6. Value of the CC component must be in ['18',
'19', '20']
7. Value must be 8 characters in the form
"CCYYMMDD"
8. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
9. Value must be greater than or equal to
associated Segment Effective Date value
10. Mandatory
11. Value of the CC component must be in ['18',
'19', '20', '99']
12. Value must not contain a pipe or asterisk
symbol
13. Value must be 100 characters or less1. Value

must be 2 characters
2. Value must be in Dual Eligible Code List
(VVL)
3. If value equals "05", then Eligibility Group
(ELG.005.087) must be "24"
4. If value equals "06", then Eligibility Group
(ELG.005.087) must be "26"
5. If Dual Eligible Code (ELG.005.085) is in
[01,02,03,04,05,06,08,09,10], then Primary
Eligibility Group Indicator (ELG.005.086) must
be "1" (Yes)
6. Mandatory
7. A parLal dual eligible (values="01", "03",
"05" or "06") then Restricted Beneﬁts Code
(ELG.005.097) must be "3"

8. (Not Dual Eligible) if value = "00", then
associated Medicare Beneﬁciary IdenLﬁer
(ELG.003.051) value must not be populated.
9. Value must be 2 characters
10. If value is in [08,10] then Restricted
Beneﬁts Code (ELG.005.097) must be "1"
11. If value equals "09", then Eligibility Group
(ELG.005.087) and Restricted Beneﬁts Code
(ELG.005.097) must not be populated
12. If value equals "10", then CHIP Code
(ELG.003.054) must be "03" (S-CHIP) and
Medicare Beneﬁciary IdenLﬁer (ELG.003.051)
must be populated
13. If value equals "01", then Eligibility Group
(ELG.005.087) must be "23"
14. If value equals "03", then Eligibility Group
(ELG.005.087) must be "25"

ELG086

ELG.005.086

PRIMARYELIGIBILITYGROUP-IND

Primary
Eligibility Group
Indicator

Mandatory

A flag indicating the eligibility record is the primary
eligibility in cases where there are multiple eligibility
records submitted with overlapping or concurrent
eligibility determinant effective and end dates.A ﬂag

indicaLng the eligibility record is the primary
eligibility in cases where there are mulLple
eligibility records submiaed with overlapping or
concurrent eligibility determinant eﬀecLve and
end dates. It is expected that an enrollees'
eligibility group assignment (ELG087 ELIGIBILITY-GROUP) will change over Lme as
his/her situaLon changes. Whenever the
eligibility group assignment changes (i.e.,
ELG087 has a diﬀerent value), a separate
ELIGIBILITY-DETERMINANTS record segment
must be created. In such situaLons, there would
be mulLple ELIGIBILITY-DETERMINANTS record
segments, each covering a diﬀerent eﬀecLve
Lme span. In such situaLons, the value in
ELG087 would be the primary eligibility group
for the eﬀecLve date span of its respecLve
ELIGIBILITY-DETERMINANTS record segment,
and the PRIMARY-ELIGIBILITY-GROUP-IND data
element on each of these segments would be
set to '1' (YES). Should a situaLon arise where a
Medicaid/CHIP enrollee has been assigned both
a primary and one or more secondary eligibility
groups, there would be two or more ELIGIBILITYDETERMINANTS record segments with
overlapping eﬀecLve Lme spans - one segment
containing the primary eligibility group and the
other(s) for the secondary eligibility group(s). To
diﬀerenLate the primary eligibility group from
the secondary group(s), only one segment
should be assigned as the primary group using
PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others

PRIMARYELIGIBILITYGROUP-IND

ELG00005

ELIGIBILITYDETERMINANT
S

X(1)

5856

1.1. Value must be 1 character

2. Value must be in Primary Eligibility Group
Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

should be assigned PRIMARY-ELIGIBILITYGROUP-IND = 0.

ELG087

ELG.005.087

ELIGIBILITYGROUP

Eligibility Group

CondiLonal The eligibility group applicable to the individual
based on the eligibility determinaLon process.
The valid value list of eligibility groups aligns
with those being used in the Medicaid and CHIP
Program Data System (MACPro).

ELIGIBILITYGROUP

ELG00005

ELIGIBILITYDETERMINANT
S

X(2)

5957

6058

1.1. Value must be 2 characters

2. Value must be in Eligibility Group List (VVL)
23. If value is "26", then Dual Eligible Code
value must be "06"
34. CondiLonal
45. Value is mandatory and must be provided
when associated Eligibility Determinant
EﬀecLve Date value is on or afer 1 January,
2014.
56. If value is in [ "72", ",73", ",74", ",75" ],
then associated Restricted Beneﬁts Code
value must equal "be in [1,7"] and State Plan
OpLon Type must equal "06"
67. If associated CHIP Code value isequals "2",
then value must be in [ "07", ,31", ",61" ]
78. If associated CHIP Code value isequals "3",
then value must be in [ "61", ",62", ",63",
",64", ",65", ",66", ",67", ",68" ]
8. Value must be 2 characters
9.]

9. If value is "23", then Dual Eligible Code
value must be in ["[01", ",02"]]
10. If value is "25", then Dual Eligible Code
value must be in ["[03", ",04"]]
11. If value is "24", then Dual Eligible Code
value must be "05"
ELG088

ELG.005.088

LEVEL-OF-CARESTATUS

Level Of Care
Status

Conditional

Mandatory

The level of care required to meet an
individual's needs and to determine LTSS
program eligibility.

LEVEL-OFCARE-STATUS

ELG00005

ELIGIBILITYDETERMINANT
S

X(3)

109

6159

6361

1.1. Value must be 3 characters

2. Value must be in Level of Care Status List
(VVL)
2. Value must be 3 characters
3. Conditional3. Mandatory

ELG089

ELG.005.089

SSDI-IND

SSDI Indicator

CondiLonal A ﬂag indicaLng if the individual is enrolled in
Social Security Disability Insurance (SSDI)
administered via the Social Security
AdministraLon (SSA).

SSDI-IND

ELG00005

ELIGIBILITYDETERMINANT
S

X(1)

1110

6462

1.1. Value must be 1 character

2. Value must be in SSDI Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal

ELG090

ELG.005.090

SSI-IND

SSI Indicator

CondiLonal A ﬂag indicaLng if the individual receives
Supplemental Security Income (SSI)
administered via the Social Security
AdministraLon (SSA).

SSI-IND

ELG00005

ELIGIBILITYDETERMINANT
S

X(1)

1211

6563

1.1. Value must be 1 character

2. Value must be in SSI Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal
4. Value must equal '0'"0" when SSI status
(ELG.005.092) equals '003'"000" or "003" or is

not populated
5. Value must equal "1" when SSI status
(ELG.005.092) equals "001" or "002"
ELG091

ELG.005.091

SSI-STATESUPPLEMENTSTATUS-CODE

SSI State
Supplement
Status Code

CondiLonal Indicates the individual's State Supplemental
Income Status.

SSI-STATESUPPLEMENTSTATUS-CODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(3)

1312

6664

6866

1.1. Value must be 3 characters

2. Value must be in SSI State Supplement
Status Code List (VVL)
23. (individual not receiving Federal SSI) If SSI
State Supplemental Status Codevalue is "001" or
"002", then SSI Status cannot(ELG.005.092)
must be "0001" or "003"
3. Value must be 3 characters

002"
4. Conditional(Individual not receiving Federal
SSI)If value is "001" or "002", then SSI
Indicator (ELG.005.090) must be "1"
5. Value must not be populated or must be
"000" when SSI Status (ELG.005.092) is not
populated or is "000"
6. CondiLonal
ELG092

ELG.005.092

SSI-STATUS

SSI Status

CondiLonal Indicates the individual's SSI Status.

SSI-STATUS

ELG00005

ELIGIBILITYDETERMINANT
S

X(3)

1413

6967

7169

1.1. Value must be 3 characters

2. Value must be in SSI Status List (VVL)
2. Value must be 3 characters

3. CondiLonal
4. Value must be populated whenWhen value is
"001" or "002", then SSI Indicator equals
'1'must be "1"
5. When value is "000" or "003" or not
populate, then SSI Indicator must be "0"

ELG093

ELG.005.093

STATE-SPECELIG-GROUP

State Speciﬁc
Eligibility Group

Mandatory

The composite of eligibility mapping factors
used to create the corresponding Maintenance
Assistance Status (MAS) and Basis of Eligibility
(BOE) values (before January 1, 2014) and
Eligibility -Group values (on or afer January 1,
2014). This ﬁeld should not include informaLon
that already appears elsewhere on the Eligible
File record even if it is part of the MAS and BOE
or Eligibility Group algorithm (e.g., age
informaLon computed from Date of Birth or
County Code).

ELG094

ELG.005.094

CONCEPTIONTO-BIRTH-IND

ConcepLon To
Birth Indicator

CondiLonal A ﬂag to idenLfy children eligible through the
concepLon to birth opLon, which is available
only through a separate State CHIP Program.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(6)

1514

7270

7775

1. If value is in the range [ 000000 .. 999999 ],
then associated Date of Death value must not be
before the start of the reporting period.
2.1. Value must be 6 characters or less
32. Mandatory

CONCEPTIONTO-BIRTH-IND

ELG00005

ELIGIBILITYDETERMINANT
S

X(1)

1615

7876

1.1. Value must be 1 character

2. Value must be in ConcepLon to Birth
Indicator List (VVL)
23. If the value is equal to "1", then the
Eligibility Group (ELG.005.087) must equal
"64"
34. If the value is equal to "1", then any
associated claims must indicate the Program
Type ='14'equals "14" (State Plan CHIP)
45. If the value is equal to "1", then CHIP
Code (ELG.003.054) must equal "3"
(Individual was not Medicaid Expansion CHIP
eligible, but was included in a separate Ltle
XXI CHIP Program
5. Value must be 1 character)
6. CondiLonal

ELG095

ELG096

ELG.005.095

ELG.005.096

ELIGIBILITYCHANGETERMIN
ATION-REASON

MAINTENANCEASSISTANCESTATUS

Eligibility
ChangeTerminaL
on Reason

Maintenance
Assistance Status

CondiLonal The reason for a change in an individual's eligibility

status. Report this reason when there is a change in
the individual's eligibility status.The reason for a

complete loss/terminaLon in an individual's
eligibility for Medicaid and CHIP. The end date of
the segment in which the value is reported must
represent the date that the complete
loss/terminaLon of Medicaid and CHIP eligibility
occurred. The reason for the terminaLon
represents the reason that the segment in which
it was reported was closed. If for a single
terminaLon in eligibility for a single individual
there are mulLple disLnct co-occurring values in
the state's system explaining the reason for the
terminaLon, and if one of the mulLple cooccurring values maps to T-MSIS ELIGIBILITYCHANGE-REASON value '21'; (Other) '22';
(Unknown), then the state should not report the
co-occurring value '21'; and/or '22'; to T-MSIS. If
there are mulLple co-occurring disLnct values
between '01'; and '19', then the state should
choose whichever is ﬁrst in the state's system.
Of the values that could logically co-occur in the
range of '01'; through '19', CMS does not
currently have a preference for any one value
over another. Do not populate if at the Lme
someone loses Medicaid eligibility they become
eligible for and enrolled in CHIP. Also do not
populate if at the Lme someone loses CHIP
eligibility they become eligible for and enrolled
in Medicaid.
Not
Applicable

ELIGIBILITYCHANGETERMI
NATIONREASON

ELG00005

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(2)

1716

7977

8078

1.1. Value must be 2 characters

2. Value must be in Eligibility Change Reason
List (VVL)
2. Value must be 2 characters
3.3. CondiLonal

ELIGIBILITYDETERMINANTS

X(1)

1. Not Applicable

ELG097

ELG.005.097

RESTRICTEDBENEFITS-CODE

Restricted
Beneﬁts Code

Mandatory

A ﬂag that indicates the scope of Medicaid or
CHIP beneﬁts to which an individual is enLtled
to.

RESTRICTEDBENEFITSCODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(1)

1917

8279

1.1. Value must be 1 character

2. Value must be in Restricted Beneﬁts Code
List (VVL)
23. (Restricted Beneﬁts) if value isequals "3"
and Dual Eligible Code (ELG.005.085) value
isequals "05", then Eligibility Group
(ELG.005.087) must be "24"
4. (Restricted Beneﬁts) if value equals "3" and
Dual Eligible Code (ELG.005.085) value equals
"06", then Eligibility Group (ELG.005.087)
must be "26"
35. (Restricted Beneﬁts) if value isequals "1"
and Dual Eligible Code (ELG.005.085) value
isequals "02", then Eligibility Group
(ELG.005.087) must be "23"
46. (Restricted Beneﬁts) if value isequals "1"
and Dual Eligible Code (ELG.005.085) value
isequals "04", then Eligibility Group
(ELG.005.087) must be "25"
57. (Restricted Beneﬁts) if value isequals "3",
then Dual Eligible Code (ELG.005.085) cannot
be "00"
68. Mandatory
7. If value is populated, then Eligibility Group
(ELG.005.087) must be populated.
8.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("[35", ",70")"
9. ]

10. If value is in [1,7] then Eligibility Group
(EGL.DE.087) must be in [72,73,74,75] and
State Plan OpLon Type (ELG.DE.163) must
equal "06"
11. (Restricted Pregnancy-Related) if value
isequals "4", then associated Sex
(ELG.002.023) value must be 'F'
10"F"
12. (Non-CiLzen) if value isequals "2", then

associated CiLzenship Indicator
(ELG.003.040) value must not be equal to "1"
1113. If value is "D", there must be a
corresponding MFP enrollment segment
(ELG00010) with EﬀecLve and End dates that
are within the Lmespan of this segment
12. Value must be 1 character
13.14. (Restricted Beneﬁts) if value isequals

"3" and Dual Eligible Code (ELG.005.085)
value isequals "01", then Eligibility Group
(ELG.005.087) must be "23"
1415. (Restricted Beneﬁts) if value isequals
"3" and Dual Eligible Code (ELG.005.085)
value isequals "03", then Eligibility Group
(ELG.005.087) must be "25"
1516. (Restricted Beneﬁts) if value is "3"
andG", then Dual Eligible Code (ELG.005.085)
value is "05", then Eligibility Group (ELG.005.087)
must be "24"in [01,03,06]

ELG098

ELG.005.098

TANF-CASHCODE

TANF Cash Code

CondiLonal A ﬂag that indicates whether the individual
received Federal Temporary Assistance for
Needy Families (TANF) beneﬁts.

TANF-CASHCODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(1)

2018

8380

1.1. Value must be 1 character

2. Value must be in TANF Cash Code List (VVL)
2. Value must be 1 character
3.3. CondiLonal

ELG099

ELG.005.099

ELIGIBILITYDETERMINANTEFF-DATE

Eligibility
Determinant
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

9(8)

2119

8481

9188

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG100

ELG.005.100

ELIGIBILITYDETERMINANTEND-DATE

Eligibility
Determinant
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

9(8)

2220

9289

9996

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG101

ELG.005.101

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(500)

2329

100363

599862

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG103

ELG.006.103

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00006"

STATE

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

X(2)

1.1. Value must be 2 characters

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

9(11)

ELG105

ELG.006.104

ELG.006.105

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

ELG00006

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG106

ELG.006.106

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

X(20)

2. Mandatory

ELG107

ELG.006.107

HEALTH-HOMESPA-NAME

Health Home
SPA Name

Mandatory

A free-form text ﬁeld for the name of the health
home program approved by CMS. This name
needs to be consistent across ﬁles to be used for
linking.

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

X(100)

141

1. Value must be 100 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

ELG108

ELG.006.108

HEALTH-HOMEENTITY-NAME

Health Home
EnLty Name

Mandatory

A ﬁeld to idenLfy the health home SPA in which
an individual is enrolled. Because an
idenLﬁcaLon numbering schema has not been
established, the enLLes' names are being used
instead.

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

X(100)

142

241

1. 1. Value must not contain a pipe or asterisk

symbols
2. Value must 100 characters or less
2. Value must not contain a pipe symbol

3. Mandatory

ELG109

ELG.006.109

HEALTH-HOMESPAPARTICIPATIONEFF-DATE

Health Home
SPA
ParLcipaLon
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

9(8)

242

249

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG110

ELG.006.110

HEALTH-HOMESPAPARTICIPATIONEND-DATE

Health Home
SPA
ParLcipaLon
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

9(8)

250

257

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG111

ELG.006.111

HEALTH-HOMEENTITY-EFF-DATE

Health Home
EnLty EﬀecLve
Date

Not
Applicable

Mandatory

The date on which the health home enLty was
approved by CMS to parLcipate in the Health
Home Program.

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

9(8)

258

265

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)in the form "CCYYMMDD"

2. Mandatory
ELG112

ELG.006.112

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00006

HEALTHHOME-SPAPARTICIPATION
-INFORMATION

X(500)

266

765

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG114

ELG.007.114

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00007

HEALTHHOME-SPAPROVIDERS

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00007"

STATE

ELG00007

HEALTHHOME-SPAPROVIDERS

X(2)

1.1. Value must be 2 characters

ELG.007.115

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG116

ELG.007.116

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG117

ELG.007.117

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

X(20)

2. Mandatory

ELG118

ELG.007.118

HEALTH-HOMESPA-NAME

Health Home
SPA Name

Mandatory

A free-form text ﬁeld for the name of the health
home program approved by CMS. This name
needs to be consistent across ﬁles to be used for
linking.

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

X(100)

141

1. Value must be 100 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

ELG119

ELG.007.119

HEALTH-HOMEENTITY-NAME

Health Home
EnLty Name

Mandatory

A ﬁeld to idenLfy the health home SPA in which
an individual is enrolled. Because an
idenLﬁcaLon numbering schema has not been
established, the enLLes' names are being used
instead.

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

X(100)

142

241

1. 1. Value must not contain a pipe or asterisk

The State-speciﬁc Medicaid Provider IdenLﬁer is
a state-assigned unique idenLﬁer that states
should report with all individual providers,
pracLce groups, faciliLes, and other enLLes.
This should be the idenLﬁer that is used in the

N/A

ELG120

ELG.007.120

HEALTH-HOMEPROV-NUM

Health Home
Provider
Number

Mandatory

symbols
2. Value must 100 characters or less
2. Value must not contain a pipe symbol

3. Mandatory
ELG00007

HEALTHHOME-SPAPROVIDERS

X(30)

242

271

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. Value must match Provider IdenLﬁer

state's Medicaid Management InformaLon
System.

ELG121

ELG.007.121

HEALTH-HOMESPA-PROVIDEREFF-DATE

Health Home
SPA Provider
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

(PRV.005.081)
43. Mandatory

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

9(8)

272

279

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG122

ELG.007.122

HEALTH-HOMESPA-PROVIDEREND-DATE

Health Home
Spa Provider
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

9(8)

280

287

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG123

ELG.007.123

HEALTH-HOMEENTITY-EFF-DATE

Health Home
EnLty EﬀecLve
Date

Mandatory

The date on which the health home enLty was
approved by CMS to parLcipate in the Health
Home Program.

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

9(8)

288

295

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Mandatory

ELG124

ELG.007.124

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG126

ELG.008.126

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00007

HEALTHHOME-SPAPROVIDERS

X(500)

296

795

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00008

HEALTHHOMECHRONICCONDITIONS

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00008"

STATE

ELG00008

HEALTHHOMECHRONICCONDITIONS

X(2)

1.1. Value must be 2 characters

HEALTHHOMECHRONICCONDITIONS

9(11)

ELG128

ELG.008.127

ELG.008.128

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

ELG00008

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG129

ELG130

ELG.008.129

ELG.008.130

MSISIDENTIFICATIONNUM

HEALTH-HOMECHRONICCONDITION

MSIS
IdenLﬁcaLon
Number

Health Home
Chronic
CondiLon

Mandatory

N/A

The chronic condiLon used to determine the
individual's eligibility for the health home
provision.

HEALTH-HOMECHRONICCONDITION

ELG00008

HEALTHHOMECHRONICCONDITIONS

X(20)

2. Mandatory

ELG00008

HEALTHHOMECHRONICCONDITIONS

X(1)

1.1. Value must be 1 character

2. Value must be in Health Home Chronic
CondiLon List (VVL)
23. If value equals "H,", associated Health
Home Chronic CondiLon Other ExplanaLon
must be provided
3. Value must be 1 character
4.4. Mandatory

ELG131

ELG.008.131

HEALTH-HOMECHRONICCONDITIONOTHEREXPLANATION

Health Home
Chronic
CondiLon Other
ExplanaLon

CondiLonal A free-text ﬁeld to capture the descripLon of
the other chronic condiLon (or condiLons)
when value "H" (Other) appears in the HealthHOME-CHRONIC-CONDITION. Home Chronic
CondiLon data element.

N/A

ELG00008

HEALTHHOMECHRONICCONDITIONS

X(50)

1. Value must be 50 characters or less
2. If associated Health Home Chronic
CondiLon (ELG.008.130) value equals "H",
then value is mandatory and must be
providedpopulated
3. Value must not contain a pipe or asterisk

symbols
4. CondiLonal

ELG132

ELG.008.132

HEALTH-HOMECHRONICCONDITION-EFFDATE

Health Home
Chronic
CondiLon
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00008

HEALTHHOMECHRONICCONDITIONS

9(8)

100

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG133

ELG.008.133

HEALTH-HOMECHRONICCONDITIONEND-DATE

Health Home
Chronic
CondiLon End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00008

HEALTHHOMECHRONICCONDITIONS

9(8)

101

108

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG134

ELG.008.134

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00008

HEALTHHOMECHRONICCONDITIONS

X(500)

109

608

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG136

ELG.009.136

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00009

LOCK-ININFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00009"

STATE

ELG00009

LOCK-ININFORMATION

X(2)

1.1. Value must be 2 characters

ELG.009.137

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG138

ELG.009.138

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00009

LOCK-ININFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG139

ELG140

ELG141

ELG.009.139

ELG.009.140

ELG.009.141

MSISIDENTIFICATIONNUM

LOCKIN-PROVNUM

LOCKIN-PROVTYPE

MSIS
IdenLﬁcaLon
Number

Lockin Provider
Num

Lockin Provider
Type

Mandatory

N/A

A code describing the provider type
classiﬁcaLon for which the provider/beneﬁciary
lock-in relaLonship exists.

PROV-TYPE

ELG00009

LOCK-ININFORMATION

X(20)

2. Mandatory

ELG00009

LOCK-ININFORMATION

X(30)

1. Value must be 30 characters or less
2. Value must be reported in Provider Identifier
(PRV.005.080) with an associated Provider
Identifier Type (PRV.005.081) equal to '1'
3. Mandatory
4. Value must match Provider Identifier
(PRV.005.081)

ELG00009

LOCK-ININFORMATION

X(2)

1. Value must be 2 characters
2. Value must be in Lockin Provider Type Code
List (VVL)
2. Value must be 2 characters

3. Mandatory

ELG142

ELG.009.142

LOCKIN-EFFDATE

Lockin EﬀecLve
Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00009

LOCK-ININFORMATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG143

ELG.009.143

LOCKIN-ENDDATE

Lockin End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00009

LOCK-ININFORMATION

9(8)

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG144

ELG.009.144

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00009

LOCK-ININFORMATION

X(500)

910

9093

5892

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG146

ELG.010.146

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00010

MFPINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00010"

STATE

ELG00010

MFPINFORMATION

X(2)

1.1. Value must be 2 characters

ELG.010.147

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG148

ELG.010.148

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00010

MFPINFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG149

ELG150

ELG.010.149

ELG.010.150

MSISIDENTIFICATIONNUM

MFP-LIVESWITH-FAMILY

MSIS
IdenLﬁcaLon
Number

MFP Lives with
Family

Mandatory

N/A

A code indicaLng if the individual lives with
his/her family or is not a parLcipant in the MFP
program.

MFP-LIVESWITH-FAMILY

ELG00010

MFPINFORMATION

X(20)

2. Mandatory

ELG00010

MFPINFORMATION

X(1)

1.1. Value must be 1 character

2. Value must be in MFP Lives with Family List
(VVL)
2. Value must be 1 character
3.3. Mandatory

ELG151

ELG.010.151

MFP-QUALIFIEDINSTITUTION

MFP Qualiﬁed
InsLtuLon

Mandatory

A code describing type of qualiﬁed insLtuLon at
the Lme of transiLon to the community for an
eligible MFP DemonstraLon parLcipant.

MFPQUALIFIEDINSTITUTION

ELG00010

MFPINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in MFP Qualiﬁed InsLtuLon
List (VVL)
2. Value must be 2 characters
3.3. Mandatory

ELG152

ELG.010.152

MFP-QUALIFIEDRESIDENCE

MFP Qualiﬁed
Residence

Mandatory

A code describing indicaLng the type of qualiﬁed
institution at the time of transition to the community
for an eligible MFP Demonstration
participantresidence.

MFPQUALIFIEDRESIDENCE

ELG00010

MFPINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in MFP Qualiﬁed Residence
List (VVL)
2. Value must be 2 characters
3.3. Mandatory

ELG153

ELG.010.153

MFP-REASONPARTICIPATIONENDED

MFP Reason
ParLcipaLon
Ended

CondiLonal A code describing why an individual's
parLcipaLon in Money Follows the Person
demonstraLon ended.

MFP-REASONELG00010
PARTICIPATIONENDED

MFPINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in MFP Reason ParLcipaLon
Ended List (VVL)
2. Value must be 2 characters
3.3. CondiLonal

4. Value must not be populated when
Enrollment End Date equals '"9999-12-31'31"
5. Value must be populated when Enrollment
End Date does not equal "9999-12-31"
ELG154

ELG155

ELG.010.154

ELG.010.155

MFPREINSTITUTIONA
LIZED-REASON

MFPENROLLMENTEFF-DATE

MFP
ReinsLtuLonaliz
ed Reason

MFP Enrollment
EﬀecLve Date

CondiLonal A code describing why the individual was
reinsLtuLonalized afer parLcipaLon in the
Money Follows the Person DemonstraLon.

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

MFPREINSTITUTION
ALIZEDREASON

ELG00010

N/A

ELG00010

MFPINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in MFP ReinsLtuLonalized
Reason List (VVL)
2. Value must be 2 characters

3. CondiLonal
MFPINFORMATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG156

ELG.010.156

MFPENROLLMENTEND-DATE

MFP Enrollment
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00010

MFPINFORMATION

9(8)

as the associated Segment EﬀecLve Date
value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]

ELG157

ELG.010.157

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG159

ELG.011.159

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00010

MFPINFORMATION

X(500)

566

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00011

STATE-PLANOPTIONPARTICIPATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00011"

STATE

ELG00011

STATE-PLANOPTIONPARTICIPATION

X(2)

1.1. Value must be 2 characters

ELG.011.160

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)

ELG161

ELG162

ELG163

ELG.011.161

ELG.011.162

ELG.011.163

RECORDNUMBER

MSISIDENTIFICATIONNUM

STATE-PLANOPTION-TYPE

Record Number

MSIS
IdenLﬁcaLon
Number

State Plan
OpLon Type

Mandatory

N/A

This ﬁeld speciﬁes the State Plan OpLons in
which the individual is enrolled. Use on
occurrence for each State Plan OpLon
enrollment.

STATE-PLANOPTION-TYPE

ELG00011

STATE-PLANOPTIONPARTICIPATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG00011

STATE-PLANOPTIONPARTICIPATION

X(20)

2. Mandatory

ELG00011

STATE-PLANOPTIONPARTICIPATION

X(2)

1.1. Value must be 2 characters

2. Value must be in State Plan OpLon Type
List (VVL)
23. If associated Eligibility Group
(ELG.005.087) value is in [ "72", ",73", ",74", ",
75" ], and Restricted Beneﬁts Code
(ELG.DE.097) is in [1,7], then value must be
"06"
3. Value must be 2 characters

4. Mandatory
5. Value must equal '02' when Program Type
(CIP.002.129) equals '13'
6. Value must equal '02' when Program Type
(COT.002.065) equals '13'

ELG164

ELG.011.164

STATE-PLANOPTION-EFFDATE

State Plan
OpLon EﬀecLve
Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00011

STATE-PLANOPTIONPARTICIPATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG165

ELG.011.165

STATE-PLANOPTION-ENDDATE

State Plan
OpLon End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00011

STATE-PLANOPTIONPARTICIPATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
ELG166

ELG.011.166

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00011

STATE-PLANOPTIONPARTICIPATION

X(500)

559

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG168

ELG.012.168

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00012

WAIVERPARTICIPATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00012"

STATE

ELG00012

WAIVERPARTICIPATION

X(2)

1.1. Value must be 2 characters

ELG.012.169

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG170

ELG.012.170

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00012

WAIVERPARTICIPATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG171

ELG.012.171

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00012

WAIVERPARTICIPATION

X(20)

2. Mandatory

ELG172

ELG173

ELG.012.172

ELG.012.173

WAIVER-ID

WAIVER-TYPE

Waiver ID

Eligible Waiver
Type

Mandatory

Field specifying the waiver or demonstraLon
which authorized payment for a claim. These IDs
must be the approved, full federal waiver ID
number assigned during the state submission
and CMS approval process. Waiver IDs should
actually only be the "core" part of the waiver
IDs, without including suﬃxes for renewals or
amendments.

N/A

Code for specifying waiver types under which
the eligible individual is covered during the
month.

WAIVER-TYPE

ELG00012

WAIVERPARTICIPATION

X(20)

1.1. Value must be 20 characters or less

2. Value must be associated with a populated
Waiver Type
2. Value must be 20 characters or less
3.3. (1115 demonstraLon waivers) If value

WAIVERPARTICIPATION

X(2)

1.1. Value must be 2 characters

2. Value must be in Waiver Type List (VVL)
23. Value must have a corresponding value in
Waiver ID (ELG.012.172)
34. Mandatory
4. Value must be 2 characters

ELG174

ELG.012.174

WAIVERENROLLMENTEFF-DATE

Waiver
Enrollment
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00012

WAIVERPARTICIPATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20'19,20,99]

ELG175

ELG.012.175

WAIVERENROLLMENTEND-DATE

Waiver
Enrollment End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00012

WAIVERPARTICIPATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
ELG176

ELG.012.176

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG178

ELG.013.178

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00012

WAIVERPARTICIPATION

X(500)

579

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00013

LTSSPARTICIPATION

X(8)

1. Mandatory
2. Value must be 8 characters
3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00013"

etc.). The last 5 digits are the segment idenLﬁer
padded with leading zeros (e.g., 00001, 00002,
00003, etc.).

ELG179

ELG.013.179

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

ELG00013

LTSSPARTICIPATION

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG180

ELG.013.180

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00013

LTSSPARTICIPATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG181

ELG182

ELG.013.181

ELG.013.182

MSISIDENTIFICATIONNUM

LTSS-LEVEL-CARE

MSIS
IdenLﬁcaLon
Number

LTSS Level of
Care

Mandatory

N/A

The level of care provided to the individual by
the long term care facility.

LTSS-LEVELCARE

ELG00013

LTSSPARTICIPATION

X(20)

2. Mandatory

ELG00013

LTSSPARTICIPATION

X(1)

1. Value must be 1 character
2. Value must be in LTSS Level of Care List
(VVL)
2. Value must be 1 character

3. Mandatory
ELG183

ELG.013.183

LTSS-PROV-NUM

LTSS Provider
Num

Mandatory

A unique idenLﬁcaLon number assigned by the
state to the long term care facility furnishing
healthcare services to the individual.

N/A

ELG00013

LTSSPARTICIPATION

X(30)

ELG184

ELG.013.184

LTSS-ELIGIBILITYEFF-DATE

LTSS Eligibility
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00013

LTSSPARTICIPATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG185

ELG.013.185

LTSS-ELIGIBILITYEND-DATE

LTSS Eligibility
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00013

LTSSPARTICIPATION

9(8)

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG186

ELG.013.186

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00013

LTSSPARTICIPATION

X(500)

588

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG188

ELG.014.188

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00014

MANAGEDCAREPARTICIPATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00014"

STATE

ELG00014

MANAGEDCAREPARTICIPATION

X(2)

1.1. Value must be 2 characters

ELG.014.189

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG190

ELG.014.190

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00014

MANAGEDCAREPARTICIPATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG191

ELG192

ELG.014.191

ELG.014.192

MSISIDENTIFICATIONNUM

MANAGEDCARE-PLAN-ID

MSIS
IdenLﬁcaLon
Number

Managed Care
Plan ID

Mandatory

N/A

The managed care plan idenLﬁcaLon number
under which the eligible individual is enrolled.
See T-MSIS Guidance Document, "CMS
Guidance: Best PracLce for ReporLng ManagedCare-Plan-ID in the Eligible File".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47565reporLngmanagedcareplantype-in-the-eligible-ﬁlemanaged-care/

N/A

See T-MSIS Guidance Document, "CMS
Guidance: Preliminary guidance for Primary
Care Case Management ReporLng".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msis-

ELG00014

MANAGEDCAREPARTICIPATION

X(20)

2. Mandatory

ELG00014

MANAGEDCAREPARTICIPATION

X(12)

1.1. Value must be 12 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 12 characters or less
3.3. Value reported must match the value

reported on State Plan IdenLﬁcaLon Number
(MCR.002.019)
4. Mandatory

coding-blog/entry/52896cms-guidance-primarycare-case-management-reporLng-updated/

ELG193

ELG.014.193

MANAGEDCARE-PLAN-TYPE

Managed Care
Plan Type

Mandatory

A model of health care delivery organized to
provide a deﬁned set of services. See T-MSIS
Guidance Document, "CMS Guidance: Best
PracLce for ReporLng Non-Emergency Medical
TransportaLon (NEMT) Prepaid Ambulatory
Health Plans (PAHPs) in the T-MSIS Managed
Care File"
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/dataguide/t-msis-codingblog/reporLng-nonemergency-medicaltransportaLon-nemt-prepaid-ambulatoryhealth-plans-pahps-in-the-tmsisblog/entry/47540managed-care-ﬁlemanagedcare/
See T-MSIS Guidance Document, "CMS
Guidance: Best PracLce for ReporLng Managed
Care Plan Type in the T-MSIS Managed Care File"
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msis-

MANAGEDCARE-PLANTYPE

ELG00014

MANAGEDCAREPARTICIPATION

X(2)

1.1. Value must be 2 characters

2. Value must be in Managed Care Plan Type
List (VVL)
2. Value must be 2 characters
3.3. Mandatory
4. Value must not be populated when Managed
Care Plan ID (ELG.014.192) is not populated
5. Value must equal the Managed Care Plan

Type (MCR.002.024) associated with the
State Plan IdenLﬁcaLon Number
(MCR.002.018)

coding-blog/entry/47564reporLngmanagedcareplantype-in-the-t-msis-managedcare-ﬁle-managed-care/

ELG194

ELG.014.194

NATIONALHEALTH-CAREENTITY-ID

National Health
Care Entity ID

Not
Applicable

N/A

ELG00014

MANAGEDCAREPARTICIPATION

X(10)

1. Not Applicable

ELG195

ELG.014.195

NATIONALHEALTH-CAREENTITY-ID-TYPE

National Health
Care Entity ID
Type

Not
Applicable

N/A

ELG00014

MANAGEDCAREPARTICIPATION

X(1)

1. Not Applicable

ELG196

ELG.014.196

MANAGEDCARE-PLANENROLLMENTEFF-DATE

Managed Care
Plan Enrollment
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00014

MANAGEDCAREPARTICIPATION

9(8)

6756

7463

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG197

ELG.014.197

MANAGEDCARE-PLANENROLLMENTEND-DATE

Managed Care
Plan Enrollment
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00014

MANAGEDCAREPARTICIPATION

9(8)

108

7564

8271

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG198

ELG.014.198

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00014

MANAGEDCAREPARTICIPATION

X(500)

119

8372

582571

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG200

ELG.015.200

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00015

ETHNICITYINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00015"

STATE

ELG00015

ETHNICITYINFORMATION

X(2)

1.1. Value must be 2 characters

ELG.015.201

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG202

ELG.015.202

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00015

ETHNICITYINFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG203

ELG.015.203

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00015

ETHNICITYINFORMATION

X(20)

2. Mandatory

ELG204

ELG.015.204

ETHNICITY-CODE

Ethnicity Code

Mandatory

A code indicaLng that the individual's ethnicity
is Hispanic, LaLno/a, or Spanish ethnicity of a
Medicaid/CHIP enrolled individual.

ETHNICITYCODE

ELG00015

ETHNICITYINFORMATION

X(1)

1.1. Value must be 1 character

2. Value must be in Ethnicity Code List (VVL)
2. Value must be 1 character
3.3. Mandatory

Ethnicity Code clariﬁcaLons:
If state has beneﬁciaries coded in their database
as "Hispanic" or "LaLno," then code them in TMSIS as "Hispanic or LaLno Unknown" (valid
value "5"). DO NOT USE "Another Hispanic,
LaLno, or Spanish Origin," "Ethnicity Unknown"
or "Ethnicity Unspeciﬁed."
NOTE 1: The "Ethnicity Unspeciﬁed" category in
T-MSIS (valid value "6") should be used with an
individual who explicitly did not provide
informaLon or refused to answer a quesLon.
ELG205

ELG.015.205

ETHNICITYDECLARATIONEFF-DATE

Ethnicity
DeclaraLon
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00015

ETHNICITYINFORMATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG206

ELG.015.206

ETHNICITYDECLARATIONEND-DATE

Ethnicity
DeclaraLon End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00015

ETHNICITYINFORMATION

9(8)

as the associated Segment EﬀecLve Date

value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]

ELG207

ELG.015.207

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG209

ELG.016.209

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00015

ETHNICITYINFORMATION

X(500)

5984

5583

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00016

RACEINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00016"

STATE

ELG00016

RACEINFORMATION

X(2)

1.1. Value must be 2 characters

ELG.016.210

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)

ELG211

ELG212

ELG.016.211

ELG.016.212

RECORDNUMBER

MSISIDENTIFICATIONNUM

Record Number

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

ELG00016

RACEINFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG00016

RACEINFORMATION

X(20)

2. Mandatory

ELG213

ELG.016.213

RACE

Race

Mandatory

A code indicaLng the individual's race either in
accordance with requirements of SecLon 4302
of the Aﬀordable Care Act classiﬁcaLons.
Race Code clariﬁcaLons:
If state has beneﬁciaries coded in their database
as "Asian" with no addiLonal detail, then code
them in T-MSIS as "Asian Unknown" (valid value
"011"). DO NOT USE "Other Asian,"
"Unspeciﬁed" or "Unknown."
". If state has beneﬁciaries coded in their
database as "NaLve Hawaiian or Other Paciﬁc
Islander" with no addiLonal detail, then code
them in T-MSIS as "NaLve Hawaiian and Other
Paciﬁc Islander Unknown" (valid value "016").
DO NOT USE "Native Hawaiian," "Other Pacific
Islander," "Unspecified" or "Unknown." DO NOT

USE "NaLve Hawaiian," "Other Paciﬁc Islander,"
"Unspeciﬁed" or "Unknown".
If state has beneﬁciaries coded in their database
as "Other" with no addiLonal detail or in a
category that is not available in the code set
provided, then code them in T-MSIS as "Other"
(valid value "018"), but only use "Other" if the
use of "Other Asian" or "Other Paciﬁc Islander"
are not appropriate. DO NOT USE "Unspeciﬁed"
or "Unknown". The "Other" valid value was
added to T-MSIS to beaer align T-MSIS with the
single-streamlined applicaLon and to
accommodate some atypical states, despite the
requirements of SecLon 4302 of the ACA.
NOTE 1: The "Other Asian" category in T-MSIS
(valid value "010") should be used in situaLons
in which an individual's speciﬁc Asian subgroup

RACE

ELG00016

RACEINFORMATION

X(3)

1.1. Value must be 3 characters

2. Value must be in Race List (VVL)
2. Value must be 3 characters

3. Mandatory

is not available in the code set provided (e.g.,
Malaysian, Burmese).
NOTE 2: The "Unspeciﬁed" category in T-MSIS
(valid value "017") should be used with an
individual who explicitly did not provide
informaLon or refused to answer a quesLon.

ELG214

ELG.016.214

RACE-OTHER

Race Other

CondiLonal A freeform ﬁeld to document the race of the
beneﬁciary when the beneﬁciary idenLﬁes
themselves as Other Asian, Other Paciﬁc
Islander (race codes 010 or 015).

N/A

ELG00016

RACEINFORMATION

X(25)

1.1. Value must be 25 characters or less

2. If associated Race (ELG.016.213) value is in
[ "010", ",015" ,018], then value must be
populated.
2

3. Value must not contain a pipe or asterisk
symbol

3. Value must be 25 characters or less
4.4. CondiLonal

ELG215

ELG.016.215

AMERICANINDIANALASKANNATIVEINDICATOR

American Indian CondiLonal "'American Indian or Alaska NaLve"' means any
Alaskan NaLve
individual deﬁned at 25 USC 1603(13), 1603(28),
Indicator
or 1679(a), or who has been determined eligible
as an Indian, pursuant to 42 CFR 136.12. This
means the individual: a. Is a member of a
Federally-recognized Indian tribe; b. Resides in
an urban center and meets one or more of the
following four criteria: i. Is a member of a tribe,
band, or other organized group of Indians,
including those tribes, bands, or groups
terminated since 1940 and those recognized
now or in the future by the State in which they
reside, or who is a descendant, in the ﬁrst or
second degree, of any such member; ii. Is an
Eskimo or Aleut or other Alaska NaLve; iii. Is
considered by the Secretary of the Interior to be
an Indian for any purpose; or iv. Is determined
to be an Indian under regulaLons promulgated
by the `'Secretary of Health and Human
Services; c. Is considered by the Secretary of the
Interior to be an Indian for any purpose; or d. Is
considered by the Secretary of Health and
Human Services to be an Indian for purposes of
eligibility for Indian health care services,
including as a California Indian, Eskimo, Aleut, or
other Alaska NaLve. NOTE Applicants who
complete Appendix B of the
Marketplace/Medicaid applicaLon and respond
aﬃrmaLvely to the two quesLons shown below
are considered to meet the deﬁniLon of an
American Indian/Alaskan NaLve. Are you a

AMERICANINDIANALASKANATIVEINDICATOR

ELG00016

RACEINFORMATION

X(1)

1.1. Value must be 1 character

2. Value must be in American Indian Alaskan
NaLve Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal

member of a federally recognized tribe? Has this
person ever goaen a service from the Indian
Health Service, a tribal health program, or urban
Indian health program, or through a referral
from one of these programs?

ELG216

ELG.016.216

RACEDECLARATIONEFF-DATE

Race
DeclaraLon
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00016

RACEINFORMATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20'19,20,99]

ELG217

ELG.016.217

RACEDECLARATIONEND-DATE

Race
DeclaraLon End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00016

RACEINFORMATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
ELG218

ELG.016.218

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG220

ELG.017.220

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00016

RACEINFORMATION

X(500)

586

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00017

DISABILITYINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00017"

padded with leading zeros (e.g., 00001, 00002,
00003, etc.).

ELG221

ELG.017.221

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

ELG00017

DISABILITYINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG222

ELG.017.222

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00017

DISABILITYINFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG223

ELG224

ELG.017.223

ELG.017.224

MSISIDENTIFICATIONNUM

DISABILITY-TYPECODE

MSIS
IdenLﬁcaLon
Number

Disability Type
Code

Mandatory

Conditional

Mandatory

ELG00017

DISABILITYINFORMATION

X(20)

N/A

DISABILITYTYPE-CODE

ELG00017

DISABILITYINFORMATION

X(2)

1. Not Applicable
2. Value must be 2 characters
2. Value must be in Disability Type Code List
(VVL)
3. ConditionalMandatory

N/A

ELG00017

DISABILITYINFORMATION

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Mandatory

in accordance with requirements of SecLon
4302 of the Aﬀordable Care Act.
ELG225

ELG.017.225

DISABILITY-TYPEEFF-DATE

Disability Type
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20'19,20,99]

ELG226

ELG.017.226

DISABILITY-TYPEEND-DATE

Disability Type
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00017

DISABILITYINFORMATION

9(8)

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG227

ELG.017.227

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG229

ELG.018.229

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00017

DISABILITYINFORMATION

X(500)

559

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00018

1115ADEMONSTRATI
ONINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00018"

etc.). The last 5 digits are the segment idenLﬁer
padded with leading zeros (e.g., 00001, 00002,
00003, etc.).

ELG230

ELG231

ELG.018.230

ELG.018.231

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

N/A

ELG00018

1115ADEMONSTRATI
ONINFORMATION

X(2)

1115ADEMONSTRATI
ONINFORMATION

9(11)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG232

ELG233

ELG234

ELG.018.232

ELG.018.233

ELG.018.234

MSISIDENTIFICATIONNUM

1115ADEMONSTRATIO
N-IND

1115A-EFF-DATE

MSIS
IdenLﬁcaLon
Number

1115A
DemonstraLon
Indicator

1115A EﬀecLve
Date

Mandatory

N/A

1115ADEMONSTRATI
ONINFORMATION

X(20)

2. Mandatory

CondiLonal Indicates that the individual parLcipates in an
1115(A)1115A demonstraLon. 1115(A)1115A is a
Center for Medicare and Medicaid InnovaLon
(CMMI) demonstraLon.

1115ADEMONSTRATI
ON-IND

Mandatory

N/A

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

ELG00018

1115ADEMONSTRATI
ONINFORMATION

X(1)

1115ADEMONSTRATI
ONINFORMATION

9(8)

1.1. Value must be 1 character

2. Value must be in 1115A DemonstraLon
Indicator List (VVL)
2. Value must be 1 character
3.3. CondiLonal

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20'19,20,99]

ELG235

ELG.018.235

1115A-ENDDATE

1115A End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00018

1115ADEMONSTRATI
ONINFORMATION

9(8)

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG236

ELG.018.236

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG238

ELG.020.238

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00018

1115ADEMONSTRATI
ONINFORMATION

X(500)

558

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

ELG00020

HCBSCHRONICCONDITIONSNON-HEALTHHOME

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00020"

etc.). The last 5 digits are the segment idenLﬁer
padded with leading zeros (e.g., 00001, 00002,
00003, etc.).

ELG239

ELG240

ELG.020.239

ELG.020.240

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

N/A

ELG00020

HCBSCHRONICCONDITIONSNON-HEALTHHOME

X(2)

HCBSCHRONICCONDITIONSNON-HEALTHHOME

9(11)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG241

ELG242

ELG243

ELG.020.241

ELG.020.242

ELG.020.243

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

HCBS-CHRONICCONDITIONNON-HEALTHHOME-CODE

HCBS Chronic
CondiLon Non
Health Home
Code

Mandatory

HCBS-CHRONICCONDITIONNON-HEALTHHOME-EFF-DATE

HCBS Chronic
CondiLon Non
Health Home
EﬀecLve Date

Mandatory

N/A

The chronic condiLon for which the eligible
person is receiving non-Health-Home home and
community based care.

HCBSCHRONICCONDITIONNON-HEALTHHOME-CODE

ELG00020

N/A

ELG00020

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

ELG00020

HCBSCHRONICCONDITIONSNON-HEALTHHOME

X(20)

2. Mandatory

HCBSCHRONICCONDITIONSNON-HEALTHHOME

X(3)

HCBSCHRONICCONDITIONSNON-HEALTHHOME

9(8)

1.1. Value must be 3 characters

2. Value must be in HCBS Chronic CondiLon
Non Health Home Code List (VVL)
2. Value must be 3 characters
3.3. Mandatory

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20'19,20,99]

ELG244

ELG.020.244

HCBS-CHRONICCONDITIONNON-HEALTHHOME-ENDDATE

HCBS Chronic
CondiLon Non
Health Home
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00020

HCBSCHRONICCONDITIONSNON-HEALTHHOME

9(8)

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG245

ELG.020.245

STATE-NOTATION

State NotaLon

OpSituaLo

nal

ELG247

ELG.001.247

SEQUENCENUMBER

Sequence
Number

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00020

HCBSCHRONICCONDITIONSNON-HEALTHHOME

X(500)

560

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

N/A

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(4)

1415

7981

8284

1.1. Value must be 4 characters or less

5. Mandatory

ELG248

ELG.021.248

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00021

ENROLLMENTTIME-SPANSEGMENT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00021"

STATE

ELG00021

ENROLLMENTTIME-SPANSEGMENT

X(2)

1.1. Value must be 2 characters

ELG.021.249

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG250

ELG.021.250

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00021

ENROLLMENTTIME-SPANSEGMENT

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG251

ELG252

ELG.021.251

ELG.021.252

MSISIDENTIFICATIONNUM

ENROLLMENTTYPE

MSIS
IdenLﬁcaLon
Number

Mandatory

Enrollment Type Mandatory

N/A

IdenLfy the type of enrollment that the eligible
person has been enrolled into as either
Medicaid/Medicaid Expansion CHIP or Separate
CHIP.

ENROLLMENTTYPE

ELG00021

ENROLLMENTTIME-SPANSEGMENT

X(20)

2. Mandatory

ELG00021

ENROLLMENTTIME-SPANSEGMENT

X(1)

1. Value must be in Enrollment Type List (VVL)
2. Value must be 1 character
3. If value equals "1,", then associated CHIP
Code (ELG.003.054) value must be in [1, 2]
4. If value equals "2,", then associated CHIP
Code (ELG.003.054) value must be "3"
5. A person enrolled in Medicaid/CHIP must
have a primary eligibility group classiﬁcaLon
for any given day of enrollment. (There may
or may not be a secondary eligibility group
classiﬁcaLon for that same day.)
6. Mandatory

ELG253

ELG.021.253

ENROLLMENTEFF-DATE

Enrollment
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00021

ENROLLMENTTIME-SPANSEGMENT

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG254

ELG.021.254

ENROLLMENTEND-DATE

Enrollment End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00021

ENROLLMENTTIME-SPANSEGMENT

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on in the form "CCYYMMDD"
2. Value must be the leap year, never April
31stafer or Sept 31st)
3. Value must be greater than or equal tothe

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
ELG255

ELG.021.255

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00021

ENROLLMENTTIME-SPANSEGMENT

X(500)

558

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

ELG257

ELG.022.257

RECORD-ID

Record ID

Mandatory

RECORD-ID

ELG00022

ELIGIBLEIDENTIFIERELG-

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00022"

X(2)

1.1. Value must be 2 characters

IDENTIFIERS

ELG.022.258

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

ELG00022

ELIGIBLEIDENTIFIERELG-

2. Value must be in State Code List (VVL)

IDENTIFIERS

2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (ELG.001.007)
ELG259

ELG.022.259

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00022

ELIGIBLEIDENTIFIERELG-

IDENTIFIERS

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

ELG260

ELG261

ELG.022.260

ELG.022.261

MSISIDENTIFICATIONNUM

ELG-IDENTIFIERTYPE

MSIS
IdenLﬁcaLon
Number

Eligible
IdenLﬁer Type

Mandatory

N/A

A code to idenLfy the kind of eligible idenLﬁer
that is captured in the Eligible IdenLﬁer data
element.

ELGIDENTIFIERTYPE

ELG00022

ELIGIBLEIDENTIFIERELG-

X(20)

IDENTIFIERS

2. Mandatory

ELG00022

ELIGIBLEIDENTIFIERELG-

X(1)

1.1. Value must be 1 character

2. Value must be in Eligible IdenLﬁer Type List
(VVL)

IDENTIFIERS

2. Value must be 1 character
3.3. Mandatory

ELG262

ELG.022.262

ELG-IDENTIFIERISSUING-ENTITYID

Eligible
IdenLﬁer
Issuing EnLty
IdenLﬁer

OpSituaLo

nal

This data element is reserved for future use.

N/A

ELG00022

ELIGIBLEIDENTIFIERELG-

IDENTIFIERS

X(18)

1. Value must be 18 characters or less
2. OpSituaLonal

ELG263

ELG.022.263

ELG-IDENTIFIEREFF-DATE

Eligible
IdenLﬁer
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00022

ELIGIBLEIDENTIFIERELG-

9(8)

IDENTIFIERS

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
ELG264

ELG.022.264

ELG-IDENTIFIEREND-DATE

Eligible
IdenLﬁer End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00022

ELIGIBLEIDENTIFIERELG-

IDENTIFIERS

9(8)

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]

ELG265

ELG.022.265

ELG-IDENTIFIER

Eligible
IdenLﬁer

Mandatory

A data element to capture the various idenLﬁers
assigned to Medicaid and CHIP beneﬁciary by
various enLLes. The speciﬁc type of idenLﬁer is
shown in the corresponding value in the Eligible
IdenLﬁer Type data element. States should
provide all Old MSIS IdenLﬁcaLon Number with
Eligible IdenLﬁer Type = 2 to T-MSIS in case the
state changes the MSIS IdenLﬁcaLon Number of
a beneﬁciary. The state should submit updates
to T-MSIS whenever an idenLﬁer is reLred or
issued.
States should provide Old MSIS IdenLﬁcaLon
Number with Reason for Change = 'MERGE' to TMSIS if the state was reporLng mulLple MSIS
IdenLﬁcaLon Numbers for a single beneﬁciary
and merges them under a single MSIS
IdenLﬁcaLon Number.
States should provide Old MSIS IdenLﬁcaLon
Number with Reason for Change = 'UNMERGE'
to T-MSIS if the state unmerges a beneﬁciary
from another beneﬁciary. For example, if a
newborn child is originally reported with the
mother's MSIS IdenLﬁcaLon Number and is
then assigned a diﬀerent MSIS IdenLﬁcaLon
Number.
States should provide Old MSIS IdenLﬁcaLon
Number with Reason for Change = 'LSE' to TMSIS if the state assigns a new MSIS
IdenLﬁcaLon Number to any beneﬁciaries
during large system enhancement in state
MMIS.
States should provide Old MSIS IdenLﬁcaLon
Number with Reason for Change = 'TCAM' to T-

N/A

ELG00022

ELIGIBLEIDENTIFIERELG-

IDENTIFIERS

X(20)

1. Value must be 20 characters or less
2. Mandatory
3. Must not contain a pipe symbol

MSIS if the Medicaid and Separate CHIP
programs use diﬀerent MSIS IdenLﬁer Number
schemas and beneﬁciaries are transferred from
CHIP to Medicaid or from Medicaid to CHIP and
a new MSIS IdenLﬁcaLon Number is issued.

ELG266

ELG.022.266

REASON-FORCHANGE

Reason for
Change

CondiLonal A code to idenLfy the reason for changing the
MSIS IdenLﬁcaLon Number of a beneﬁciary and
only required for ELG-IDENTIFIER-TYPEEligible
IdenLﬁer Type = '2-Old MSIS IdenLﬁcaLon
Number'. For example, If MSIS IdenLﬁcaLon
Number of a beneﬁciary is being changed due to
'Merge with other MSIS ID' or 'Unmerge'.

REASON-FORCHANGE

ELG00022

ELIGIBLEIDENTIFIERELG-

IDENTIFIERS

X(10)

106

1.1. Value must be 10 characters or less

2. Value must be in Reason for Change List
(VVL)
2. Value must be 10 characters or less
3.3. CondiLonal

4. (Old MSIS IdenLﬁcaLon Number) value
must be populated when Eligible IdenLﬁer
Type (ELG.022.261) equals '2'"2"

ELG267

ELG.022.267

STATE-NOTATION

State NotaLon

OpSituaLo

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

CondiLonal This data element provides the beneﬁciary's or
their household's income as a percentage of the
federal poverty level. Used to assign the
beneﬁciary to the eligibility group that covered
their Medicaid or CHIP beneﬁts. If the
beneﬁciary's income was assessed using
mulLple methodologies (MAGI and Non-MAGI),
report the income that applies to their primary
eligibility group.

N/A

ELG00003

TYPE-OFSERVICE

ELG00009

nal

ELG269

ELG.003.269

ELIGIBLEFEDERALPOVERTY-LEVELPERCENTAGE

Eligible Federal
Poverty Level
Percentage

ELG00022

ELIGIBLEIDENTIFIERELG-

X(500)

107

606

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

VARIABLE9(3)
DEMOGRAPHIC
S-ELIGIBILITY

167

169

1. Value must be between 000 and 400
inclusively
2. CondiLonal

LOCK-ININFORMATION

1. Value must be 3 characters
2. CondiLonal
3. Value must be in Type of Service List (VVL)

IDENTIFIERS

ELG.009.270

LOCKED-INSRVCS

Locked In
Services

CondiLonal The type(s) of services that are locked-in.

X(3)

ELG271

ELG.015.271

ETHNICITYOTHER

Ethnicity Other

CondiLonal A freeform ﬁeld to document the ethnicity of
the beneﬁciary when the beneﬁciary idenLﬁes
themselves as Another Hispanic, LaLno, or
Spanish origin (ethnicity code 4).

N/A

ELG00015

ETHNICITYINFORMATION

X(25)

1. Value must be 25 characters or less
2. If Ethnicity Code (ELG.015.204) equals "4"
(Other), then value must be populated
3. CondiLonal

ELG272

ELG.001.272

FILESUBMISSIONMETHOD

File Submission
Method

Mandatory

FILESUBMISSIONMETHOD

ELG00001

FILE-HEADERRECORDELIGIBILITY

X(2)

1. Value must be 2 characters
2. Value must be in File Submission Method
List (VVL)
3. Mandatory

ELG273

ELG.003.273

APPLICATIONSIGNATUREDATE

ApplicaLon
Signature Date

CondiLonal The date that a beneﬁciary signed their
Medicaid or CHIP applicaLon. If the beneﬁciary
was deemed eligible via an administraLve
determinaLon then a signature may not be
applicable/available.

N/A

ELG00003

VARIABLE9(8)
DEMOGRAPHIC
S-ELIGIBILITY

170

177

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. CondiLonal
3. Value must be less than the Variable
Demographic Element End Date

ELG274

ELG.005.274

ELIGIBILITYREDETERMINATI
ON-DATE

Eligibility
RedeterminaLo
n Date

CondiLonal The date by which a person's Medicaid or CHIP
eligibility must be redetermined, per
1915(i)(1)(I), 42 CFR 435.916, 435.926, any
other applicable regulaLons, or waiver of these
regulaLons. This is eﬀecLvely the "expiraLon
date" of the eligibility characterisLcs with which
the date is being reported. Upon this date the
state is required to perform a renewal or
redeterminaLon of the individual's eligibility.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

9(8)

104

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. CondiLonal
3. Value must be greater than the Eligibility
Determinant EﬀecLve Date

ELG275

ELG.005.275

ELIGIBILITYEXTENSIONCODE

Eligibility
Extension Code

CondiLonal A code to idenLfy the authority used to extend
eligibility during the period of coverage. This
code should correspond to the eligibility
characterisLcs, including eligibility
redeterminaLon date, with which the code is
being reported.

ELIGIBILITYEXTENSIONCODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(3)

105

107

1. Value must be 3 characters or less
2. Value must be in Eligibility Extension Code
List (VVL)
3. CondiLonal

ELG276

ELG.005.276

ELIGIBILITYEXTENSIONOTHER-TEXT

Eligibility
Extension Other
Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the “other” authority used to extend eligibility;
required when 995 is used.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(50)

108

157

1. Value must be 50 characters or less
2. CondiLonal
3. If Eligibility Extension Code is "Other", then
value must be populated

The ﬁle submission method (e.g., TFFR, RHFR, IT,
or CSO) used by the state to build and submit
the ﬁle. This should correspond with the state's
declared ﬁle submission method for the same
ﬁle type and Lme period.

ELG277

ELG.005.277

CONTINUOUSELIGIBILITYCODE

ConLnuous
Eligibility Code

CondiLonal A code to idenLfy the authority used to provide
conLnuous eligibility during the period of
coverage

CONTINUOUSELIGIBILITYCODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(3)

158

160

1. Value must be 3 characters
2. Value must be in ConLnuous Eligibility
Code List (VVL)
3. CondiLonal

ELG278

ELG.005.278

CONTINUOUSELIGIBILITYOTHER-TEXT

ConLnuous
Eligibility Other
Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the "other" authority used to provide
conLnuous eligibility.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(50)

161

210

1. Value must not be more than 50 characters
long
2. CondiLonal
3. If ConLnuous Eligibility Code is "Other",
then value must be populated

ELG279

ELG.005.279

INCOMESTANDARDCODE

Income
Standard Code

CondiLonal An indicator that idenLﬁes the income standard
used by the state to assign the corresponding
primary eligibility group.

INCOMESTANDARDCODE

ELG00005

ELIGIBILITYDETERMINANT
S

X(2)

211

212

1. Value must be 2 characters
2. Value must be in Income Standard Code
List (VVL)
3. CondiLonal

ELG280

ELG.005.280

INCOMESTANDARDOTHER-TEXT

Income
Standard Other
Text

CondiLonal A free-form text ﬁeld where a state can idenLfy
the "other" income standard used to assign the
corresponding primary eligibility group.
Required when "Other" is reported to Income
Standard Code.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(50)

213

262

1. Value must be 50 characters or less
2. CondiLonal
3. If Income Standard Code equals "Other",
then value must be populated

ELG281

ELG.005.281

ELIGIBILITYTERMINATIONREASON-OTHERTYPE-TEXT

Eligibility
TerminaLon
Reason Other
Type Text

CondiLonal Value must be populated with a state-speciﬁc
reason for terminaLon when the ELIGIBILITYTERMINATION-REASON value is 'Other'.

N/A

ELG00005

ELIGIBILITYDETERMINANT
S

X(100)

263

362

1. Value must be 100 characters or less
2. Value must be populated when Eligibility
TerminaLon Reason equals "22" (Other)
3. Value must not be populated when
Eligibility TerminaLon Reason does not equal
"22" (Other)
4. CondiLonal

ELG282

ELG.023.282

RECORD-ID

Record ID

Mandatory

The Record ID represents the type of segment
being reported. The Record ID communicates
how the contents of a given row of data should
be interpreted depending on which segment
type the Record ID represents. Each type of
segment collects diﬀerent data elements, so
each segment type has a disLnct layout. The
ﬁrst 3 characters idenLfy the relevant ﬁle (e.g.,
ELG, PRV, CIP, etc.). The last 5 digits are the
segment idenLﬁer padded with leading zeros
(e.g., 00001, 00002, 00003, etc.).

RECORD-ID

ELG00023

SOGI

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "ELG00023"

ELG283

ELG.023.283

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

ELG00023

SOGI

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
4. Value must be the same as Submieng
State (ELG.001.007)

ELG284

ELG.023.284

RECORDNUMBER

Record Number

Mandatory

N/A

ELG00023

SOGI

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

ELG285

ELG.023.285

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

A state-assigned unique idenLﬁcaLon number
used to idenLfy a Medicaid/CHIP enrolled
individual. Value may be an SSN, temporary SSN
or State-assigned eligible individual idenLﬁer.
MSIS IdenLﬁcaLon Numbers are a unique "key"
value used to maintain referenLal integrity of
data distributed over mulLples ﬁles, segments
and reporLng periods. See T-MSIS Guidance
Document, "CMS Guidance: ReporLng Shared
MSIS IdenLﬁcaLon Numbers" for informaLon on
reporLng the MSIS IdenLﬁcaLon Numbers ID for
pregnant women, unborn children, mothers,
and their deemed newborns younger than 1
year of age who share the same MSIS
IdenLﬁcaLon Number.
haps://www.medicaid.gov/tmsis/dataguide/tmsis-coding-blog/reporLng-shared-msisidenLﬁcaLon-numbers-eligibility/

ELG286

ELG.023.286

SEX-ASSIGNEDAT-BIRTH

Sex Assigned at
Birth

CondiLonal This is the response from the beneﬁciary to an
opLonal quesLon posed to them on their
Medicaid or CHIP applicaLon regarding the
individual’s sex assigned at birth (e.g., according
to an original birth cerLﬁcate or similar
document). T-MSIS does not deﬁne or maintain
these quesLons or responses. They are deﬁned
and maintained via the CMS single streamlined
applicaLon and state Medicaid and CHIP
agencies. T-MSIS is intended to reﬂect those
sources and may be updated periodically as
necessary to align with naLonal standards and
common pracLces. For more informaLon, see:
haps://www.medicaid.gov/sites/default/ﬁles/2
023-11/cib11092023.pdf.

N/A

ELG00023

SOGI

X(20)

1. Value must be 20 characters or less
2. Mandatory

SEX-ASSIGNEDAT-BIRTH

ELG00023

SOGI

X(1)

1. Value must be 1 character
2. Value must be in Sex Assigned at Birth List
(VVL)
3. CondiLonal

ELG287

ELG.023.287

SEX-ASSIGNEDAT-BIRTHOTHER-TEXT

Sex Assigned at
Birth Other Text

N/A

ELG00023

SOGI

X(100)

142

1. Value must be 100 characters or less
2. CondiLonal
3. If Sex Assigned at Birth equals "5" (Other),
then value must be populated

ELG288

ELG.023.288

GENDERIDENTITY

Gender IdenLty

CondiLonal This is the response from the beneﬁciary to an
opLonal quesLon posed to them on their
Medicaid or CHIP applicaLon regarding the
individual’s gender idenLfy-MSIS does not
deﬁne or maintain these quesLons or
responses. They are deﬁned and maintained via
the CMS single streamlined applicaLon and
state Medicaid and CHIP agencies. T-MSIS is
intended to reﬂect those sources and may be
updated periodically as necessary to align with
naLonal standards and common pracLces. For
more informaLon, see
haps://www.medicaid.gov/sites/default/ﬁles/2
023-11/cib11092023.pdf.

GENDERIDENTITY

ELG00023

SOGI

X(1)

143

1. Value must be 1 character
2. Value must be in Gender IdenLty List (VVL)
3. CondiLonal

ELG289

ELG.023.289

GENDERIDENTITYOTHER-TEXT

Gender IdenLty
Other Text

CondiLonal This is the response from the beneﬁciary to an
opLonal quesLon posed to them on their
Medicaid or CHIP applicaLon regarding the
individual’s gender idenLfy if their response is
not reﬂected by the values available for Gender
IdenLty.

N/A

ELG00023

SOGI

X(100)

144

243

1. Value must be 100 characters or less
2. CondiLonal
3. If Gender IdenLty equals "7" (Other), then
value must be populated

ELG290

ELG.023.290

SEXUALORIENTATION

Sexual
OrientaLon

CondiLonal This is the response from the beneﬁciary to an
opLonal quesLon posed to them on their
Medicaid or CHIP applicaLon regarding the
individual’s sexual orientaLon-MSIS does not
deﬁne or maintain these quesLons or
responses. They are deﬁned and maintained via
the CMS single streamlined applicaLon and
state Medicaid and CHIP agencies. T-MSIS is
intended to reﬂect those sources and may be
updated periodically as necessary to align with
naLonal standards and common pracLces. For
more informaLon, see
haps://www.medicaid.gov/sites/default/ﬁles/2
023-11/cib11092023.pdf.

ELG291

ELG.023.291

SEXUALORIENTATIONOTHER-TEXT

Sexual
OrientaLon
Other Text

ELG292

ELG.023.292

SOGI-EFF-DATE

ELG293

ELG.023.293

SOGI-END-DATE

SEXUALORIENTATION

ELG00023

SOGI

X(1)

244

1. Value must be 1 character
2. Value must be in Sexual OrientaLon List
(VVL)
3. CondiLonal

CondiLonal This is the response from the beneﬁciary to an
N/A
opLonal quesLon posed to them on their
Medicaid or CHIP applicaLon regarding the
individual’s sexual orientaLon if their response is
not reﬂected by the values available for Sexual
OrientaLon.

ELG00023

SOGI

X(100)

245

344

1. Value must be 100 characters or less
2. CondiLonal
3. If Sex OrientaLon equals "6" (Other), then
value must be populated

SOGI EﬀecLve
Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

ELG00023

SOGI

9(8)

345

352

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Segment End Date value
3. Mandatory
4. Value of the CC component must be "20"

SOGI End Date

Mandatory

The last calendar day on which all the other data N/A
elements in the same segment were eﬀecLve.

ELG00023

SOGI

9(8)

353

360

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
3. Mandatory
4. Value of the CC component must be in
[20,99]

ELG294

ELG.023.294

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

ELG00023

SOGI

X(500)

361

860

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

T-MSIS Data Dic,onary – MCR File Changes Between Versions 2.4.0 and 4.0.0

MCR001 MCR.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00001"

DATADICTIONARYVERSION

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(1)

1. Value must be 1 character
2. Value must be in Submission TransacLon
Type List (VVL)

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(3)

MCR00001 FILE-HEADERRECORD-

X(9)

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

MCR003 MCR.001.003

MCR004 MCR.001.004

MCR005 MCR.001.005

SUBMISSIONTRANSACTIONTYPE

FILE-ENCODINGSPECIFICATION

DATA-MAPPINGDOCUMENTVERSION

Submission
TransacLon
Type

File Encoding
SpeciﬁcaLon

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state

N/A

2. Value must be 1 character

3. Mandatory
4

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

1. Value must be 9 characters or less
2. Mandatory

submission ﬁle. Use the version number specified

MANAGEDCARE

on the title page of the data mapping document

MCR006 MCR.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

MCR007 MCR.001.007

MCR008 MCR.001.008

SUBMITTINGSTATE

DATE-FILECREATED

Submieng
State

Date File
Created

Mandatory

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(8)

1. Value must equal
'MNGDCARE'"MNGDCARE"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(2)

1.1. Value must be 2 characters

MCR00001 FILE-HEADERRECORDMANAGEDCARE

9(8)

The date on which the ﬁle was created.

STATE

N/A

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same for all records
8

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory
MCR009 MCR.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

MCR00001 FILE-HEADERRECORDMANAGEDCARE

9(8)

2. Value must be equal to or earlier than
associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"

MCR010 MCR.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

MCR00001 FILE-HEADERRECORDMANAGEDCARE

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
MCR011 MCR.001.011

MCR013 MCR.001.013

FILE-STATUSINDICATOR

TOT-REC-CNT

File Status
Indicator

Total Record
Count

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

FILE-STATUSINDICATOR

N/A

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(1)

MCR00001 FILE-HEADERRECORDMANAGEDCARE

9(11)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
12

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the

ﬁle header record.
5. Mandatory

MCR014 MCR.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

MCR016 MCR.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(500)

1415

8284

5813

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

MCR00002 MANAGEDCARE-MAIN

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00002"

STATE

MCR00002 MANAGEDCARE-MAIN

X(2)

1.1. Value must be 2 characters

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (MCR.001.007)

MCR018 MCR.002.018

RECORDNUMBER

Record Number

Mandatory

N/A

MCR00002 MANAGEDCARE-MAIN

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

MCR019 MCR.002.019

STATE-PLAN-IDNUM

State Plan ID
Number

Mandatory

The ID number a state issues to a managed care
enLty

N/A

MCR00002 MANAGEDCARE-MAIN

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR020 MCR.002.020

MANAGEDCARECONTRACT-EFFDATE

Managed Care
Contract
EﬀecLve Date

Mandatory

The first calendar day on which allstart date of the
other data elements inmanaged care contract
period with the same segment were effectivestate.

N/A

MCR00002 MANAGEDCARE-MAIN

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. Value must be before or the same as the
associated Segment End Date value
4. in the form "CCYYMMDD"

2. Mandatory
5. Value of the CC component must be in ['18',
'19', '20']
6. Mandatory
7.3. Value must occur before Managed Care

Contract End Date (MCR.002.021)
MCR021 MCR.002.021

MANAGEDCARECONTRACT-ENDDATE

Managed Care
Contract End
Date

Mandatory

The expiraLon date of the managed care
contract period with the state.

N/A

MCR00002 MANAGEDCARE-MAIN

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Mandatory
MCR022 MCR.002.022

MANAGEDCARE-NAME

Managed Care
Name

Mandatory

The name of the managed care enLty under
contract with the State Medicaid Agency. The
name should be as it appears on the contract.

N/A

MCR00002 MANAGEDCARE-MAIN

X(55)

104

1.1. Value must be 55 characters or less

2. Value must not contain a pipe or asterisk
symbol

2. Value must be 55 characters or less
3.3. Mandatory

MCR023 MCR.002.023

MANAGEDCARE-PROGRAM

Managed Care
Program

Mandatory

The state program through which a managed
care plan is approved to operate.

MANAGEDCAREPROGRAM

MCR00002 MANAGEDCARE-MAIN

X(1)

105

1.1. Value must be 1 character

2. Value must be in Managed Care Program
List (VVL)
2. Value must be 1 character
3.3. Mandatory

MCR024 MCR.002.024

MANAGEDCARE-PLAN-TYPE

Managed Care
Plan Type

Mandatory

The type of managed care plan that corresponds
to the State Plan IdenLﬁcaLon Number. The
value reported in this data element should
match the Managed Care Plan Type value
reported on the Eligible ﬁle for the
corresponding managed care plan number.
Assign plan type value "15" for plans that
primarily cover non-emergency medical
transportaLon (NEMT).
See T-MSIS Guidance Document, "CMS
Guidance: Best PracLce for ReporLng NonEmergency Medical TransportaLon (NEMT)
Prepaid Ambulatory Health Plans (PAHPs) in the
T-MSIS Managed Care File"
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/dataguide/t-msis-codingblog/reporLng-nonemergency-medicaltransportaLon-nemt-prepaid-ambulatoryhealth-plans-pahps-in-the-tmsisblog/entry/47540managed-care-ﬁlemanagedcare/
See T-MSIS Guidance Document, "CMS
Guidance: Best PracLce for ReporLng ManagedCARE-PLAN- Care Plan Type in the T-MSIS
Managed Care File"
haps://www.medicaid.gov/medicaid/data-and-

MANAGEDCARE-PLANTYPE

MCR00002 MANAGEDCARE-MAIN

X(2)

106

107

1.1. Value must be 2 characters

2. Value must be in Managed Care Plan Type
List (VVL)
2. Value must be 2 characters
3.3. Mandatory

systems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47564reporLng-

managedcareplantype-in-the-t-msis-managedcare-ﬁle-managed-care/

MCR025 MCR.002.025

MCR026 MCR.002.026

REIMBURSEMEN
TARRANGEMENT

MANAGEDCARE-PROFITSTATUS

Reimbursement
Arrangement

Managed Care
Proﬁt Status

Mandatory

A code indicaLng the how the managed care
enLty is reimbursed.

A code denoLng the proﬁt status of managed
care enLty.

REIMBURSEME
NTARRANGEMEN
T

MCR00002 MANAGEDCARE-MAIN

MANAGEDCARE-PROFITSTATUS

MCR00002 MANAGEDCARE-MAIN

X(2)

108

109

1.1. Value must be 2 characters

2. Value must be in Reimbursement
Arrangement List (VVL)
2. Value must be 2 characters
3.3. Mandatory

X(2)

110

111

1.1. Value must be 2 characters

2. Value must be in Managed Care Proﬁt
Status List (VVL)

2. Value must be 2 characters
3.3. Mandatory

MCR027 MCR.002.027

CORE-BASEDSTATISTICALAREA-CODE

Core Based
StaLsLcal Area
Code

Mandatory

A code signifying whether the Managed Care
CORE-BASEDOrganizaLon's (MCO) service area falls into one
STATISTICALor more metropolitan or micropolitan staLsLcal AREA-CODE
areas. Whenever a service area straddles two
types of areas (e.g., metropolitan &and
micropolitan, metropolitan &and non-CBSA
area) classify the service area based on the
denser classiﬁcaLon. Metropolitan and
micropolitan staLsLcal areas (metro and micro
areas) are geographic enLLes deﬁned by the
U.S. Oﬃce of Management and Budget (OMB).
The term "Core Based StaLsLcal Area" (CBSA) is
a collecLve term for both metro and micro
areas. A metro area contains a core urban area
of 50,000 or more populaLon, and a micro area
contains an urban core of at least 10,000 (but
less than 50,000) populaLon. Each metro or
micro area consists of one or more counLes and
includes the counLes containing the core urban
area, as well as any adjacent counLes that have
a high degree of social and economic integraLon
(as measured by commuLng to work) with the
urban core. The U.S. Oﬃce of Management and
Budget (OMB) deﬁnes metropolitan or
micropolitan staLsLcal areas based on published
standards. The standards for deﬁning the areas
are reviewed and revised once every ten years,
prior to each decennial census. Between
censuses, the deﬁniLons are updated annually
to reﬂect the most recent Census Bureau
populaLon esLmates. The current deﬁniLons
are as of December 2009. See the hyperlink
below for further informaLon.

MCR00002 MANAGEDCARE-MAIN

X(1)

112

1.1. Value must be 1 character

2. Value must be in Core Based StaLsLcal
Area Code List (VVL)
2. Value must be 1 character
3.3. Mandatory

hap://www.whitehouse.gov/sites/default/ﬁles/
omb/assets/bulleLns/b10-02.pdf

MCR028 MCR.002.028

PERCENTBUSINESS

Percent
Business

Mandatory

The percentage of the managed care enLty's
total revenue that is derived from contracts with
Medicare (Part C and D) in the state and State
Medicaid agency contract(s) prior calendar year.
Include Medicaid and Medicare in calculaLon of
percentage of business in public programs for
IRS health insurer tax exempLon as required in
ACA.

N/A

MCR00002 MANAGEDCARE-MAIN

9(3)

113

115

1. Value must be between 0000 and 100
inclusively
2. Mandatory

MCR029 MCR.002.029

MCR030 MCR.002.030

MANAGEDCARE-SERVICEAREA

MANAGEDCARE-MAIN-RECEFF-DATE

Managed Care
Service Area

Managed Care
Main Record
EﬀecLve Date

Mandatory

IdenLﬁes the geographic unit under which the
managed care enLty is under contract to
provide services. The value reported in
Managed Care Service Area should represent
the geographical unit of the values reported in
the Managed Care Service Area Name. See TMSIS Guidance Document, "CMS Guidance: Best
PracLce for ReporLng Managed Care Service
Area in the Managed Care File"
".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47542reporLngmanagedcareservicearea-in-the-managed-careﬁle-managed-care/

MANAGEDCARE-SERVICEAREA

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00002 MANAGEDCARE-MAIN

X(1)

116

1.1. Value must be 1 character

2. Value must be in Managed Care Service
Area List (VVL)
2. Value must be 1 character
3.3. Mandatory
4. When value equals '"2'", the associated

Managed Care Service Area Name
(MCR.004.058) value must be a valid US
County Code

MCR00002 MANAGEDCARE-MAIN

9(8)

117

124

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
MCR031 MCR.002.031

MANAGEDCARE-MAIN-RECEND-DATE

Managed Care
Main Record
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00002 MANAGEDCARE-MAIN

9(8)

125

132

same as the associated Segment EﬀecLve
Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]

MCR032 MCR.002.032

STATE-NOTATION

State NotaLon

OpSituaLo

nal

MCR034 MCR.003.034

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00002 MANAGEDCARE-MAIN

X(500)

133

632

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00003"

STATE

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(2)

1.1. Value must be 2 characters

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (MCR.001.007)

MCR036 MCR.003.036

RECORDNUMBER

Record Number

Mandatory

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

MCR037 MCR.003.037

STATE-PLAN-IDNUM

State Plan ID
Number

Mandatory

The ID number a state issues to a managed care
enLty.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR038 MCR.003.038

MANAGEDCARE-LOCATIONID

Managed Care
LocaLon ID

Mandatory

A ﬁeld to diﬀerenLate a managed care enLty's
service locaLons through adding a sequenLal
number in this data element idenLﬁer ﬁeld. Use
sequenLal numbers to indicate addiLonal
services locaLons.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(15)

1.1. Value must be 15 characters or less

2. Value must not contain a pipe symbol
23. Each managed care enLty's locaLons
must have a unique idenLﬁer
3. (Managed care entity's service location
address)4. Value must be populated if

associated Managed Care Address Type
(MCR.003.041) equals 3
4. Value must be 15 characters or less

(Managed care enLty's service locaLon
address)
5. Mandatory
MCR039 MCR.003.039

MANAGEDCARE-LOCATIONAND-CONTACTINFO-EFF-DATE

Managed Care
LocaLon and
Contract
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]

MCR040 MCR.003.040

MANAGEDCARE-LOCATIONAND-CONTACTINFO-END-DATE

Managed Care
LocaLon and
Contract End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

9(8)

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
MCR041 MCR.003.041

MCR042 MCR.003.042

MANAGEDCARE-ADDRTYPE

MANAGEDCARE-ADDR-LN1

Managed Care
Address Type

Managed Care
Address Line 1

Mandatory

The type of address for the managed care
organizaLon submiaed in the recordManaged
Care Main segment.

The managed care enLty's address listed on the
contract with the state.

MANAGEDCARE-ADDRTYPE

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(1)

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(60)

1.1. Value must be 1 character

2. Value must be in Managed Care Address
Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

125

MCR043 MCR.003.043

MANAGEDCARE-ADDR-LN2

Managed Care
Address Line 2

CondiLonal The managed care enLty's address listed on the
contract with the state.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(60)

126

185

MCR044 MCR.003.044

MANAGEDCARE-ADDR-LN3

Managed Care
Address Line 3

CondiLonal The managed care enLty's address listed on the
contract with the state.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(60)

186

245

MCR045 MCR.003.045

MANAGEDCARE-CITY

Managed Care
City

Mandatory

The city component of an address associated
with a given enLty (e.g. person, organizaLon,
agency, etc.).

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(28)

246

273

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR046 MCR.003.046

MANAGEDCARE-STATE

Managed Care
State

Mandatory

The ANSI state numeric code for the U.S. state,
STATE
Territory, or the District of Columbia code of the
of the managed care enLty's address as listed on
the contract with the state.

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(2)

274

275

1.1. Value must not be more than 2

characters
2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory

MCR047 MCR.003.047

MANAGEDCARE-ZIP-CODE

Managed Care
ZIP Code

Mandatory

U.S. ZIP Code component of an address
associated with a given enLty (e.g. person,
organizaLon, agency, etc.)

ZIP-CODE

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(9)

276

284

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. Mandatory

MCR048 MCR.003.048

MANAGEDCARE-COUNTY

Managed Care
County

Mandatory

The ANSI County numeric code for the county or
county equivalent. One county code should be
captured for each of a managed care enLty's
locaLons idenLﬁed.

COUNTY

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(3)

285

287

1.1. Value must be 3 characters

Phone number for a given enLty (e.g. person,
organizaLon, agency).

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(10)

MCR049 MCR.003.049

MANAGEDCARETELEPHONE

Managed Care
Phone Number

OpSituaLo

nal

2. Value must be in US County Code List (VVL)
2. Value must be 3 characters or less
3.3. Mandatory

288

297

1. Value must be 10 characters, digits (0-9) onlydigit number
2. OpSituaLonal

MCR050 MCR.003.050

MCR051 MCR.003.051

MCR052 MCR.003.052

MANAGEDCARE-EMAIL

Managed Care
Email

OpSituaLo

MANAGEDCARE-FAXNUMBER

Managed Care
Fax Number

OpCondiLo

STATE-NOTATION

State NotaLon

OpSituaLo

nal

MCR054 MCR.004.054

RECORD-ID

Record ID

Mandatory

The email address of the managed care enLty
listed on the contract with the state.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(60)

298

357

1. Must contain the '@'"@" symbol
2. May contain uppercase and lowercase
LaLn leaers A to Z and a to z
3. May contain digits 0-9
4. Must contain a dot '.'"." that is not the ﬁrst
or last character and provided that it does
not appear consecuLvely
5. Value must be 60 characters or less
6. OpSituaLonal

A fax number, including area code, as listed on
the contract with the state.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(10)

358

367

1. Optional1. Value must be 10-digit number

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00003 MANAGEDCARELOCATIONAND-CONTACTINFO

X(500)

368

867

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

MCR00004 MANAGEDCARE-SERVICEAREA

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00004"

2. CondiLonal

padded with leading zeros (e.g., 00001, 00002,
00003, etc.).

MCR055 MCR.004.055

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

MCR00004 MANAGEDCARE-SERVICEAREA

X(2)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (MCR.001.007)
MCR056 MCR.004.056

MCR057 MCR.004.057

RECORDNUMBER

STATE-PLAN-IDNUM

Record Number

State Plan ID
Number

Mandatory

N/A

The ID number a state issues to a managed care
enLty

N/A

MCR00004 MANAGEDCARE-SERVICEAREA

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

MCR00004 MANAGEDCARE-SERVICEAREA

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR058 MCR.004.058

MANAGEDCARE-SERVICEAREA-NAME

Managed Care
Service Area
Name

CondiLonal The speciﬁc idenLﬁers for the counLes, ciLes,
regions, ZIP Codes and/or other geographic
areas that the managed care enLty serves.

MANAGEDCARE-SERVICEAREA-NAME

MCR00004 MANAGEDCARE-SERVICEAREA

X(30)

2. Value must be in Managed Care Service
Area Name List (VVL)
23. If associated Managed Care Service Area
(MCR.002.029) is in [2,3,4,5,6], then value is
mandatory and must be provided
34. Value must not contain a pipe or asterisk
symbol

Put each zip code, city, county, region, or other
area descriptor on a separate record. Use 5 digit
zip codes when service area deﬁniLon is zip
code based. Use ANSI codes when service area
is deﬁned by counLes or ciLes. The value
reported in Managed Care Service Area should
represent the geographical unit of the values
reported in the Managed Care Service Area
Name.

4. Value must be 30 characters or less
5.5. CondiLonal

6. If associated Managed Care Service Area
(MCR.002.029) equals '5'"5" (zip code), then
value must be a 5-digit zip code
7. If associated Managed Care Service Area
(MCR.002.029) equals '2'"2" (county code),
then value must be a 3-digit number

See T-MSIS Guidance Document, "CMS
Guidance: Best PracLce for ReporLng Managed
Care Service Area in the Managed Care File".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47542reporLngmanagedcareservicearea-in-the-managed-careﬁle-managed-care/
MCR059 MCR.004.059

MANAGEDCARE-SERVICEAREA-EFF-DATE

Managed Care
Service Area
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

1.1. Value must be 30 characters or less

N/A

MCR00004 MANAGEDCARE-SERVICEAREA

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]

MCR060 MCR.004.060

MANAGEDCARE-SERVICEAREA-END-DATE

Managed Care
Service Area
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00004 MANAGEDCARE-SERVICEAREA

9(8)

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
MCR061 MCR.004.061

STATE-NOTATION

State NotaLon

OpSituaLo

nal

MCR063 MCR.005.063

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00004 MANAGEDCARE-SERVICEAREA

X(500)

579

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00005"

MCR064 MCR.005.064

MCR065 MCR.005.065

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

N/A

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

X(2)

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

9(11)

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (MCR.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

MCR066 MCR.005.066

STATE-PLAN-IDNUM

State Plan ID
Number

Mandatory

The ID number a state issues to a managed care
enLty

N/A

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR067 MCR.005.067

OPERATINGAUTHORITY

OperaLng
Authority

Mandatory

The type of operaLng authority through which
the managed care enLty receives its contract
authority. The Managed Care Plan Type assigned
to the manage care plan in the Managed Care
Main segment should be consistent with the
OperaLng Authority value reported.

OPERATINGAUTHORITY

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

X(2)

1.1. Value must be 2 characters

See T-MSIS Guidance Document, "CMS
Guidance: Best PracLce for ReporLng Managed
Care Plan Type in the T-MSIS Managed Care File"
".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47566reporLngmanagedcareplantype-in-the-t-msis-managedcare-ﬁle-managed-care/

2. Value must be in OperaLng Authority List
(VVL)
2. Value must be 2 characters or less
3.3. Mandatory

MCR068 MCR.005.068

WAIVER-ID

Waiver ID

Mandatory

Field specifying the ID of the waiver,
demonstraLon or other authority which
authorizes the state to operate the managed
care program. These IDs must be the approved,
full federal ID number assigned during the state
submission and CMS approval process.

N/A

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

X(20)

1. Value must be 20 characters or less
2. Mandatory

MCR069 MCR.005.069

MANAGEDCARE-OPAUTHORITY-EFFDATE

Managed Care
Op Authority
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
MCR070 MCR.005.070

MANAGEDCARE-OPAUTHORITYEND-DATE

Managed Care
Op Authority
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

9(8)

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
MCR071 MCR.005.071

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00005 MANAGEDCAREOPERATINGAUTHORITY

X(500)

571

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

MCR073 MCR.006.073

RECORD-ID

Record ID

Mandatory

RECORD-ID

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00006"

STATE

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

X(2)

1.1. Value must be 2 characters

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

9(11)

MCR075 MCR.006.075

MCR076 MCR.006.076

SUBMITTINGSTATE

RECORDNUMBER

STATE-PLAN-IDNUM

Submieng
State

Record Number

State Plan ID
Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

The ID number a state issues to a managed care
enLty

N/A

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (MCR.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR077 MCR.006.077

MCR078 MCR.006.078

MANAGEDCARE-PLAN-POP

MANAGEDCARE-PLAN-POPEFF-DATE

Managed Care
Plan PopulaLon

Managed Care
Plan PopulaLon
EﬀecLve Date

Mandatory

The eligibility group(s) the state is authorized to
enroll in managed care plans by its operaLng
authority. Submit a separate record segment for
each eligibility group that can be enrolled in the
managed care program in which the managed
care plan is parLcipaLng.

ELIGIBILITYGROUP

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

9(2)

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

9(8)

1.1. Value must be 2 characters

2. Value must be in Managed Care Plan Pop
List (VVL)
2. Value must be 2 characters
3.3. Mandatory

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
MCR079 MCR.006.079

MANAGEDCARE-PLAN-POPEND-DATE

Managed Care
Plan PopulaLon
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

9(8)

value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
MCR080 MCR.006.080

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00006 MANAGEDCARE-PLANPOPULATIONENROLLED

X(500)

551

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

MCR082 MCR.007.082

RECORD-ID

Record ID

Mandatory

RECORD-ID

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00007"

STATE

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

X(2)

1.1. Value must be 2 characters

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

9(11)

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

X(12)

MCR084 MCR.007.084

MCR085 MCR.007.085

SUBMITTINGSTATE

RECORDNUMBER

STATE-PLAN-IDNUM

Submieng
State

Record Number

State Plan ID
Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

The ID number a state issues to a managed care
enLty

N/A

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (MCR.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR086 MCR.007.086

MCR087 MCR.007.087

MCR088 MCR.007.088

ACCREDITATIONORGANIZATION

DATEACCREDITATIONACHIEVED

DATEACCREDITATIONEND

AccreditaLon
OrganizaLon

Date
AccreditaLon
Achieved

Date
AccreditaLon
End

Mandatory

IdenLfy the accreditaLon awarded to the
managed care enLty.

The date the organizaLon achieved
accreditaLon.

The date when organizaLon's accreditaLon
ends.

ACCREDITATIO
NORGANIZATION

N/A

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

X(2)

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

9(8)

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

9(8)

1.1. Value must be 2 characters

2. Value must be in AccreditaLon
OrganizaLon List (VVL)
2. Value must be 2 characters
3.3. Mandatory

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
7

as the associated Segment EﬀecLve Date
value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
MCR089 MCR.007.089

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00007 MANAGEDCAREACCREDITATIO
NORGANIZATIO
N

X(500)

551

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

MCR091

MCR.008.091

RECORD-ID

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(8)

1. Not Applicable

MCR092

MCR.008.092

SUBMITTINGSTATE

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(2)

1. Not Applicable

MCR093

MCR.008.093

RECORD-NUMBER

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

9(11)

1. Not Applicable

MCR094

MCR.008.094

STATE-PLAN-IDNUM

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(12)

1. Not Applicable

MCR095

MCR.008.095

NATIONALHEALTH-CAREENTITY-ID

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(10)

1. Not Applicable

MCR096

MCR.008.096

NATIONALHEALTH-CAREENTITY-ID-TYPE

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(1)

1. Not Applicable

MCR097

MCR.008.097

NATIONALHEALTH-CAREENTITY-NAME

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(50)

1. Not Applicable

MCR098

MCR.008.098

NATIONALHEALTH-CAREENTITY-ID-INFOEFF-DATE

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

9(8)

102

1. Not Applicable

MCR099

MCR.008.099

NATIONALHEALTH-CAREENTITY-ID-INFOEND-DATE

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

9(8)

103

110

1. Not Applicable

MCR100

MCR.008.100

STATE-NOTATION

Not Applicable

Not
Applicable

N/A

MCR00008

NATIONALHEALTH-CAREENTITY-ID-INFO

X(500)

111

610

1. Not Applicable

MCR102

MCR.009.102

RECORD-ID

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

X(8)

1. Not Applicable

MCR103

MCR.009.103

SUBMITTINGSTATE

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

X(2)

1. Not Applicable

MCR104

MCR.009.104

RECORD-NUMBER

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

9(11)

1. Not Applicable

MCR105

MCR.009.105

STATE-PLAN-IDNUM

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

X(12)

1. Not Applicable

MCR106

MCR.009.106

CHPID

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

X(10)

1. Not Applicable

MCR107

MCR.009.107

SHPID

Not Applicable

Not
Applicable

SEX-ASSIGNEDAT-BIRTH

MCR00009

CHPID-SHPIDRELATIONSHIPS

X(10)

1. Not Applicable

MCR108

MCR.009.108

CHPID-SHPIDRELATIONSHIPEFF-DATE

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

9(8)

1. Not Applicable

MCR109

MCR.009.109

CHPID-SHPIDRELATIONSHIPEND-DATE

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

9(8)

1. Not Applicable

MCR110

MCR.009.110

STATE-NOTATION

Not Applicable

Not
Applicable

N/A

MCR00009

CHPID-SHPIDRELATIONSHIPS

X(500)

569

1. Not Applicable

SEQUENCENUMBER

Sequence
Number

Mandatory

To enable states to sequenLally number ﬁles,
when related, follow-on ﬁles are necessary (i.e.,
update ﬁles, replacement ﬁles). This should
begin with 1 for the original Create submission
type and be incremented by one for each
Replacement or Update submission for the
same reporLng period and ﬁle type (subject
area).

N/A

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(4)

1314

7880

8183

1.1. Value must be 4 characters or less

MCR112 MCR.001.112

5. Mandatory

MCR113 MCR.001.113

FILESUBMISSIONMETHOD

File Submission
Method

Mandatory

FILESUBMISSIONMETHOD

MCR00001 FILE-HEADERRECORDMANAGEDCARE

X(2)

1. Value must be 2 characters
2. Value must be in File Submission Method
List (VVL)
3. Mandatory

MCR114 MCR.010.114

RECORD-ID

Record ID

Mandatory

RECORD-ID

MCR00010 MANAGEDCARE-ID

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "MCR00010"

MCR115 MCR.010.115

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

MCR00010 MANAGEDCARE-ID

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
4. Value must be the same as Submieng
State (MCR.001.007)

MCR116 MCR.010.116

RECORDNUMBER

Record Number

Mandatory

N/A

MCR00010 MANAGEDCARE-ID

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

MCR117 MCR.010.117

STATE-PLAN-IDNUM

State Plan ID
Number

Mandatory

The ID number a state issues to a managed care
enLty

N/A

MCR00010 MANAGEDCARE-ID

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

MCR118 MCR.010.118

MANAGEDCARE-PLANOTHER-ID-TYPE

Managed Care
Plan Other ID
Type

Mandatory

A code to idenLfy the kind of managed care
idenLﬁer that is captured in the Managed Care
IdenLﬁer data element. The state should submit
updates to T-MSIS whenever an idenLﬁer is
reLred or issued.

MANAGEDCARE-PLANOTHER-ID-TYPE

MCR00010 MANAGEDCARE-ID

X(2)

1. Value must be 2 characters
2. Value must be in Managed Care Plan Other
ID Type List (VVL)
3. Mandatory

MCR119 MCR.010.119

MANAGEDCARE-PLANOTHER-ID

Managed Care
Plan Other ID

Mandatory

A data element to capture the various IDs used
to idenLfy a managed care plan. The speciﬁc
type of idenLﬁer is deﬁned in the corresponding
value in the Managed Care Plan IdenLﬁer Type
data element.

N/A

MCR00010 MANAGEDCARE-ID

X(30)

1. Value must be 30 characters
2. Value must not contain a pipe or asterisk
symbol
3. Mandatory

MCR120 MCR.010.120

MANAGEDCARE-ID-EFFDATE

Managed Care
ID EﬀecLve
Date

Mandatory

The date the organizaLon achieved
accreditaLon.

N/A

MCR00010 MANAGEDCARE-ID

9(8)

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Segment End Date value
3. Mandatory
4. Value of the CC component must be in
[19,20,99]

MCR121 MCR.010.121

MANAGEDCARE-ID-ENDDATE

Managed Care
ID End Date

Mandatory

The date when organizaLon's accreditaLon
ends.

N/A

MCR00010 MANAGEDCARE-ID

9(8)

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be the afer or the same as the
associated Segment EﬀecLve Date value
3. Mandatory
4. Value of the CC component must be in
[19,20,99]

MCR122 MCR.010.122

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

MCR00010 MANAGEDCARE-ID

X(500)

581

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

T-MSIS Data Dic,onary – PRV File Changes Between Versions 2.4.0 and 4.0.0

PRV001

PRV.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

PRV00001

FILE-HEADERRECORDPROVIDER

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00001"

DATADICTIONARYVERSION

PRV00001

FILE-HEADERRECORDPROVIDER

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

PRV00001

FILE-HEADERRECORDPROVIDER

X(1)

1. Value must be 1 character
2. Value must be in Submission TransacLon
Type List (VVL)

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

PRV.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

PRV003

PRV004

PRV.001.003

PRV.001.004

SUBMISSIONTRANSACTIONTYPE

FILE-ENCODINGSPECIFICATION

Submission
TransacLon
Type

File Encoding
SpeciﬁcaLon

Mandatory

2. Value must be 1 character

3. Mandatory
PRV00001

FILE-HEADERRECORDPROVIDER

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

PRV005

PRV.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

X(9)

1. Value must be 9 characters or less
2. Mandatory

submission ﬁle. Use the version number specified
on the title page of the data mapping document

PRV006

PRV.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

PRV007

PRV.001.007

SUBMITTINGSTATE

Submieng
State

Mandatory

PRV00001

FILE-HEADERRECORDPROVIDER

X(8)

1. Value must equal 'PROVIDER'"PROVIDER"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

PRV00001

FILE-HEADERRECORDPROVIDER

X(2)

1.1. Value must be 2 characters

STATE

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same for all records
PRV008

PRV.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the ﬁle was created.

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

9(8)

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory
PRV009

PRV.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

9(8)

2. Value must be equal to or earlier than
associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"

PRV010

PRV.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
PRV011

PRV.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

PRV00001

FILE-HEADERRECORDPROVIDER

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
PRV013

PRV.001.013

TOT-REC-CNT

Total Record
Count

Mandatory

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the

ﬁle header record.
5. Mandatory

PRV014

PRV.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

PRV016

PRV.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

X(500)

1415

8284

5813

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

PRV00002

PROVATTRIBUTESMAIN

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00002"

STATE

PRV00002

PROVATTRIBUTESMAIN

X(2)

1.1. Value must be 2 characters

PRV.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)

PRV018

PRV019

PRV020

PRV.002.018

PRV.002.019

PRV.002.020

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

PROVATTRIBUTES-EFFDATE

Record Number

Mandatory

Submieng
State Provider
ID

Mandatory

Provider
Aaributes
EﬀecLve Date

Mandatory

N/A

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00002

PROVATTRIBUTESMAIN

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00002

PROVATTRIBUTESMAIN

X(30)

PROVATTRIBUTESMAIN

9(8)

1. Value must be 30 characters or less
2. Mandatory
3. Value must be 8 characters in the form
"CCYYMMDD"

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
PRV021

PRV.002.021

PROVATTRIBUTESEND-DATE

Provider
Aaributes End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00002

PROVATTRIBUTESMAIN

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]

PRV022

PRV023

PRV024

PRV025

PRV.002.022

PRV.002.023

PRV.002.024

PRV.002.025

PROV-DOINGBUSINESS-ASNAME

PROV-LEGALNAME

PROVORGANIZATIONNAME

PROV-TAX-NAME

Provider DBA
Name

Provider Legal
Name

Provider
OrganizaLon
Name

Provider Tax
Name

CondiLonal The provider's name that is commonly used by
the public when the "doing-business-as" name
is diﬀerent than the legal name. DBA is an
abbreviaLon for "doing business as." Registering
a DBA is required to operate a business under a
name that diﬀers from the company's legal
name. If DBA name is the same as the legal
name, do not populate DBA name.

N/A

Mandatory

The name as it appears on the provider
agreement between the state and the enLty.
Both persons and other enLLes can have a legal
name.

N/A

CondiLonal The name of the provider when the provider is
an organizaLon. If the provider organizaLon
name exceeds 60 characters submit only the
ﬁrst 60 characters of the name. Provider
OrganizaLon Name should be same as provider
last name when provider is an individual.

N/A

Mandatory

N/A

The name that the provider enLty uses on IRS
ﬁlings.

PRV00002

PROVATTRIBUTESMAIN

X(100)

167

1.1. Value must be 100 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 100 characters or less
3.3. CondiLonal

PRV00002

PROVATTRIBUTESMAIN

X(100)

168

267

1.1. Value must be 100 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 100 characters or less
3.3. Mandatory

PRV00002

PROVATTRIBUTESMAIN

X(60)

268

327

1.1. Value must be 60 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 60 characters or less
3.3. CondiLonal

PRV00002

PROVATTRIBUTESMAIN

X(100)

328

427

1.1. Value must be 100 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 100 characters or less
3.3. Mandatory

PRV026

PRV.002.026

FACILITY-GROUPINDIVIDUALCODE

Facility Group
Individual Code

Mandatory

A code to idenLfy whether the Submieng State
Provider IdenLﬁer is assigned to an individual,
group, or a facility.

PRV027

PRV.002.027

TEACHING-IND

Teaching
Indicator

CondiLonal A code indicaLng if the provider's organizaLon is
a teaching facility.

FACILITYGROUPINDIVIDUALCODE

PRV00002

PROVATTRIBUTESMAIN

X(2)

428

429

1. Value must be in Facility Group Individual
Code List (VVL)
2. Value must be 2 characters
3. Mandatory
4. (Individual) If value equals '"03'", then
Provider First Name (PRV.002.028) must be
populated
5. (organization) if value does not Individual)
NPPES EnLty Type Code associate with this
NPI must equal '03', then Provider Middle Initial
(PRV.002.029) must not be populated"1"
(Individual)
6. (Individual) If value equals '"03'", then
Provider Last Name (PRV.002.030) must be
populated
7. (Individual) If value equals '"03'", then
Provider Sex (PRV.002.031) must be
populated
8. (Individual) If value equals '"03'", then
Provider Date of Birth (PRV.002.034) must be
populated
9. (OrganizaLon) If value equals '"01'" or
'"02'", then Provider Date of Death
(PRV.002.035) must not be populated
10. (OrganizaLon) If value does not equal
"03", then Provider Middle IniLal
(PRV.002.029) must not be populated
11. (OrganizaLon) NPPES EnLty Type Code
associate with this NPI must equal "2"
(OrganizaLon)

TEACHING-IND

PRV00002

PROVATTRIBUTESMAIN

X(1)

430

1.1. Value must be 1 character

2. Value must be in Teaching Indicator List
(VVL)
23. Value must be 1 character
3."0" when Facility Group Individual Code

(PRV.002.026) equals '02' or '03'
4. CondiLonal

PRV028

PRV.002.028

PROV-FIRSTNAME

Provider First
Name

CondiLonal Individual's ﬁrst name; ﬁrst name component of
full name (e.g. First Name, Middle IniLal, Last
Name).

N/A

PRV00002

PROVATTRIBUTESMAIN

X(30)

431

460

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

PRV029

PRV.002.029

PROV-MIDDLEINITIAL

Provider Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

PRV00002

PROVATTRIBUTESMAIN

X(1)

461

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
PRV030

PRV.002.030

PROV-LASTNAME

Provider Last
Name

CondiLonal Individual's last name; last name component of
full name (e.g. First Name, Middle IniLal, Last
Name).

N/A

PRV00002

PROVATTRIBUTESMAIN

X(30)

462

491

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

PRV031

PRV.002.031

SEX

Sex

CondiLonal Either individual's biological sex or their selfidenLﬁed sex.

SEX

PRV00002

PROVATTRIBUTESMAIN

X(1)

492

1.1. Value must be 1 character

PROVATTRIBUTESMAIN

X(2)

PRV032

PRV.002.032

OWNERSHIPCODE

Ownership
Code

CondiLonal A code denoLng the ownership interest and/or
managing control informaLon. The valid values
list is a Medicare standard list.

OWNERSHIPCODE

PRV00002

2. Value must be in Sex List (VVL)
2. Value must be 1 character

3. CondiLonal
17

493

494

1.1. Value must be 2 characters

2. Value must be in Ownership Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

4. Value is mandatory when associated
Facility Group Individual Code (PRV.002.026)
is in ['01, '02'01,02] (organizaLon)

PRV033

PRV.002.033

PROV-PROFITSTATUS

Provider Proﬁt
Status

Mandatory

A code denoLng the proﬁt status of the
provider.

PROV-PROFITSTATUS

PRV00002

PROVATTRIBUTESMAIN

X(2)

495

496

1.1. Value must be 2 characters

2. Value must be in Provider Proﬁt Status List
(VVL)
2. Value must be 2 characters
3.3. Mandatory

PRV034

PRV.002.034

DATE-OF-BIRTH

Date of Birth

CondiLonal An individual's date of birth.

N/A

PRV00002

PROVATTRIBUTESMAIN

9(8)

497

504

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be less than or equal to
associated End of Time Period (PRV.001.010)
4. Value must be less than or equal to associated
Date File Created (PRV.001.008)
5.3. CondiLonal
64. The diﬀerence between current value and

Start of Time Period (PRV.001.009) must be
between 18 and 85 years
PRV035

PRV.002.035

DATE-OF-DEATH

Date of Death

CondiLonal The date an individual died on.

N/A

PRV00002

PROVATTRIBUTESMAIN

9(8)

505

512

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. CondiLonal
43. If populated, value must be on or afer
individual's Date of Birth
54. Value must be less than or equal to
associated End of Time Period (PRV.001.010)
65. There can only be one value on all records
when the value is populated
76. When populated, the diﬀerence between
value and Date of Birth (PRV.002.034) must
be 18 years or greater

PRV036

PRV.002.036

ACCEPTINGNEW-PATIENTSIND

AccepLng New
PaLents
Indicator

Mandatory

An indicator to idenLfy providers who are
accepLng new paLents.

ACCEPTINGNEW-PATIENTSIND

PRV00002

PROVATTRIBUTESMAIN

X(1)

513

1.1. Value must be 1 character

2. Value must be in AccepLng New PaLents
Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

PRV037

PRV.002.037

STATE-NOTATION

State NotaLon

OpSituaLo

nal

PRV039

PRV.003.039

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00002

PROVATTRIBUTESMAIN

X(500)

2223

5145

10134

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00003"

STATE

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(2)

1.1. Value must be 2 characters

PRV.003.040

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)

PRV041

PRV042

PRV043

PRV.003.041

PRV.003.042

PRV.003.043

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

Record Number

Submieng
State Provider
ID

PROV-LOCATION- Provider
ID
LocaLon ID

Mandatory

Not
Applicable

Mandatory

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(30)

PROVLOCATIONAND-CONTACTINFO

X(5)

1. Value must be 30 characters or less
2. Mandatory
3. Value must not contain a pipe symbol

1. Value must not contain a pipe symbol
2. 1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

PRV044

PRV.003.044

PROV-LOCATION- Provider
AND-CONTACTLocaLon &and
INFO-EFF-DATE
Contact Info
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,19,99]
PRV045

PRV.003.045

PROV-LOCATION- Provider
AND-CONTACTLocaLon &and
INFO-END-DATE
Contact Info
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
PRV046

PRV047

PRV.003.046

PRV.003.047

PROV-ADDRTYPE

ADDR-LN1

Provider
Address Type

Provider
Address Line 1

Mandatory

The type of address and contact informaLon for
the provider submiaed in the record segment.

The ﬁrst line of a potenLally mulL-line physical
street or mailing address for a given enLty (e.g.
person, organizaLon, agency, etc.).

PROV-ADDRTYPE

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(1)

PROVLOCATIONAND-CONTACTINFO

X(60)

1.1. Value must be 1 character

2. Value must be in Provider Address Type List
(VVL)
2. Value must be 1 character
3.3. Mandatory

133

PRV048

PRV.003.048

ADDR-LN2

Provider
Address Line 2

CondiLonal The second line of a mulL-line physical street or
mailing address for a given enLty (e.g. person,
organizaLon, agency, etc.).

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(60)

134

193

PRV049

PRV.003.049

ADDR-LN3

Provider
Address Line 3

CondiLonal The third line of a mulL-line physical street or
mailing address for a given enLty (e.g. person,
organizaLon, agency, etc.).

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(60)

194

253

PRV050

PRV.003.050

ADDR-CITY

Provider City

Mandatory

The city component of an address associated
with a given enLty (e.g. person, organizaLon,
agency, etc.).

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(28)

254

281

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

PRV051

PRV.003.051

ADDR-STATE

Provider State

Mandatory

The ANSI numeric state code component of an
address associated with a given enLty (e.g.
person, organizaLon, agency, etc.)

STATE

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(2)

282

283

1.1. Value must be 2 characters

2. Value must be in State Code List (VVL)
2. Value must be 2 characters

3. Mandatory

PRV052

PRV.003.052

ADDR-ZIP-CODE

Provider ZIP
Code

Mandatory

U.S. ZIP Code component of an address
associated with a given enLty (e.g. person,
organizaLon, agency, etc.)

ZIP-CODE

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(9)

284

292

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. Value must be in ZIP Code List (VVL)
3. Mandatory

PRV053

PRV.003.053

ADDRTELEPHONE

Provider Phone
Number

OpSituaLo

Phone number for a given enLty (e.g. person,
organizaLon, agency).

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(10)

293

302

1. Value must be 10 characters, digits (0-9) onlydigit number
2. OpSituaLonal

nal

PRV054

PRV055

PRV056

PRV057

PRV058

PRV.003.054

PRV.003.055

PRV.003.056

PRV.003.057

PRV.003.058

ADDR-EMAIL

Provider
Address Email

OpSituaLo

Provider
Address Fax

OpSituaLo

ADDR-BORDERSTATE-IND

Address Border
State Indicator

Mandatory

ADDR-COUNTY

Provider County
Code

Mandatory

ADDR-FAX-NUM

STATE-NOTATION

State NotaLon

nal

OpSituaLo

nal

The email address of the provider for the
locaLon being captured on this record

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(60)

303

362

The fax number of the provider for the locaLon
being captured on this record.

N/A

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(10)

363

372

1. Value must be 10 characters, digits (0-9) onlydigit number
2. OpSituaLonal

A code idenLfy an out of state provider enrolled
with the state (The provider locaLon is out of
state, but for payment purposes the provider is
treated as an in-state provider.)

ADDR-BORDERSTATE-IND

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(1)

373

1.1. Value must be 1 character

Standard ANSI code used to idenLfy a speciﬁc
U.S. County.

COUNTY

PRV00003

PROVLOCATIONAND-CONTACTINFO

X(3)

PROVLOCATIONAND-CONTACTINFO

X(500)

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00003

2. Value must be in Address Border State
Indicator List (VVL)
23. Mandatory
19

374

376

1.1. Value must be 3 characters

2. Value must be in US County Code List (VVL)
2. Value must be 3 characters
3.3. Mandatory

377

876

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

PRV060

PRV.004.060

RECORD-ID

Record ID

Mandatory

RECORD-ID

PRV00004

PROVLICENSINGINFO

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00004"

STATE

PRV00004

PROVLICENSINGINFO

X(2)

1.1. Value must be 2 characters

PRV.004.061

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)
PRV062

PRV063

PRV.004.062

PRV.004.063

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

Record Number

Submieng
State Provider
ID

Mandatory

N/A

PRV00004

PROVLICENSINGINFO

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00004

PROVLICENSINGINFO

X(30)

1. Value must be 30 characters or less
2. Mandatory
3. Value must not contain a pipe symbol

state's Medicaid Management InformaLon
System.

PRV064

PRV065

PRV.004.064

PRV.004.065

PROV-LOCATION- Provider
ID
LocaLon ID

PROV-LICENSEEFF-DATE

Not
Applicable

Mandatory

Provider License Mandatory
EﬀecLve Date

N/A

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00004

PROVLICENSINGINFO

X(5)

PROVLICENSINGINFO

9(8)

1. Value must not contain a pipe symbol
2. 1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]

PRV066

PRV.004.066

PROV-LICENSEEND-DATE

Provider License Mandatory
End Date

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00004

PROVLICENSINGINFO

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
PRV067

PRV.004.067

LICENSE-TYPE

License Type

Mandatory

A code to idenLfy the kind of license or
accreditaLon number that is captured in the
License-OR-ACCREDITATION- or AccreditaLon
Number data element.

LICENSE-TYPE

PRV00004

PROVLICENSINGINFO

X(1)

1.1. Value must be 1 character

2. Value must be in License Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

PRV068

PRV.004.068

LICENSEISSUING-ENTITYID

License Issuing
EnLty ID

Mandatory

A free text ﬁeld to capture the idenLty of the
enLty issuing the license or accreditaLon. Enter
the applicable state code, county code,
municipality name, "DEA", professional society's
name, or the CLIA accreditaLon body's name.
(county) -If associated License Type is equal to 1
and issuing authority is a State, then value must
be ANSI State abbreviaLon code.- If associated
License Type is equal to 1 and issuing authority
is a county, then value must be a 5-digit,
concatenated code consisLng of the ANSI 2-digit
state code plus the ANSI county 3-digit code of
the applicable.
If associated License Type is equal to 1 and the
issuing authority is the State, then value must be a 5digit, concatenated code consisting of the ANSI 2
digit state code plus the ANSI 3 digit county code.
For example, Orange County, CA would be 06059
Orange County, NC 37135. . A list of codes can be

found here:
haps://www.nrcs.usda.gov/wps/portal/nrcs/det
ail/naLonal/home/?cid=nrcs143_013697
(CLIA)

If associated License Type is equal to 1 and
issuing authority is a municipality, then enter a
text string with the name of the municipality.
If associated License Type is equal to 3, then
enter the text string idenLfying the professional
society issuing the accreditaLon.
If associated License Type is equal to 4, then
value must be the text string idenLfying the CLIA
accreditaLon body's name.
(Professional society accreditation) if associated

N/A

PRV00004

PROVLICENSINGINFO

X(60)

133

1.1. Value must be 60 characters or less

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 60 characters or less
3. (required) 3. Mandatory
4. If associated License or Accreditation
Number (PRV.005.069) value is populated,Type
equals "2", then value is mandatory and must
be provided
4. Mandatory
5. Value must equal 'DEA' when associated
License Type equals '2'"DEA"

License Type is equal to three, then enter the text
string identifying the professional society issuing the
accreditation.
(DEA) if associated License Type is equal to 2 , then
value must be the text string "DEA"
(state) if associated License Type is equal to 1 and
issuing authority is a State, then value must be a 2
digit ANSI State abbreviation code.

PRV069

PRV070

PRV.004.069

PRV.004.070

LICENSE-ORACCREDITATIONNUMBER

STATE-NOTATION

License or
AccreditaLon
Number

State NotaLon

Mandatory

OpSituaLo

nal

A data element to capture the license or
accreditaLon number issued to the provider by
the licensing enLty or accreditaLon body
idenLﬁed in the License-ISSUING-ENTITY- Issuing
EnLty ID data element.

N/A

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00004

PROVLICENSINGINFO

X(20)

134

153

1.1. Value must be 20 characters or less

2. Value must not contain a pipe and asterisk
symbol
2. Value must be 20 characters or less
3.3. Mandatory

PRV00004

PROVLICENSINGINFO

X(500)

154

653

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

PRV072

PRV.005.072

RECORD-ID

Record ID

Mandatory

RECORD-ID

PRV00005

PROVIDENTIFIERS

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00005"

STATE

PRV00005

PROVIDENTIFIERS

X(2)

1.1. Value must be 2 characters

PRV.005.073

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)
PRV074

PRV075

PRV.005.074

PRV.005.075

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

Record Number

Submieng
State Provider
ID

Mandatory

N/A

PRV00005

PROVIDENTIFIERS

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00005

PROVIDENTIFIERS

X(30)

1. Value must be 30 characters or less
2. Mandatory
3. Value must not contain a pipe symbol

state's Medicaid Management InformaLon
System.

PRV076

PRV077

PRV.005.076

PRV.005.077

PROV-LOCATION- Provider
ID
LocaLon ID

Not
Applicable

PROVIDENTIFIER-TYPE

Mandatory

Provider
IdenLﬁer Type

Mandatory

N/A

A code to idenLfy the kind of provider idenLﬁer
that is captured in the Provider IdenLﬁer data
element. The state should submit updates to TMSIS whenever an idenLﬁer is reLred or issued.
see Provider IdenLﬁer Type List (VVL.146)

PROVIDENTIFIERTYPE

PRV00005

PROVIDENTIFIERS

X(5)

PROVIDENTIFIERS

X(1)

1. Value must not contain a pipe symbol
2. 1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

1.1. Value must be 1 character

2. Value must be in Provider IdenLﬁer Type
List (VVL)
23. Mandatory
3. Value must be 1 character
4. When value equals '"2'", the associated

Provider IdenLﬁer (PRV.005.081) must be a
valid NPI

PRV078

PRV.005.078

PROVIDENTIFIERISSUING-ENTITYID

Provider
IdenLﬁer
Issuing EnLty ID

Mandatory

A free text ﬁeld to capture the idenLty of the
enLty that issued the provider idenLﬁer in the
PROV-IDENTIFIERProvider IdenLﬁer (PRV.005.081)
data element. For (State Tax ID), if associated
Provider IdenLﬁer Type (DEPRV.005.077) value is
equal to 6, then value must be the name of the
state's taxaLon division. For (Other), if
associated Provider IdenLﬁer Type
(DEPRV.005.077) value is equal to 8, then value
must be the name of the enLty that issued the
idenLﬁer.

N/A

PRV00005

PROVIDENTIFIERS

X(18)

1.1. Value must be 18 characters or less

2. Value must not contain a pipe or asterisk
symbol
23. (State-speciﬁc Medicaid Provider) if
associated Provider IdenLﬁer Type
(PRV.005.077) value is equal to equals "1,",
then value must equal (PRV.005.073)
Submieng State
34. (NPI) if associated Provider IdenLﬁer Type
(PRV.005.077) value is equal to equals "2,",
then value must equal 'NPI'
4"NPI"
5. (Medicare) if associated Provider IdenLﬁer
Type (PRV.005.077) value is equal to equals
"3,", then value must equal 'CMS'
5"CMS"
6. (NCPDP) if associated Provider IdenLﬁer
Type (PRV.005.077) value is equal to equals
"4,", then value must equal 'NCPDP'
6"NCPDP"
7. (Federal Tax ID) if associated Provider
IdenLﬁer Type (PRV.005.077) value is equal to
equals "5,", then value must equal 'IRS'
7"IRS"
8. (SSN) if associated Provider IdenLﬁer Type
(PRV.005.077) value is equal to equals "7,",
then value must be equal to 'SSA'
8. Value must be 18 characters or less

"SSA"
9. Mandatory

PRV079

PRV.005.079

PROVIDENTIFIER-EFFDATE

Provider
IdenLﬁer
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00005

PROVIDENTIFIERS

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
PRV080

PRV.005.080

PROVIDENTIFIER-ENDDATE

Provider
IdenLﬁer End
Date

Mandatory

The firstlast calendar day on which all of the
other data elements in the same segment were
eﬀecLve.

N/A

PRV00005

PROVIDENTIFIERS

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
PRV081

PRV.005.081

PROVIDENTIFIER

Provider
IdenLﬁer

Mandatory

A data element to capture the various ways
used to disLnguish providers from one another
on claims and other interacLons between
providers and other enLLes. The speciﬁc type of
idenLﬁer is deﬁned in the corresponding value
in the PROVIDER-IDENTIFIER- Provider IdenLﬁer
Type data element.

N/A

PRV00005

PROVIDENTIFIERS

X(1230) 10

103121

1. Value must be 30 characters or less
2. Mandatory
23. Value must not contain a pipe or asterisk
symbol
34. Value must have an associated Provider
IdenLﬁer Type (PRV.005.077)
45. One record must have a Provider
IdenLﬁer Type (PRV.005.077) equal to "1"
5. Value must be 12 characters or less

PRV082

PRV.005.082

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00005

PROVIDENTIFIERS

X(500)

104122

603621

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

PRV084

PRV.006.084

RECORD-ID

Record ID

Mandatory

RECORD-ID

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00006"

STATE

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

X(2)

1.1. Value must be 2 characters

PROVTAXONOMYCLASSIFICATIO
N

9(11)

PRV086

PRV087

PRV.006.085

PRV.006.086

PRV.006.087

SUBMITTINGSTATE

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

Submieng
State

Record Number

Submieng
State Provider
ID

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

PROVCLASSIFICATIONTYPEN/A

PRV00006

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

X(30)

1. Value must be 30 characters or less
2. Mandatory
3. Value must be in Provider Classification Type
List (VVL)

state's Medicaid Management InformaLon
System.

PRV088

PRV.006.088

PROVCLASSIFICATIONTYPE

Provider
ClassiﬁcaLon
Type

Mandatory

A code to idenLfy the schema used in the
Provider ClassiﬁcaLon Code ﬁeld to categorize
providers. See T-MSIS Guidance Document,
"CMS Guidance: Best PracLce for ReporLng
Provider ClassiﬁcaLon Type and Provider
ClassiﬁcaLon Code in the T-MSIS Provider File"
".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/tmsisdataguide/t-msiscoding-blog/entry/47562cms-technicalinstrucLons-provider-classiﬁcaLonrequirements-in-tmsis/
A provider may be reported with mulLple acLve
record segments with the same Provider
ClassiﬁcaLon Type if diﬀerent Provider
ClassiﬁcaLon Code values apply.

PROVCLASSIFICATIO
N-TYPE

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

X(1)

1.1. Value must be 1 character

2. Value must be in Provider ClassiﬁcaLon
Type List (VVL)
2. Value must be 1 character
3.3. Mandatory

PRV089

PRV.006.089

PROVCLASSIFICATIONCODE

Provider
ClassiﬁcaLon
Code

Mandatory

The code values from the categorizaLon schema
idenLﬁed in the Provider ClassiﬁcaLon Type
data element. Note: States should apply these
classiﬁcaLon schemas consistently across all
providers.

PROVCLASSIFICATIO
N-CODE-TYPE4, PROVTAXONOMY,
PROV-TYPE,
PROVSPECIALTY

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

X(20)

1.1. Value must be 20 characters or less

2. If associated Provider ClassiﬁcaLon Type
equals "1,", value must be in Provider
Taxonomy List (VVL)
23. If associated Provider ClassiﬁcaLon Type
equals "2,", value must be in Provider
Specialty Code List (VVL)
34. If associated Provider ClassiﬁcaLon Type
equals "3,", value must be in Provider Type
Code List (VVL)
45. If associated Provider ClassiﬁcaLon Type
equals "4,", value must be in Provider
Authorized Category of Service Code List
(VVL)
5. Value must be 20 characters or less
6.6. Mandatory

PRV090

PRV.006.090

PROVTAXONOMYCLASSIFICATIONEFF-DATE

Provider
Taxonomy
ClassiﬁcaLon
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
PRV091

PRV.006.091

PROVTAXONOMYCLASSIFICATIONEND-DATE

Provider
Taxonomy
ClassiﬁcaLon
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]

PRV092

PRV.006.092

STATE-NOTATION

State NotaLon

OpSituaLo

nal

PRV094

PRV.007.094

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00006

PROVTAXONOMYCLASSIFICATIO
N

X(500)

588

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

PRV00007

PROVMEDICAIDENROLLMENT

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00007"

STATE

PRV00007

PROVMEDICAIDENROLLMENT

X(2)

1.1. Value must be 2 characters

PRV.007.095

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)

PRV096

PRV097

PRV098

PRV.007.096

PRV.007.097

PRV.007.098

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

PROVMEDICAID-EFFDATE

Record Number

Mandatory

Submieng
State Provider
ID

Mandatory

Provider
Medicaid
EﬀecLve Date

Mandatory

N/A

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00007

PROVMEDICAIDENROLLMENT

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00007

PROVMEDICAIDENROLLMENT

X(30)

PROVMEDICAIDENROLLMENT

9(8)

1. Value must be 30 characters or less
2. Mandatory
3. Value must be 8 characters in the form
"CCYYMMDD"

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
PRV099

PRV.007.099

PROVMEDICAID-ENDDATE

Provider
Medicaid End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00007

PROVMEDICAIDENROLLMENT

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]

PRV100

PRV101

PRV.007.100

PRV.007.101

PROVMEDICAIDENROLLMENTSTATUS-CODE

Provider
Medicaid
Enrollment
Status Code

Mandatory

STATE-PLANENROLLMENT

State Plan
Enrollment

Mandatory

A code represenLng the provider's Medicaid
and/or CHIP enrollment status for the Lme span
speciﬁed by the PROV-MEDICAID-EFF-Provider
Medicaid EﬀecLve Date and PROV-MEDICAIDEND-Provider Medicaid End Date data elements.
Note: The State-PLAN- Plan Enrollment data
element idenLﬁes whether the provider is
enrolled in Medicaid, CHIP, or both.

PROVMEDICAIDENROLLMENTSTATUS-CODE

PRV00007

The state plan with which a provider has an
aﬃliaLon and is able to provide services to the
state's fee for service enrollees.

STATE-PLANENROLLMENT

PRV00007

PROVMEDICAIDENROLLMENT

X(2)

1.1. Value must be 2 characters

2. Value must be in Provider Medicaid
Enrollment Status Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

PROVMEDICAIDENROLLMENT

X(1)

1.1. Value must be 1 character

2. Value must be in State Plan Enrollment List
(VVL)
2. Value must be 1 character
3.3. Mandatory

PRV102

PRV.007.102

PROVENROLLMENTMETHOD

Provider
Enrollment
Method

Mandatory

Process by which a provider was enrolled in
Medicaid or CHIP.

PROVENROLLMENTMETHOD

PRV00007

PROVMEDICAIDENROLLMENT

X(1)

1.1. Value must be 1 character

2. Value must be in Provider Enrollment
Method List (VVL)
2. Value must be 1 character
3.3. Mandatory

PRV103

PRV.007.103

APPL-DATE

ApplicaLon
Date

Mandatory

The date on which the provider applied for
enrollment into the State's Medicaid and/or
CHIP program.

N/A

PRV00007

PROVMEDICAIDENROLLMENT

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must not be earlier than associated
Provider Medicaid EﬀecLve Date
(PRV.007.098) value
43. Mandatory

PRV104

PRV.007.104

STATE-NOTATION

State NotaLon

OpSituaLo

nal

PRV106

PRV.008.106

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00007

PROVMEDICAIDENROLLMENT

X(500)

579

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

PRV00008

PROVAFFILIATEDGROUPS

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00008"

STATE

PRV00008

PROVAFFILIATEDGROUPS

X(2)

1.1. Value must be 2 characters

PRV.008.107

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)
PRV108

PRV.008.108

RECORDNUMBER

Record Number

Mandatory

N/A

PRV00008

PROVAFFILIATEDGROUPS

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV109

PRV110

PRV111

PRV.008.109

PRV.008.110

PRV.008.111

SUBMITTINGSTATE-PROV-ID

Submieng
State Provider
ID

Mandatory

SUBMITTINGSTATE-PROV-IDOF-AFFILIATEDENTITY

Submieng
State Provider
ID of Aﬃliated
EnLty

Mandatory

PROVAFFILIATEDGROUP-EFFDATE

Provider
Aﬃliated Group
EﬀecLve Date

Mandatory

N/A

The unique, state-assigned idenLﬁcaLon
number for the group or subpart with which the
individual or subpart is associated. (The
submieng state's unique idenLﬁer for the
group. (Note: The group will also be in the
provider data set as a provider (i.e., the groupas-a-provider).

N/A

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00008

PROVAFFILIATEDGROUPS

X(30)

PROVAFFILIATEDGROUPS

X(1230) 5

PROVAFFILIATEDGROUPS

9(8)

1. Value must be 30 characters or less
2. Mandatory
3. Value must not contain a pipe symbol

6381

1.1. Value must be 30 characters or less

2. Value must not contain a pipe symbol
2. Value must be 12 characters or less

3. Mandatory

6482

7189

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
PRV112

PRV.008.112

PROVAFFILIATEDGROUP-ENDDATE

Provider
Aﬃliated Group
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00008

PROVAFFILIATEDGROUPS

9(8)

7290

7997

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory

54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]

PRV113

PRV.008.113

STATE-NOTATION

State NotaLon

OpSituaLo

nal

PRV115

PRV.009.115

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00008

PROVAFFILIATEDGROUPS

X(500)

8098

5797

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

PRV00009

PROVAFFILIATEDPROGRAMS

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00009"

STATE

PRV00009

PROVAFFILIATEDPROGRAMS

X(2)

1.1. Value must be 2 characters

PRV.009.116

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)

PRV117

PRV118

PRV119

PRV.009.117

PRV.009.118

PRV.009.119

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

AFFILIATEDPROGRAM-TYPE

Record Number

Mandatory

Submieng
State Provider
ID

Mandatory

Aﬃliated
Program Type

Mandatory

N/A

AFFILIATEDPROGRAMTYPEN/A

PRV00009

A code to identify the category of program that the
provider is affiliated.

AFFILIATEDPROGRAMTYPE

PRV00009

see Affiliated Program Type List (VVL.004)
(health plan federal assigned) if associated Affiliated
Program Type (DE) value is 1, then value must be the
federal-assigned plan ID of the health plan in which a
provider is enrolled to provide services.
(health plan state assigned) if associated Affiliated
Program Type (DE) value is 2, then value must be the
state-assigned plan ID of the health plan in which a
provider is enrolled to provide services.
(waiver) if associated Affiliated Program Type (DE)
value is 3, then value must be the core Federal
Waiver ID in which a provider is allowed to deliver
services to eligible beneficiaries.
(health home entity) if associated Affiliated Program
Type (DE) value is 4, then value must be the name of
a health home in which a provider is participating.

PRV00009

PROVAFFILIATEDPROGRAMS

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PROVAFFILIATEDPROGRAMS

X(30)

PROVAFFILIATEDPROGRAMS

X(1)

1. Value must be 30 characters or less
2. Mandatory
3. Value must be in Affiliated Program Type List
(VVL)

1.1. Value must be 1 character

2. Value must be in Aﬃliated Program Type
List (VVL)
2. Value must be 1 character
3.3. Mandatory

(other) if associated Affiliated Program Type (DE)
value is 5, then value must be an identifier for
something other than a health plan, waiver, or
health home entity.A code to idenLfy the

category of program that the provider is
aﬃliated.
PRV120

PRV.009.120

AFFILIATEDPROGRAM-ID

Aﬃliated
Program ID

Mandatory

A data element to identify the Medicaid/CHIP
programs, waivers and demonstrations in which the
provider participates.
(health plan federal assigned) if associated Affiliated
Program Type (DE) value is 1, then value must be the
federal-assigned plan ID of the health plan in which a
provider is enrolled to provide services.
(health plan state assigned) if associated Affiliated
Program Type (DE) value is 2, then value must be the
state-assigned plan ID of the health plan in which a
provider is enrolled to provide services.
(waiver) if associated Affiliated Program Type (DE)
value is 3, then value must be the core Federal
Waiver ID in which a provider is allowed to deliver
services to eligible beneficiaries.
(health home entity) if associated Affiliated Program
Type (DE) value is 4, then value must be the name of
a health home in which a provider is participating.
(other) if associated Affiliated Program Type (DE)
value is 5, then value must be an identifier for
something other than a health plan, waiver, or
health home entity.A data element to idenLfy the

Medicaid/CHIP programs, waivers and
demonstraLons in which the provider
parLcipates.

N/A

PRV00009

PROVAFFILIATEDPROGRAMS

X(50)

102

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

PRV121

PRV.009.121

PROVAFFILIATEDPROGRAM-EFFDATE

Provider
Aﬃliated
Program
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00009

PROVAFFILIATEDPROGRAMS

9(8)

103

110

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
PRV122

PRV.009.122

PROVAFFILIATEDPROGRAM-ENDDATE

Provider
Aﬃliated
Program End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00009

PROVAFFILIATEDPROGRAMS

9(8)

111

118

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
PRV123

PRV.009.123

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

PRV00009

PROVAFFILIATEDPROGRAMS

X(500)

119

618

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

PRV125

PRV.010.125

RECORD-ID

Record ID

Mandatory

RECORD-ID

PRV00010

PROV-BEDTYPE-INFO

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "PRV00010"

STATE

PRV00010

PROV-BEDTYPE-INFO

X(2)

1.1. Value must be 2 characters

PRV.010.126

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (PRV.001.007)
PRV127

PRV128

PRV.010.127

PRV.010.128

RECORDNUMBER

SUBMITTINGSTATE-PROV-ID

Record Number

Submieng
State Provider
ID

Mandatory

N/A

PRV00010

PROV-BEDTYPE-INFO

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

PRV00010

PROV-BEDTYPE-INFO

X(30)

1. Value must be 30 characters or less
2. Mandatory
3. Value must not contain a pipe symbol

state's Medicaid Management InformaLon
System.

PRV129

PRV130

PRV.010.129

PRV.010.130

PROV-LOCATION- Provider
ID
LocaLon ID

Not
Applicable

BED-TYPE-EFFDATE

Mandatory

Bed Type
EﬀecLve Date

Mandatory

N/A

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00010

PROV-BEDTYPE-INFO

X(5)

PROV-BEDTYPE-INFO

9(8)

1. Value must not contain a pipe symbol
2. 1. Value must be 5 characters or less

2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]

PRV131

PRV.010.131

BED-TYPE-ENDDATE

Bed Type End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

PRV00010

PROV-BEDTYPE-INFO

9(8)

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
PRV134

PRV.010.134

BED-TYPE-CODE

Bed Type Code

Mandatory

A code to classify beds available at a facility.

BED-TYPECODE

PRV00010

PROV-BEDTYPE-INFO

X(1)

1.1. Value must be 1 character

2. Value must be in Bed Type Code List (VVL)
2. Value must be 1 character
3.3. Mandatory

PRV135

PRV.010.135

BED-COUNT

Bed Count

Mandatory

A count of the number of beds available at the
facility for the category of bed idenLﬁed in the
Bed Type Code data element. Beds should not
be counted twice under diﬀerent bed types. See
T-MSIS Guidance Document, "CMS Guidance:
Best PracLce for ReporLng Provider Bed
InformaLon in the T-MSIS Provider File"

N/A

PRV00010

PROV-BEDTYPE-INFO

9(5)

1. Value must be 5 digits or less
2. Mandatory

N/A

PRV00010

PROV-BEDTYPE-INFO

X(500)

578

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

".
haps://www.medicaid.gov/medicaid/data-andsystems/macbis/tmsis/dataguide/t-msis-codingblog/reporLng-provider-bed-informaLon-in-thetmsis-blog/entry/47561provider-ﬁle-provider/
PRV136

PRV.010.136

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

PRV138

PRV.001.138

SEQUENCENUMBER

Sequence
Number

Mandatory

N/A

PRV00001

FILE-HEADERRECORDPROVIDER

X(4)

1314

7880

8183

1.1. Value must be 4 characters or less

5. Mandatory

PRV139

PRV.001.139

FILESUBMISSIONMETHOD

File Submission
Method

Mandatory

FILESUBMISSIONMETHOD

PRV00001

FILE-HEADERRECORDPROVIDER

X(2)

1. Value must be 2 characters
2. Value must be in File Submission Method
List (VVL)
3. Mandatory

PRV140

PRV.002.140

ATYPICAL-PROVIND

Atypical
Provider
Indicator

Mandatory

An indicator to idenLfy whether the provider is
an atypical provider and therefore not eligible
for an NPI.

ATYPICALPROV-IND

PRV00002

PROVATTRIBUTESMAIN

X(1)

514

1. Value must be 1 character
2. Value must be in Atypical Provider
Indicator code list (VVL)
3. Mandatory

T-MSIS Data Dic,onary – TPL File Changes Between Versions 2.4.0 and 4.0.0

TPL001

TPL.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

TPL00001

FILE-HEADERRECORD-TPL

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "TPL00001"

DATADICTIONARYVERSION

TPL00001

FILE-HEADERRECORD-TPL

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
34. Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

TPL00001

FILE-HEADERRECORD-TPL

X(1)

1. Value must be 1 character
2. Value must be in Submission TransacLon
Type List (VVL)

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

TPL.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle. Use the version number specified on the Cover
Sheet of the data dictionary" to V2.4.

TPL003

TPL004

TPL.001.003

TPL.001.004

SUBMISSIONTRANSACTIONTYPE

FILE-ENCODINGSPECIFICATION

Submission
TransacLon
Type

File Encoding
SpeciﬁcaLon

Mandatory

2. Value must be 1 character

3. Mandatory
TPL00001

FILE-HEADERRECORD-TPL

X(3)

1.1. Value must be 3 characters

2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
2. Value must be 3 characters
3.3. Mandatory

TPL005

TPL.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state

N/A

TPL00001

FILE-HEADERRECORD-TPL

X(9)

1. Value must be 9 characters or less
2. Mandatory

submission ﬁle. Use the version number specified
on the title page of the data mapping document

TPL006

TPL.001.006

FILE-NAME

File Name

Not
Applicable

Mandatory

TPL007

TPL.001.007

SUBMITTINGSTATE

Submieng
State

Mandatory

TPL00001

FILE-HEADERRECORD-TPL

X(8)

1. Value must equal 'TPL-FILE'"TPL-FILE"
2. Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

TPL00001

FILE-HEADERRECORD-TPL

X(2)

1.1. Value must be 2 characters

STATE

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same for all records
TPL008

TPL.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the ﬁle was created.

N/A

TPL00001

FILE-HEADERRECORD-TPL

9(8)

1.1. The date must be a valid calendar date in

4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory
TPL009

TPL.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

This value must be the ﬁrst day of the reporLng
month, regardless of the actual date span of the
data in the ﬁle.

N/A

TPL00001

FILE-HEADERRECORD-TPL

9(8)

2. Value must be equal to or earlier than
associated Date File Created
63. Value must be before associated End of
Time Period
74. Mandatory
5. Value of the CC component must be "20"

TPL010

TPL.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

TPL00001

FILE-HEADERRECORD-TPL

9(8)

associated Date File Created
54. Value must be equal to or afer associated
Start of Time Period
65. Mandatory
TPL011

TPL.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

TPL00001

FILE-HEADERRECORD-TPL

X(1)

1.1. Value must be 1 character

2. For producLon ﬁles, value must be equal
to 'P'
2. Value must be 1 character

"P"
3. Value must be in File Status Indicator List
(VVL)
4. Mandatory
TPL012

TPL.001.012

SSN-INDICATOR

SSN Indicator

Mandatory

SSN-INDICATOR

TPL00001

FILE-HEADERRECORD-TPL

X(1)

1.1. Value must be 1 character

2. Value must be in SSN Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

TPL013

TPL.001.013

TOT-REC-CNT

Total Record
Count

Mandatory

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

TPL00001

FILE-HEADERRECORD-TPL

9(11)

1.1. Value must be 11 digits or less

2. Value must be a posiLve integer
23. Value must be between 0:99999999999
(inclusive)
3. Value must be 11 digits or less
4.4. Value must equal the number of records

included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory
TPL014

TPL.001.014

STATE-NOTATION

State NotaLon

OpSituaLo

nal

TPL016

TPL.002.016

RECORD-ID

Record ID

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

TPL00001

FILE-HEADERRECORD-TPL

X(500)

1516

8385

5824

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

RECORD-ID

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "TPL00002"

STATE

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(2)

1.1. Value must be 2 characters

TPL.002.017

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (TPL.001.007)

TPL018

TPL019

TPL.002.018

TPL.002.019

RECORDNUMBER

MSISIDENTIFICATIONNUM

Record Number

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(20)

2. Mandatory

TPL020

TPL.002.020

TPL-HEALTHINSURANCECOVERAGE-IND

TPL Health
Insurance
Coverage
Indicator

Mandatory

A ﬂag to indicate that the Medicaid/CHIP eligible TPL-HEALTHperson has some form of third party insurance
INSURANCEcoverage.
COVERAGE-IND

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(1)

1.1. Value must be 1 character

2. Value must be in [0, 1] or not populated
3. Value must be in TPL Health Insurance
Coverage Indicator List (VVL)
2. Value must be 1 character
3.4. Mandatory
45. When value equals '"1'", there must be

one corresponding TPL Medicaid Eligible
Person Health Insurance Coverage
InformaLon (TPL.003) segment with the same
MSIS ID.
TPL021

TPL.002.021

TPL-OTHERCOVERAGE-IND

TPL Other
Coverage
Indicator

Mandatory

A ﬂag to indicate that the Medicaid/CHIP eligible TPL-OTHERperson has some other form of third party
COVERAGE-IND
funding besides insurance coverage.

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(1)

1.1. Value must be 1 character

2. Value must be in TPL Other Coverage
Indicator List (VVL)
2. Value must be 1 character
3.3. Mandatory

TPL022

TPL.002.022

ELIGIBLE-FIRSTNAME

Eligible First
Name

Mandatory

The ﬁrst name of the individual to whom the
services were provided.

TPL023

TPL.002.023

ELIGIBLEMIDDLE-INIT

Eligible Middle
IniLal

CondiLonal Individual's middle iniLal; middle iniLal
component of full name (e.g. First Name,
Middle IniLal, Last Name).

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(30)

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(1)

1. Value may include any alphanumeric
characters, digits or symbols
2. Value must be 1 character
32. Value must not contain a pipe or asterisk

symbols
43. CondiLonal
TPL024

TPL.002.024

ELIGIBLE-LASTNAME

Eligible Last
Name

Mandatory

The last name of the individual to whom the
services were provided.

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(30)

104

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

TPL025

TPL.002.025

ELIG-PRSNMAIN-EFF-DATE

Eligible Person
Main EﬀecLve
Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

9(8)

105

112

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20']
6. Value must be equal to or less than the
individual's Date of Death
(ELG.002.025)19,20,99]

TPL026

TPL.002.026

ELIG-PRSNMAIN-END-DATE

Eligible Person
Main End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

9(8)

113

120

same as the associated Segment EﬀecLve
Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
TPL027

TPL.002.027

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

TPL00002

TPL-MEDICAIDELIGIBLEPERSON-MAIN

X(500)

121

620

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

TPL029

TPL.003.029

RECORD-ID

Record ID

Mandatory

RECORD-ID

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "TPL00003"

STATE

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(2)

1.1. Value must be 2 characters

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

9(11)

TPL031

TPL.003.030

TPL.003.031

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

TPL00003

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (TPL.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

TPL032

TPL.003.032

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(20)

2. Mandatory

TPL033

TPL.003.033

INSURANCECARRIER-IDNUM

Insurance
Carrier ID
Number

CondiLonal The state's internalstate-assigned idenLﬁcaLon
number of the Third Party Liability Insurance
carrier(TPL) EnLty.

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

TPL034

TPL.003.034

INSURANCEPLAN-ID

Insurance Plan
ID

CondiLonal The ID number issued by the Insurance carrier
providing third party liability insurance coverage
to beneﬁciaries. Typically the Plan ID/Plan
Number is on the beneﬁciaries' insurance card.

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(20)

1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

TPL035

TPL036

TPL037

TPL.003.035

TPL.003.036

TPL.003.037

GROUP-NUM

MEMBER-ID

INSURANCEPLAN-TYPE

Group Number

Member ID

Insurance Plan
Type

CondiLonal The group number of the TPL health insurance
policy.

CondiLonal Member idenLﬁcaLon number as it appears on
the card issued by the TPL insurance carrier.

CondiLonal Code to classify the type of insurance plan
providing TPL coverage.

N/A

INSURANCEPLAN-TYPE

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(16)

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(20)

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(2)

1.1. Value must be 16 characters or less
2. Value must not contain a pipe or asterisk

symbol
2. Value must be 16 characters or less

3. CondiLonal

109

1.1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk

symbol
2. Value must be 20 characters or less

3. CondiLonal

110

111

1.1. Value must be 2 characters or less

2. Value must be in Insurance Plan Type List
(VVL)
23. CondiLonal
3. Value must be 2 characters or less
4.4. Value must have an associated Insurance

Plan ID

TPL038

TPL.003.038

ANNUALDEDUCTIBLEAMT

Annual
DeducLble
Amount

CondiLonal Annual amount paid each year by the enrollee
in the plan before a health plan beneﬁt begins.

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

S9(11)
V99

1110

1142

1264

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. CondiLonal

TPL044

TPL.003.044

POLICY-OWNERFIRST-NAME

Policy Owner
First Name

Not
Applicable

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCE-

X(30)

1211

1275

1564

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbolssymbol
3. If TPL Health Insurance Coverage Indicator

Mandatory

Individual's ﬁrst name; ﬁrst name component of
full name (e.g. First Name, Middle IniLal, Last
Name).

(TPL.002.020) equals "1", then value is

Mandatory

COVERAGEINFO

TPL045

TPL.003.045

POLICY-OWNERLAST-NAME

Policy Owner
Last Name

Not
Applicable

Mandatory

Individual's last name; last name component of
full name (e.g. First Name, Middle IniLal, Last
Name).

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(30)

1312

1575

1864

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbolssymbol
3. If TPL Health Insurance Coverage Indicator
(TPL.002.020) equals "1", then value is

Mandatory

TPL046

TPL.003.046

POLICY-OWNERSSN

Policy Owner
SSN

CondiLonal Unique idenLﬁer issued to an individual by the
SSA for the purpose of idenLﬁcaLon.

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(9)

1413

1875

1953

1. Value must be 9-digit number
2. For any individual, the value must be the
same over all segment eﬀecLve and end
dates
3. CondiLonal

TPL047

TPL.003.047

POLICY-OWNERCODE

Policy Owner
Code

CondiLonal This code idenLﬁes the relaLonship of the policy
holder to the Medicaid/CHIP beneﬁciary.

POLICYOWNER-CODE

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(2)

1514

1964

1975

1.1. Value must be 2 characters

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

9(8)

TPL048

TPL.003.048

INSURANCECOVERAGE-EFFDATE

Insurance
Coverage
EﬀecLve Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00003

2. Value must be in Policy Owner Code List
(VVL)
2. Value must be 2 characters
3.3. CondiLonal

1615

1986

2053

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value

43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]

TPL049

TPL.003.049

INSURANCECOVERAGE-ENDDATE

Insurance
Coverage End
Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

9(8)

1716

2064

2131

value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99']
6. When associated Date of Death (ELG.002.025)
is populated, data element value must be less
than or equal to Date of Death19,20,99]

TPL050

TPL.003.050

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(500)

214

713

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

TPL052

TPL.004.052

RECORD-ID

Record ID

Mandatory

RECORD-ID

TPL00004

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "TPL00004"

STATE

TPL00004

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(2)

1.1. Value must be 2 characters

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

9(11)

TPL054

TPL.004.053

TPL.004.054

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

TPL00004

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (TPL.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

TPL055

TPL.004.055

INSURANCECARRIER-IDNUM

Insurance
Carrier ID
Number

Mandatory

The state's internalstate-assigned idenLﬁcaLon
number of the Third Party Liability Insurance
carrier(TPL) EnLty.

N/A

TPL00004

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(12)

1. Mandatory
2. Value must be 12 characters or less
3. Value must not contain a pipe or asterisk
symbols

TPL056

TPL.004.056

INSURANCEPLAN-ID

Insurance Plan
ID

Mandatory

The ID number issued by the Insurance carrier
providing third party liability insurance coverage
to beneﬁciaries. Typically the Plan ID/Plan
Number is on the beneﬁciary'ies' insurance card.

N/A

TPL00004

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(20)

1.1. Value must be 20 characters or less

Code to classify the enLty providing TPL
coverage.

INSURANCEPLAN-TYPE

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(2)

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(2)

TPL057

TPL058

TPL.004.057

TPL.004.058

INSURANCEPLAN-TYPE

COVERAGE-TYPE

Insurance Plan
Type

Coverage Type

Mandatory

This code identifiesCode indicaLng the
relationshiplevel of the coverage being provided
under this policy holder tofor the insured by the
Medicaid/CHIP beneficiary.
see Policy Owner Code List (VVL.099)TPL carrier.

COVERAGETYPE

TPL00004

2. Value must not contain a pipe or asterisk
symbol
2. Value must be 20 characters or less

symbols
3. Mandatory
6

1.1. Value must be 2 characters or less

2. Value must be in Insurance Plan Type List
(VVL)
23. Mandatory
3. Value must be 2 characters or less
4.4. Value must have an associated Insurance

Plan ID
7

1.1. Value must be 2 characters

2. Value must be in Coverage Type List (VVL).
2. Value must be 2 characters

)
3. Mandatory

TPL059

TPL060

TPL.004.059

TPL.004.060

INSURANCECATEGORIESEFF-DATE

INSURANCECATEGORIESEND-DATE

Insurance
Categories
EﬀecLve Date

Insurance
Categories End
Date

Mandatory

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00004

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

9(8)

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

9(8)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20'19,20,99]
9

value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'19,20,99]
TPL061

TPL.004.061

STATE-NOTATION

State NotaLon

OpSituaLo

nal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

TPL00004

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGECATEGORIES

X(500)

573

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

TPL063

TPL.005.063

RECORD-ID

Record ID

Mandatory

RECORD-ID

TPL00005

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "TPL00005"

STATE

TPL00005

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

X(2)

1.1. Value must be 2 characters

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

9(11)

TPL065

TPL.005.064

TPL.005.065

SUBMITTINGSTATE

RECORDNUMBER

Submieng
State

Record Number

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

N/A

TPL00005

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (TPL.001.007)
3

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

TPL066

TPL067

TPL068

TPL.005.066

TPL.005.067

TPL.005.068

MSISIDENTIFICATIONNUM

TYPE-OF-OTHERTHIRD-PARTYLIABILITY

OTHER-TPL-EFFDATE

MSIS
IdenLﬁcaLon
Number

Type of Other

Mandatory

Third Party
Liability TPL

Other TPL
EﬀecLve Date

Mandatory

N/A

TPL00005

This code idenLﬁes the other types of liabiliLes
an individual may have which are not
necessarily deﬁned as a health insurance plan
listed Insurance-TYPE- Type Plan.

TYPE-OFOTHER-THIRDPARTYLIABILITY

TPL00005

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00005

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

X(20)

2. Mandatory

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

X(1)

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

9(8)

1. If value equals "Other". then Policy Owner
(TPL.003.044-047) information is not required
2. Value must be 1 character
32. Value must be in Type of Other Third-

Party Liability List (VVL)
43. Mandatory
6

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be before or the same as the
associated Segment End Date value
43. Mandatory
54. Value of the CC component must be in

['18', '19', '20']
6.19,20,99]
5. Value must occur on or before individual's
Date of Death (ELG.002.025) when populated

TPL069

TPL070

TPL.005.069

TPL.005.070

OTHER-TPL-ENDDATE

STATE-NOTATION

Other TPL End
Date

State NotaLon

Mandatory

OpSituaLo

nal

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

TPL00005

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

9(8)

TPL-MEDICAIDELIGIBLEOTHER-THIRDPARTYCOVERAGEINFORMATION

X(500)

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
8

558

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

TPL072

TPL.006.072

RECORD-ID

Record ID

Mandatory

RECORD-ID

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(8)

1. Value must be 8 characters
2. Mandatory
2. 3. Value must be in Record ID List (VVL)
4. Value must equal "TPL00006"

STATE

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(2)

1.1. Value must be 2 characters

TPL.006.073

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3.3. Mandatory

4. Value must be the same as Submieng
State (TPL.001.007)
TPL074

TPL075

TPL.006.074

TPL.006.075

RECORDNUMBER

INSURANCECARRIER-IDNUM

Record Number

Insurance
Carrier ID
Number

Mandatory

N/A

The state's internalstate-assigned idenLﬁcaLon
number of the Third Party Liability Insurance
carrier(TPL) EnLty.

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

9(11)

1.1. Value must be 11 digits or less

2. Value must be unique within record
segment over all records associated with a
given Record ID
2. Value must be greater than or equal to 1
3. Value must be 11 digits or less
4.3. Mandatory

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(12)

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

TPL076

TPL.006.076

TPL-ENTITYADDR-TYPE

TPL EnLty
Address Type

Conditional

Mandatory

The type of address for a TPL EnLty submiaed in
the record segment.

TPL-ENTITYADDR-TYPE

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(2)

1.1. Value must be 2 characters

2. Value must be in TPL EnLty Address Type
List (VVL)
2. Value must be 2 characters
3. Conditional3. Mandatory

TPL077

TPL.006.077

INSURANCECARRIER-ADDRLN1

Insurance
Carrier Address
Line 1

OpSituaLo

nal

The ﬁrst line of a potenLally mulL-line physical
street or mailing address for a given enLty (e.g.
person, organizaLon, agency, etc.).

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(60)

1. Value must be 60 characters or less
2. Value must not be equal to associated
Address Line 2 or Address Line 3 value(s)
3. Value must not contain a pipe or asterisk
symbols
4. SituaLonal
5. When populated, the associated Address
Type is required
5. Optional

TPL078

TPL.006.078

INSURANCECARRIER-ADDRLN2

Insurance
Carrier Address
Line 2

CondiLonal The second line of a mulL-line physical street or
mailing address for a given enLty (e.g. person,
organizaLon, agency, etc.).

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(60)

155

TPL079

TPL.006.079

INSURANCECARRIER-ADDRLN3

Insurance
Carrier Address
Line 3

CondiLonal The third line of a mulL-line physical street or
mailing address for a given enLty (e.g. person,
organizaLon, agency, etc.).

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(60)

156

215

1. Value of the CC component must be "20"
2. Value must be 860 characters in the form
"CCYYMMDD"
3. The date must be a valid calendar date (i.e. Feb
29th only on the leap year, never April 31st or
Sept 31st)
4less
2. Value must not be equal to or after the value
of associated End of Time Period Address Line 1

or Address Line 2 value(s)
3. If Address Line 2 is not populated, then
value should not be populated
4. Value must not contain a pipe or asterisk

symbols
5. MandatoryCondiLonal

TPL080

TPL081

TPL082

TPL083

TPL084

TPL.006.080

TPL.006.081

TPL.006.082

TPL.006.083

TPL.006.084

INSURANCECARRIER-CITY

Insurance
Carrier City

OpSituaLo

INSURANCECARRIER-STATE

Insurance
Carrier State

OpSituaLo

nal

INSURANCECARRIER-ZIPCODE

Insurance
Carrier ZIP Code

OpSituaLo

INSURANCECARRIERPHONE-NUM

Insurance
Carrier Phone
Number

OpSituaLo

TPL-ENTITYCONTACT-INFOEFF-DATE

TPL EnLty
Contact Info
EﬀecLve Date

Mandatory

nal

The city component of an address associated
with a given enLty (e.g. person, organizaLon,
agency, etc.).

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(28)

216

243

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

The ANSI state numeric code for the U.S. state,
Territory, or the District of Columbia code of the
TPL Insurance carrier.

STATE

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(2)

244

245

1.1. Value must be 2 characters

The ZIP Code for the locaLon being captured on
the TPL EnLty Contact InformaLon record.

N/AZIP-CODE

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(9)

246

254

1. Value may only be 5 digits (0-9) (Example:
91320) or 9 digits (0-9) (Example: 913200011)
2. OptionalValue must be in ZIP Code List
(VVL)
3. SituaLonal

Phone number for a given enLty (e.g. person,
organizaLon, agency).

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(10)

255

264

1. Value must be 10 characters, digits (0-9) onlydigit number
2. OpSituaLonal

The ﬁrst calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

9(8)

265

272

1. Value of the CC component must be "20"
2. Value must be 8 characters in the form
"CCYYMMDD"
3.1. The date must be a valid calendar date
(i.e. Feb 29th only onin the form "CCYYMMDD"

2. Value must be in State Code List (VVL)
2. Value must be 2 characters
3. OpSituaLonal

2. Value must be before or the same as the
leap year, never April 31st or Sept 31st)
4. Value must be equal to or after the value of
associated Segment End of Time Period
5Date value

3. Mandatory

4. Value of the CC component must be in
[19,20,99]

TPL085

TPL.006.085

TPL-ENTITYCONTACT-INFOEND-DATE

TPL EnLty
Contact Info
End Date

Mandatory

The last calendar day on which all of the other
data elements in the same segment were
eﬀecLve.

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

9(8)

273

280

1. Value must be 8 characters in the form
"CCYYMMDD"
2. 1. The date must be a valid calendar date
(i.e. Feb 29th only on the leap year, never April
31st or Sept 31st)
3. in the form "CCYYMMDD"

2. Value must be greater than or equal to
associated Segment EﬀecLve Date value
43. Mandatory
54. Value of the CC component must be in
['18', '19', '20', '99'18,19,20,99]
TPL086

TPL.006.086

STATE-NOTATION

State NotaLon

OpSituaLo

nal

TPL088

TPL.001.088

SEQUENCENUMBER

Sequence
Number

Mandatory

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(500)

1517

3281

7820

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

N/A

TPL00001

FILE-HEADERRECORD-TPL

X(4)

1415

7981

8284

1.1. Value must be 4 characters or less

5. Mandatory

TPL089

TPL090

TPL091

TPL.003.089

TPL.006.090

TPL.006.091

COVERAGE-TYPE

Coverage Type

Mandatory

A code to indicate the level of coverage being
provided under this policy for the insured by the
TPL carrier.

COVERAGETYPE

TPL00003

TPL-MEDICAIDELIGIBLEPERSONHEALTHINSURANCECOVERAGEINFO

X(2)

1017

2112

2113

1.1. Value must be 2 characters

2. Value must be in Coverage Type List (VVL).
2. Value must be 2 characters

)
3. Mandatory

INSURANCECARRIER-NAICCODE

Insurance
Carrier NAIC
Code

OpSituaLo

The NaLonal AssociaLon of Insurance
Commissioners (NAIC) code of the TPL Insurance
carrier.

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(10)

1615

7281

7290

nal

1. Value must be 10 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

INSURANCECARRIER-NAME

Insurance
Carrier Name

OpSituaLo

The name of the TPL Insurance carrier.

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(30)

1716

7291

8320

1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. OpSituaLonal

nal

TPL092

TPL.006.092

NATIONALHEALTH-CAREENTITY-ID-TYPE

National Health
Care Entity ID
Type

Not
Applicable

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(1)

821

1. Not Applicable

TPL093

TPL.006.093

NATIONALHEALTH-CAREENTITY-ID

National Health
Care Entity ID

Not
Applicable

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(10)

822

831

1. Not Applicable

TPL094

TPL.006.094

NATIONALHEALTH-CAREENTITY-NAME

National Health
Care Entity Name

Not
Applicable

N/A

TPL00006

TPL-ENTITYCONTACTINFORMATION

X(50)

832

881

1. Not Applicable

TPL095

TPL.001.095

FILESUBMISSIONMETHOD

File Submission
Method

Mandatory

The ﬁle submission method (e.g., TFFR, RHFR, IT,
or CSO) used by the state to build and submit
the ﬁle. This should correspond with the state's

FILESUBMISSIONMETHOD

TPL00001

FILE-HEADERRECORD-TPL

X(2)

1. Value must be 2 characters
2. Value must be in File Submission Method
List (VVL)
3. Mandatory

declared ﬁle submission method for the same
ﬁle type and Lme period.

T-MSIS Data Dic,onary – FTX File Changes Between Versions 2.4.0 and 4.0.0

FTX001

FTX.001.001

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00001

FILE-HEADERRECORD-FTX

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00001"

FTX002

FTX.001.002

DATADICTIONARYVERSION

Data DicLonary
Version

Mandatory

A data element to capture the version of the TMSIS data dicLonary that was used to build the
ﬁle.

DATADICTIONARYVERSION

FTX00001

FILE-HEADERRECORD-FTX

X(10)

1. Value must be 10 characters or less
2. Value must be in Data DicLonary Version
List (VVL)
3. Value must not include the pipe ("|")
symbol
4. Mandatory

FTX003

FTX.001.003

SUBMISSIONTRANSACTIONTYPE

Submission
TransacLon
Type

Mandatory

A data element to idenLfy the whether the
transacLons in the ﬁle are original submissions
of the data, a resubmission of a previously
submiaed ﬁle, or correcLons of edit rejects.

SUBMISSIONTRANSACTIONTYPE

FTX00001

FILE-HEADERRECORD-FTX

X(1)

1. Value must be 1 character
2. Value must be in Submission TransacLon
Type List (VVL)
3. Mandatory

FTX004

FTX.001.004

FILE-ENCODINGSPECIFICATION

File Encoding
SpeciﬁcaLon

Mandatory

Denotes which supported ﬁle encoding standard
was used to create the ﬁle.

FILEENCODINGSPECIFICATION

FTX00001

FILE-HEADERRECORD-FTX

X(3)

1. Value must be 3 characters
2. Value must be in File Encoding
SpeciﬁcaLon List (VVL)
3. Mandatory

FTX005

FTX.001.005

DATA-MAPPINGDOCUMENTVERSION

Data Mapping
Document
Version

Mandatory

IdenLﬁes the version of the T-MSIS data
mapping document used to build a state
submission ﬁle.

N/A

FTX00001

FILE-HEADERRECORD-FTX

X(9)

1. Value must be 9 characters or less
2. Mandatory

FTX006

FTX.001.006

FILE-NAME

File Name

Mandatory

A code to idenLfy the subject area to which the
records in its ﬁle relate. Each T-MSIS submission
ﬁle should only contain records for one subject
area (i.e., Eligible, Third-party liability, Provider,
Managed Care Plan InformaLon, InpaLent,
Long-Term Care, Other, Pharmacy Claim, and
Financial TransacLons).

N/A

FTX00001

FILE-HEADERRECORD-FTX

X(8)

1. Value must equal "FINTRANS"
2. Mandatory

FTX007

FTX.001.007

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00001

FILE-HEADERRECORD-FTX

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX008

FTX.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the ﬁle was created.

N/A

FTX00001

FILE-HEADERRECORD-FTX

9(8)

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be less than current date
4. Value must be equal to or afer the value
of associated End of Time Period
5. Mandatory

FTX009

FTX.001.009

START-OF-TIMEPERIOD

Start of Time
Period

Mandatory

newly acquired SSN for at least one monthly
submission of the Eligible File so that T-MSIS can
associated the temporary MSIS IdenLﬁcaLon
Number and the social security number.

N/A

FTX00001

FILE-HEADERRECORD-FTX

9(8)

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be equal to or earlier than
associated Date File Created
3. Value must be before associated End of
Time Period
4. Mandatory
5. Value of the CC component must be "20"

FTX010

FTX.001.010

END-OF-TIMEPERIOD

End of Time
Period

Mandatory

This value must be the last day of the reporLng
month, regardless of the actual date span.

N/A

FTX00001

FILE-HEADERRECORD-FTX

9(8)

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be equal to or earlier than
associated Date File Created
4. Value must be equal to or afer associated
Start of Time Period
5. Mandatory

FTX011

FTX.001.011

FILE-STATUSINDICATOR

File Status
Indicator

Mandatory

A code to indicate whether the records in the
ﬁle are test or producLon records.

FILE-STATUSINDICATOR

FTX00001

FILE-HEADERRECORD-FTX

X(1)

1. Value must be 1 character
2. Value must be in File Status Indicator List
(VVL)
3. For producLon ﬁles, value must be equal
to "P"
4. Mandatory

FTX012

FTX.001.012

SSN-INDICATOR

SSN Indicator

Mandatory

with the temporary MSIS IdenLﬁcaLon Number
and the SSN ﬁeld should be space-ﬁlled, or
blank. When the SSN becomes known, the MSIS
IdenLﬁcaLon Number ﬁeld should conLnue to
be populated with the temporary MSIS
IdenLﬁcaLon Number and the SSN ﬁeld should
be populated with the

SSN-INDICATOR

FTX00001

FILE-HEADERRECORD-FTX

X(1)

1. Value must be 1 character
2. Value must be in SSN Indicator List (VVL)
3. Mandatory

FTX013

FTX.001.013

TOT-REC-CNT

Total Record
Count

Mandatory

A count of all records in the ﬁle except for the
ﬁle header record. This count will be used as a
control total to help assure that the ﬁle did not
become corrupted during transmission.

N/A

FTX00001

FILE-HEADERRECORD-FTX

9(11)

1. Value must be 11 digits or less
2. Value must be a posiLve integer
3. Value must be between 0:99999999999
(inclusive)
4. Value must equal the number of records
included in the ﬁle submission except for the
ﬁle header record.
5. Mandatory

FTX014

FTX.001.014

SEQUENCENUMBER

Sequence
Number

Mandatory

N/A

FTX00001

FILE-HEADERRECORD-FTX

X(4)

1. Value must be 4 characters or less
2. Value must between 1 and 9999
3. Value must be equal to the largest of any
prior values for the same reporLng period
and ﬁle type, plus 1 (i.e. incremented by 1)
4. Value must not contain a pipe symbol
5. Mandatory

FTX015

FTX.001.015

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00001

FILE-HEADERRECORD-FTX

X(500)

582

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX017

FTX.002.017

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00002

INDIVIDUALCAPITATIONPMPM

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00002"

FTX018

FTX.002.018

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX019

FTX.002.019

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX020

FTX.002.020

ICN-ORIG

Original ICN

CondiLonal A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

FTX021

FTX.002.021

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(50)

121

FTX023

FTX.002.023

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00002

INDIVIDUALCAPITATIONPMPM

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX024

FTX.002.024

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX025

FTX.002.025

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX026

FTX.002.026

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX027

FTX.002.027

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX028

FTX.002.028

PAYER-ID

Payer ID

Mandatory

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

197

198

1. Value must be 2 characters
2. Value must be in Payer ID Type List (VVL)
3. Mandatory
4. When value equals "01" then Payer ID
must equal Submieng State (FTX.001.007)
5. When value equals "02" then Payer ID
must equal State Plan IdenLﬁcaLon Number
(MCR.002.019)
6. When value equals "04" then Payer ID
must equal must equal Submieng State
Provider IdenLﬁer (PRV.002.019)

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system. The payer is the subject taking the
acLon of either making a payment or taking a
recoupment, as opposed to the payee who is
the object of the transacLon. The payer is the
enLty that is either making a payment or
recouping a payment from another enLty or
individual. The payee is the individual or enLty
that is either receiving a payment or having a
previous payment recouped.
This will typically correspond to the X12 820
Premium Payer.

FTX029

FTX.002.029

PAYER-ID-TYPE

Payer ID Type

Mandatory

This is a qualiﬁer that indicates what type of ID
the payer ID is. For example, if the payer ID
represents the state Medicaid or CHIP agency,
then the payer ID type will indicate that the
payer ID should be interpreted as a submieng
state code.

FTX030

FTX.002.030

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX031

FTX.002.031

PAYER-MCRPLAN-TYPE

Payer MCR Plan
Type

CondiLonal This describes the type of managed care plan or
care coordinaLon model of the payer, when
applicable. The valid value list is comprised of
the standard managed care plan type list from
the MCR and ELG ﬁles and a complementary list
of care coordinaLon models.

MANAGEDCARE-PLANTYPE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

299

300

1. Value must be 2 characters
2. Value must be in Managed Care Plan Type
List (VVL)
3. If Payer ID Type equals "02", then value
must be populated
4. If Payer ID Type does not equal "02", then
value must not be populated
5. CondiLonal

FTX032

FTX.002.032

PAYER-MCRPLAN-TYPEOTHER-TEXT

Payer MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payer
ID was reported with a PAYER-MCR-PLAN-OROTHER-TYPE of "Other".

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

301

400

1. Value must be 100 characters or less
2. Value must be populated when Payer MCR
Plan Type equals "95"
3. CondiLonal

FTX033

FTX.002.033

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(30)

401

430

1. Value must be 30 characters or less
2. Mandatory

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system. The payee is the individual or enLty that
is either receiving a payment or having a
previous payment recouped. The payee is the
object of the transacLon, as opposed to the
payer who is the subject taking the acLon of
either making a payment or taking a
recoupment.
This will typically correspond to the X12 820
Premium Receiver.

FTX034

FTX.002.034

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

FTX035

FTX.002.035

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

FTX036

FTX.002.036

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

This is a qualiﬁer that indicates what type of ID
the payee ID is. For example, if the payee ID
represents a provider ID, then the payee ID type
will indicate that the payee ID should be
interpreted as a provider ID.

PAYEE-ID-TYPE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

431

432

1. Value must be 2 characters
2. Value must be in Payee IdenLﬁer Type List
(VVL)
3. If value equals "01", then Payee IdenLﬁer
must equal Submieng State (FTX.001.007)
4. If value equals "02", then Payee IdenLﬁer
must equal State Plan IdenLﬁcaLon Number
(MCR.002.019)
5. If value in [04,05], then Payee IdenLﬁer
must equal Submieng State Provider
IdenLﬁer (PRV.002.019)
6. If value equals "06", then Payee IdenLﬁer
must equal Provider IdenLﬁer (PRV.005.081)
where Provider IdenLﬁer Type (PRV.005.077)
equals "2"
7. If value equals "07", then Payee IdenLﬁer
must equal Insurance Carrier IdenLﬁcaLon
Number (TPL.006.075)
8. If value equals "08", then Payee IdenLﬁer
must equal MSIS IdenLﬁcaLon Number
(ELG.002.019)
9. Mandatory

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

CondiLonal This describes the type of managed care plan or
care coordinaLon model of the payee, when
applicable. The valid value code set is comprised
of the standard managed care plan type list
from the MCR and ELG ﬁles and a
complementary list of care coordinaLon models.

MANAGEDCARE-PLANTYPE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

533

534

1. Value must be 2 characters
2. Value must be in Managed Care Plan Type
List (VVL)
3. If Payee ID Type is in [02,03], then value
must be populated
4. If Payee ID Type is not [02,03], then value
must not be populated
5. CondiLonal

FTX037

FTX.002.037

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

535

634

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX038

FTX.002.038

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(30)

635

664

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

665

666

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

FTX039

FTX.002.039

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

This is a qualiﬁer that indicates what type of tax
ID the payee tax ID is. For example, if the payee
tax ID represents a SSN, then the payee tax ID
type will indicate that the payee tax ID should
be interpreted as a SSN.

FTX040

FTX.002.040

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

667

766

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX041

FTX.002.041

CONTRACT-ID

Contract
IdenLﬁer

CondiLonal

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

767

866

1. Value must be 100 characters or less
2. CondiLonal
3. If SubcapitaLon Indicator equals "01", then
value must be populated

Managed care plan contract ID

FTX042

FTX.002.042

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(20)

867

886

1. Value must be 20 characters or less
2. Mandatory
3. Value must match MSIS IdenLﬁcaLon
Number (ELG.021.019)
4. When Adjustment Indicator does not equal
"1", there must be a valid record of type
Enrollment Time Span where the CapitaLon
Period Start Date is equal to or greater than
Enrollment Start Date and CapitaLon Period
End Date is less than or equal to Enrollment
End Date

FTX043

FTX.002.043

CAPITATIONPERIOD-STARTDATE

CapitaLon
Period Start
Date

Mandatory

The date represenLng the beginning of the
N/A
period covered by the capitaLon or subcapitaLon payment or recoupment; for example,
the ﬁrst day of the calendar month of
beneﬁciary enrollment in the managed care plan
that the payment is intended to cover (whether
or not the beneﬁciary actually receives services
during that month).

FTX00002

INDIVIDUALCAPITATIONPMPM

9(8)

887

894

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated CapitaLon Period End Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX044

FTX.002.044

CAPITATIONPERIOD-ENDDATE

CapitaLon
Period End Date

Mandatory

The date represenLng the end of the period
covered by the capitaLon or sub-capitaLon
payment or recoupment; for example, the last
day of the calendar month of beneﬁciary
enrollment in the managed care plan that the
payment is intended to cover (whether or not
the beneﬁciary actually receives services during
that month).

FTX00002

INDIVIDUALCAPITATIONPMPM

9(8)

895

902

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be afer or the same as the
associated CapitaLon Period Start Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

N/A

FTX045

FTX.002.045

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

A code to indicate the Federal funding source
for the payment.

FTX046

FTX.002.046

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

903

904

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00002

INDIVIDUALCAPITATIONPMPM

X(5)

956

960

1. Value must be 5 characters or less
2. When MBESCBES Form equals "21.P",
value must be in 21.P Form List (VVL)
3. When MBESCBES Form equals "21BASE",
value must be in 21BASE Form List (VVL)
4. When MBESCBES Form equals "64.21U",
value must be in 64.21U Form List (VVL)
5. When MBESCBES Form equals
"64.10BASE", value must be in 64.10BASE
Form List (VVL)
6. When MBESCBES Form equals "64.9P",
value must be in 64.9P Form List (VVL)
7. When MBESCBES Form equals "64.9A",
value must be in 64.9A Form List (VVL)
8. When MBESCBES Form equals "64.9BASE",
value must be in 64.9BASE Form List (VVL)
9. When MBESCBES Form equals "64.21UP",
value must be in 64.21UP Form List (VVL)
10. If SubcapitaLon Indicator equals "01",
then value must be populated
11. CondiLonal
12. When populated, an associated
MBESCBES Form Group and MBESCBES Form
must be populated

FTX047

FTX.002.047

MBESCBESFORM

MBESCBES
Form

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00002

INDIVIDUALCAPITATIONPMPM

X(50)

906

955

1. Value must be 50 characters or less
2. When MBESCBES Form Group equals "1",
value must be in MBESCBES Form Group 1
List (VVL)
3. When MBESCBES Form Group equals "2",
value must be in MBESCBES Form Group 2
List (VVL)
4. When MBESCBES Form Group equals "3",
value must be in MBESCBES Form Group 3
List (VVL)
5. If SubcapitaLon Indicator equals "01", then
value must be populated
6. CondiLonal

FTX048

FTX.002.048

MBESCBESFORM-GROUP

MBESCBES
Form Group

MBESCBESFORM-GROUP

FTX00002

INDIVIDUALCAPITATIONPMPM

X(1)

905

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. If SubcapitaLon Indicator equals "01", then
value must be populated
4. CondiLonal

FTX049

FTX.002.049

WAIVER-ID

Waiver ID

CondiLonal Field specifying the waiver or demonstraLon
which authorized payment. These IDs must be
the approved, full federal waiver ID number
assigned during the state submission and CMS
approval process. Waiver IDs should actually
only be the "core" part of the waiver IDs,
without including suﬃxes for renewals or
amendments.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(20)

961

980

1. Value must be 20 characters or less
2. Value must be associated with a populated
Waiver Type
3. (1115 demonstraLon) If value begins with
"11-W-" or "21-W-", the associated Claim
Waiver Type value must be 01 or in [21-30]
4. (1115 demonstraLon) If value begins
with"11-W-" or "21-W-", then the value must
include slash “/” in the 11th posiLon followed
by the last digit of the CMS Region [0-9] in
the 12th posiLon
5. (1915(b) or 1915(c) waivers) If value begins
with the two-leaer state abbreviaLon
followed by a period (.), the associated

Waiver Type value must be in [02-20,32,33]
6. CondiLonal

FTX050

FTX.002.050

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

981

982

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. Value must match Eligible Waiver Type
(ELG.012.173) for the enrollee for the same
Lme period
5. CondiLonal

FTX051

FTX.002.051

FUNDING-CODE

Funding Code

CondiLonal A code to indicate the source of non-federal
share funds.

FUNDINGCODE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

983

984

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. If SubcapitaLon Indicator equals "01", then
value must be populated
4. CondiLonal

FTX052

FTX.002.052

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

CondiLonal A code to indicate the type of non-federal share
used by the state to ﬁnance its expenditure to
the provider. In the event of two sources, states
are to report the porLon which represents the
largest proporLon not funded by the Federal
government.

FUNDINGSOURCENONFEDERALSHARE

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

985

986

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share List (VVL)
3. If SubcapitaLon Indicator equals "01", then
value must be populated
4. CondiLonal

FTX053

FTX.002.053

SDP-IND

State Directed
Payment
Indicator

Mandatory

Indicates whether the ﬁnancial transacLon from
an MC plan to a provider or other enLty is a
type of State Directed Payment.

SDP-IND

FTX00002

INDIVIDUALCAPITATIONPMPM

X(1)

987

1. Value must be 1 character
2. Value must be in State Directed Payment
Indicator List (VVL)
3. Mandatory

FTX054

FTX.002.054

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

988

989

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX055

FTX.002.055

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(15)

990

1004

1. Value must be 15 characters or less
2. CondiLonal

SUBCAPITATIO
N-IND

FTX00002

INDIVIDUALCAPITATIONPMPM

X(1)

1005

1. Value must be 1 character
2. Value must be in SubcapLtaLon Indicator
List (VVL)
3. Mandatory

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(50)

1006

1055

1. Value must be 50 characters or less
2. If SubcapitaLon Indicator equals "01", then
value must be populated
3. CondiLonal

YY = Calendar Year (last two characters of the
calendar year of the state plan amendment);
NNNN = SPA number (a four character number
beginning with 0001) States should track their
submissions to assign sequenLal numbers to
their submissions. The system will not permit
reuse of a previously used SPA ID for a package
that has been formally submiaed; xxxx = an
SituaLonal entry for speciﬁc SPA types
FTX056

FTX.002.056

SUBCAPITATIONIND

SubcapitaLon
Ind

Mandatory

Indicates whether the transacLon represents a
sub-capitaLon payment between a managed
care plan and a sub-capitated enLty or subcapitated network provider or not. A subcapitaLon payment could also be between a
sub-capitated enLty and another sub-capitated
enLty or sub-capitated network provider.

FTX057

FTX.002.057

PAYMENT-CATXREF

Payment Cat
Xref

CondiLonal Cross-reference to the applicable payment
category in the managed care plan's contract
with the state Medicaid/CHIP agency or their
ﬁscal intermediary.

FTX058

FTX.002.058

RATE-CELLDESCRIPTIONTEXT

Rate Cell
DescripLon Text

CondiLonal This is the descripLon of the rate cell from the
rate seeng process that applies to the
capitaLon payment. For example, a rate cell may
represent the monthly capitaLon rate paid for
adults with chronic condiLons who live in a rural
area. If the rate paid for this capitaLon payment
is based on the rate cell for adults with chronic
condiLons who live in a rural area, then the rate
cell descripLon could be "Adults with chronic
condiLons living in a rural area."

FTX059

FTX.002.059

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

FTX060

FTX.002.060

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

FTX061

FTX.002.061

MEMO

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

1056

1155

1. Value must be 100 characters or less
2. CondiLonal

CondiLonal Expenditure Authority Type is the federal statute EXPENDITUREor regulaLon under which the expenditure is
AUTHORITYauthorized/jusLﬁed. The federal statute or
TYPE
regulaLon is usually referenced in either the
Medicaid or CHIP State Plan or waiver
documentaLon. For waivers, do not reference
the federal statute or regulaLon being waived
by the waiver. For waivers, referring to the
waiver authority is suﬃcient. If the federal
statute or regulaLon is not available in the list of
valid values, choose the value for "Other" and
report the authority in the Expenditure
Authority Type Text.

FTX00002

INDIVIDUALCAPITATIONPMPM

X(2)

1156

1157

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. If SubcapitaLon Indicator equals "01", then
value must be populated
4. CondiLonal

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(100)

1158

1257

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(500)

1258

1757

1. Value must be 500 characters or less
2. CondiLonal

FTX062

FTX.002.062

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00002

INDIVIDUALCAPITATIONPMPM

X(500)

1758

2257

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX064

FTX.003.064

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00003"

FTX065

FTX.003.065

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX066

FTX.003.066

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX067

FTX.003.067

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX068

FTX.003.068

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(50)

121

FTX070

FTX.003.070

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX071

FTX.003.071

PAYMENT-ORRECOUPMENTDATE

Payment Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX072

FTX.003.072

PAYMENTAMOUNT

Payment
Amount

Mandatory

The dollar amount being paid to the payee.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX073

FTX.003.073

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX074

FTX.003.074

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX075

FTX.003.075

PAYER-ID

Payer ID

Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

197

198

1. Value must be 2 characters
2. Value must be in Payer ID Type List (VVL)
3. Mandatory
4. When value equals "01" then Payer ID
must equal Submieng State (FTX.001.007)

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX076

FTX.003.076

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX077

FTX.003.077

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

FTX078

FTX.003.078

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(30)

299

328

1. Value must be 30 characters or less
2. Mandatory

PAYEE-ID-TYPE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

329

330

This will typically correspond to the X12 820
Premium Receiver.
FTX079

FTX.003.079

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

FTX080

FTX.003.080

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX081

FTX.003.081

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(30)

431

460

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

461

462

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

FTX082

FTX.003.082

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX083

FTX.003.083

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(100)

463

562

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX084

FTX.003.084

INSURANCECARRIER-IDNUM

Insurance
Carrier
IdenLﬁcaLon
Number

Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(12)

563

574

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

The state-assigned idenLﬁcaLon number of the
Third Party Liability (TPL) EnLty.

FTX085

FTX.003.085

INSURANCEPLAN-ID

Insurance Plan
IdenLﬁer

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(20)

575

594

1. Value must not contain a pipe or asterisk
symbol
2. Value must be 20 characters or less
3. CondiLonal

FTX086

FTX.003.086

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(20)

595

614

1. Value must be 20 characters or less
2. Mandatory
3. Value must match MSIS IdenLﬁcaLon
Number (ELG.021.019)
4. When Adjustment Indicator does not equal
"1", there must be a valid record of type
Enrollment Time Span where the Payment
Period Start Date is equal to or greater than
Enrollment Start Date and Payment Period
End Date is less than or equal to Enrollment
End Date.

FTX087

FTX.003.087

MEMBER-ID

Member
IdenLﬁer

CondiLonal Member idenLﬁcaLon number as it appears on
the card issued by the TPL insurance carrier.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(20)

615

634

1. Value must be 20 characters or less
2. CondiLonal

A state-assigned unique idenLﬁcaLon number
used to idenLfy a Medicaid/CHIP enrolled
individual. Value may be an SSN, temporary SSN
or State-assigned eligible individual idenLﬁer.
MSIS IdenLﬁcaLon Numbers are a unique “key”
value used to maintain referenLal integrity of
data distributed over mulLples ﬁles, segments
and reporLng periods. See T-MSIS Guidance
Document, "CMS Guidance: ReporLng Shared
MSIS IdenLﬁcaLon Numbers" for informaLon on
reporLng the MSIS IdenLﬁcaLon Numbers ID for
pregnant women, unborn children, mothers,
and their deemed newborns younger than 1
year of age who share the same MSIS
IdenLﬁcaLon Number.
haps://www.medicaid.gov/tmsis/dataguide/tmsis-coding-blog/reporLng-shared-msisidenLﬁcaLon-numbers-eligibility/

FTX088

FTX.003.088

PREMIUMPERIOD-STARTDATE

Premium Period
Start Date

Mandatory

The date represenLng the beginning of the
period covered by the premium payment or
recoupment; for example, the ﬁrst day of the
calendar month of beneﬁciary coverage in the
insurance plan that the payment is intended to
cover (whether or not the beneﬁciary actually
receives services during that month).

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

9(8)

635

642

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Coverage Period End Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX089

FTX.003.089

PREMIUMPERIOD-ENDDATE

Premium Period
End Date

Mandatory

The date represenLng the end of the period
covered by the premium payment or
recoupment; for example, the last day of the
calendar month of beneﬁciary coverage in the
insurance plan that the payment is intended to
cover (whether or not the beneﬁciary actually
receives services during that month).

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

9(8)

643

650

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be afer or the same as the
associated Premium Period Start Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX090

FTX.003.090

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

A code to indicate the Federal funding source
for the payment.

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

651

652

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

FTX091

FTX.003.091

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

A code indicaLng the category of service for the
paid claim. The category of service is the line
item from the MBES/CBES expenditure form
(e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.)
that states use to report their expenditures and
request federal ﬁnancial parLcipaLon.

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(5)

704

708

FTX092

FTX.003.092

MBESCBESFORM

MBESCBES
Form

Mandatory

The MBES or CBES form to which the
expenditure will be mapped (e.g., CMS-64 Base,
CMS-64.21U, CMS-21, etc.). This should be
determined by the state's MBES/CBES reporLng
process. The MBES or CBES form reported here
will determine what the meaning of the
corresponding MBES/CBES category of service
value is.

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(50)

654

703

FTX093

FTX.003.093

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

FTX094

FTX.003.094

WAIVER-ID

Waiver ID

FTX095

FTX.003.095

WAIVER-TYPE

Waiver Type

Indicates group of MBES/CBES forms that this
payment applies to (e.g., the CMS-64.9 Base
form is for Title XIX-funded Medicaid, the CMS64.21 form is for Title XXI-funded Medicaidexpansion CHIP (M-CHIP), and the CMS-21 Base
form is for Title XXI-funded separate CHIP (SCHIP)).

MBESCBESFORM-GROUP

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(1)

653

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(20)

709

728

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

729

730

FTX096

FTX.003.096

FUNDING-CODE

Funding Code

Mandatory

A code to indicate the source of non-federal
share funds.

FUNDINGCODE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

731

732

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

FTX097

FTX.003.097

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

733

734

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share List (VVL)
3. Mandatory

FTX098

FTX.003.098

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

735

736

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX099

FTX.003.099

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(15)

737

751

1. Value must be 15 characters or less
2. CondiLonal

FTX100

FTX.003.100

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

Expenditure Authority Type is the federal statute EXPENDITUREor regulaLon under which the expenditure is
AUTHORITYauthorized/jusLﬁed. The federal statute or
TYPE
regulaLon is usually referenced in either the
Medicaid or CHIP State Plan or waiver
documentaLon. For waivers, do not reference
the federal statute or regulaLon being waived
by the waiver. For waivers, referring to the
waiver authority is suﬃcient. If the federal
statute or regulaLon is not available in the list of
valid values, choose the value for "Other" and
report the authority in the Expenditure
Authority Type Text.

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(2)

752

753

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

FTX101

FTX.003.101

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(100)

754

853

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

FTX102

FTX.003.102

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(500)

854

1353

1. Value must be 500 characters or less
2. CondiLonal

FTX103

FTX.003.103

STATE-NOTATION

State NotaLon

SituaLonal

N/A

FTX00003

INDIVIDUALHEALTHINSURANCEPREMIUMPAYMENT

X(500)

1354

1853

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

FTX105

FTX.004.105

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00004"

FTX106

FTX.004.106

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX107

FTX.004.107

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX108

FTX.004.108

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX109

FTX.004.109

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(50)

121

FTX111

FTX.004.111

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX112

FTX.004.112

PAYMENT-DATE

Payment Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value of the CC component must be equal
to "20"
3. Mandatory

FTX113

FTX.004.113

PAYMENTAMOUNT

Payment
Amount

Mandatory

The dollar amount being paid to the payee.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX114

FTX.004.114

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX115

FTX.004.115

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX116

FTX.004.116

PAYER-ID

Payer ID

Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

197

198

1. Value must be 2 characters
2. Value must be in Payer ID Type List (VVL)
3. Mandatory
4. When value equals "01" then Payer ID
must equal Submieng State (FTX.001.007)

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

This will typically correspond to the X12 820
Premium Payer.
FTX117

FTX.004.117

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX118

FTX.004.118

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

FTX119

FTX.004.119

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(30)

299

328

1. Value must be 30 characters or less
2. Mandatory

PAYEE-ID-TYPE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

329

330

This will typically correspond to the X12 820
Premium Receiver.
FTX120

FTX.004.120

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

FTX121

FTX.004.121

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX122

FTX.004.122

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(30)

431

460

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

461

462

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

FTX123

FTX.004.123

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX124

FTX.004.124

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(100)

463

562

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX125

FTX.004.125

INSURANCECARRIER-IDNUM

Insurance
Carrier
IdenLﬁcaLon
Number

Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(12)

563

574

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX126

FTX.004.126

INSURANCEPLAN-ID

Insurance Plan
IdenLﬁer

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(20)

575

594

1. Value must not contain a pipe or asterisk
symbol
2. Value must be 20 characters or less
3. CondiLonal

The state-assigned idenLﬁcaLon number of the
Third Party Liability (TPL) EnLty.

FTX127

FTX.004.127

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

CondiLonal A state-assigned unique idenLﬁcaLon number
used to idenLfy a Medicaid/CHIP enrolled
individual. Value may be an SSN, temporary SSN
or State-assigned eligible individual idenLﬁer.
MSIS IdenLﬁcaLon Numbers are a unique “key”
value used to maintain referenLal integrity of
data distributed over mulLples ﬁles, segments
and reporLng periods. See T-MSIS Guidance
Document, "CMS Guidance: ReporLng Shared
MSIS IdenLﬁcaLon Numbers" for informaLon on
reporLng the MSIS IdenLﬁcaLon Numbers ID for
pregnant women, unborn children, mothers,
and their deemed newborns younger than 1
year of age who share the same MSIS
IdenLﬁcaLon Number.
haps://www.medicaid.gov/tmsis/dataguide/tmsis-coding-blog/reporLng-shared-msisidenLﬁcaLon-numbers-eligibility/
MSIS-IDENTIFICATION-NUM is condiLonal in the
FTX00004 segment because some members of a
private group policy may not be eligible for
Medicaid or CHIP, though at least one member
of the group policy must be eligible for Medicaid
or CHIP. There should be one FTX00004 segment
for each member of the group policy for which
the premium assistance payment is being paid,
regardless of whether the member of the group
policy was eligible for and enrolled in Medicaid
or CHIP.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(20)

595

614

1. Value must be 20 characters or less
2. CondiLonal
3. Value must match MSIS IdenLﬁcaLon
Number (ELG.021.019)
4. When Adjustment Indicator does not equal
"1", there must be a valid record of type
Enrollment Time Span where the Premium
Period Start Date is equal to or greater than
Enrollment Start Date and Premium Period
End Date is less than or equal to Enrollment
End Date

FTX128

FTX.004.128

SSN

CondiLonal The SSN of the member of the group insurance
policy. Each FTX00004 segment represents a
diﬀerent member of a given group insurance
policy. Typically all members of the group
insurance policy will have both an MSIS ID and
an SSN. Under some circumstances, it’s possible
that or more members of a group insurance
policy do not have an MSIS ID, but do have an
SSN, if they are included on the group insurance
policy but not eligible for Medicaid or CHIP. It’s
also possible that one or more members of a
group insurance policy do not have an SSN. If a
member of a group insurance policy does not
have an SSN, leave this ﬁeld blank.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(9)

615

623

1. Value must be 9-digit number
2. CondiLonal

FTX129

FTX.004.129

MEMBER-ID

Member
IdenLﬁer

CondiLonal Member idenLﬁcaLon number as it appears on
the card issued by the TPL insurance carrier.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(20)

624

643

1. Value must be 20 characters or less
2. CondiLonal

FTX130

FTX.004.130

GROUP-NUM

Group Num

CondiLonal The group number of the TPL health insurance
policy.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(16)

644

659

1. Value must be 16 characters or less
2. Value must not contain a pipe symbol
3. CondiLonal

FTX131

FTX.004.131

POLICY-OWNERCODE

Policy Owner
Code

CondiLonal This code idenLﬁes the relaLonship of the policy
holder to the Medicaid/CHIP beneﬁciary.

POLICYOWNER-CODE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

660

661

1. Value must be 2 characters
2. Value must be in Policy Owner Code List
(VVL)
3. CondiLonal

FTX132

FTX.004.132

PREMIUMPERIOD-STARTDATE

Premium Period
Start Date

Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

9(8)

662

669

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Premium Period End Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX133

FTX.004.133

PREMIUMPERIOD-ENDDATE

Premium Period
End Date

Mandatory

FTX134

FTX.004.134

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

CondiLonal A code to indicate the Federal funding source
for the payment.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

9(8)

670

677

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

678

679

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. If Policy Owner Code equals "01", then
value must be populated
4. CondiLonal

FTX135

FTX.004.135

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(5)

731

735

1. Value must be 5 characters or less
2. When MBESCBES Form equals "21.P",
value must be in 21.P Form List (VVL)
3. When MBESCBES Form equals "21BASE",
value must be in 21BASE Form List (VVL)
4. When MBESCBES Form equals "64.21U",
value must be in 64.21U Form List (VVL)
5. When MBESCBES Form equals
"64.10BASE", value must be in 64.10BASE
Form List (VVL)
6. When MBESCBES Form equals "64.9P",
value must be in 64.9P Form List (VVL)
7. When MBESCBES Form equals "64.9A",
value must be in 64.9A Form List (VVL)
8. When MBESCBES Form equals "64.9BASE",
value must be in 64.9BASE Form List (VVL)
9. When MBESCBES Form equals "64.21UP",
value must be in 64.21UP Form List (VVL)
10. If Policy Owner Code equals "01", then
value must be populated
11. CondiLonal
12. When populated, an associated
MBESCBES Form Group and MBESCBES Form
must be populated

FTX136

FTX.004.136

MBESCBESFORM

MBESCBES
Form

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(50)

681

730

1. Value must be 50 characters or less
2. When MBESCBES Form Group equals "1",
value must be in MBESCBES Form Group 1
List (VVL)
3. When MBESCBES Form Group equals "2",
value must be in MBESCBES Form Group 2
List (VVL)
4. When MBESCBES Form Group equals "3",
value must be in MBESCBES Form Group 3
List (VVL)
5. If Policy Owner Code equals "01", then
value must be populated
6. CondiLonal

FTX137

FTX.004.137

MBESCBESFORM-GROUP

MBESCBES
Form Group

MBESCBESFORM-GROUP

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(1)

680

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. If Policy Owner Code equals "01", then
value must be populated
4. CondiLonal

FTX138

FTX.004.138

WAIVER-ID

Waiver ID

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(20)

736

755

Waiver Type value must be in [02-20,32,33]
6. CondiLonal

FTX139

FTX.004.139

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

756

757

FTX140

FTX.004.140

FUNDING-CODE

Funding Code

CondiLonal A code to indicate the source of non-federal
share funds.

FUNDINGCODE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

758

759

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. If Policy Owner Code equals "01", then
value must be populated
4. CondiLonal

FTX141

FTX.004.141

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

760

761

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share List (VVL)
3. If Policy Owner Code equals "01", then
value must be populated
4. Mandatory

FTX142

FTX.004.142

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

FTX143

FTX.004.143

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

SOURCELOCATION

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

762

763

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(15)

764

778

1. Value must be 15 characters or less
2. CondiLonal

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(2)

779

780

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. If Policy Owner Code equals "01", then
value must be populated
4. CondiLonal

YY = Calendar Year (last two characters of the
calendar year of the state plan amendment);
NNNN = SPA number (a four character number
beginning with 0001) States should track their
submissions to assign sequenLal numbers to
their submissions. The system will not permit
reuse of a previously used SPA ID for a package
that has been formally = an SituaLonal entry for
speciﬁc SPA types
FTX144

FTX.004.144

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

FTX145

FTX.004.145

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(100)

781

880

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

FTX146

FTX.004.146

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(500)

881

1380

1. Value must be 500 characters or less
2. CondiLonal

FTX147

FTX.004.147

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00004

GROUPINSURANCEPREMIUMPAYMENT

X(500)

1381

1880

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX149

FTX.005.149

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00005

COSTSHARINGOFFSET

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00005"

FTX150

FTX.005.150

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00005

COSTSHARINGOFFSET

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX151

FTX.005.151

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00005

COSTSHARINGOFFSET

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX152

FTX.005.152

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00005

COSTSHARINGOFFSET

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX153

FTX.005.153

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00005

COSTSHARINGOFFSET

X(50)

121

FTX155

FTX.005.155

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00005

COSTSHARINGOFFSET

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX156

FTX.005.156

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00005

COSTSHARINGOFFSET

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX157

FTX.005.157

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00005

COSTSHARINGOFFSET

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX158

FTX.005.158

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00005

COSTSHARINGOFFSET

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX159

FTX.005.159

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00005

COSTSHARINGOFFSET

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX160

FTX.005.160

PAYER-ID

Payer ID

Mandatory

N/A

FTX00005

COSTSHARINGOFFSET

X(30)

167

196

1. Value must be 30 characters or less
2. Value must equal Submieng State
(FTX.001.007)
3. Mandatory

PAYER-ID-TYPE

FTX00005

COSTSHARINGOFFSET

X(2)

197

198

1. Value must be 2 characters
2. Value must be in Payer ID Type List (VVL)
3. Mandatory
4. When value equals "01" then Payer ID
must equal Submieng State (FTX.001.007)

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system. The payer is the subject taking the
acLon of either making a payment or taking a
recoupment, as opposed to the payee who is
the object of the transacLon. The payer is the
enLty that is either making a payment or
recouping a payment from another enLty or
individual. The payee is the individual or enLty
that is either receiving a payment or having a
previous payment recouped.
For beneﬁciary Cost Sharing Oﬀset, the payer is
always the state and the payee is always a
beneﬁciary.

FTX161

FTX.005.161

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX162

FTX.005.162

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

N/A

FTX00005

COSTSHARINGOFFSET

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX163

FTX.005.163

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00005

COSTSHARINGOFFSET

X(30)

299

328

1. Value must be 30 characters or less
2. Value must equal MSIS IdenLﬁcaLon
Number (ELG.002.019)
3. Mandatory

PAYEE-ID-TYPE

FTX00005

COSTSHARINGOFFSET

X(2)

329

330

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system. The payee is the individual or enLty that
is either receiving a payment or having a
previous payment recouped. The payee is the
object of the transacLon, as opposed to the
payer who is the subject taking the acLon of
either making a payment or taking a
recoupment.
For beneﬁciary Cost Sharing Oﬀset, the
beneﬁciary is always the payee.

FTX164

FTX.005.164

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

must equal MSIS IdenLﬁcaLon Number
(ELG.002.019)
9. Mandatory

FTX165

FTX.005.165

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00005

COSTSHARINGOFFSET

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX166

FTX.005.166

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

MANAGEDCARE-PLANTYPE

FTX00005

COSTSHARINGOFFSET

X(2)

431

432

FTX167

FTX.005.167

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00005

COSTSHARINGOFFSET

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX168

FTX.005.168

PAYEE-TAX-ID

Payee Tax ID

Mandatory

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system.

N/A

FTX00005

COSTSHARINGOFFSET

X(30)

533

562

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00005

COSTSHARINGOFFSET

X(2)

563

564

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

The payee is the individual or enLty that is
either receiving a payment or having a previous
payment recouped. The payee is the object of
the transacLon, as opposed to the payer who is
the subject taking the acLon of either making a
payment or taking a recoupment.
FTX169

FTX.005.169

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX170

FTX.005.170

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00005

COSTSHARINGOFFSET

X(100)

565

664

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX171

FTX.005.171

CONTRACT-ID

Contract
IdenLﬁer

CondiLonal

N/A

FTX00005

COSTSHARINGOFFSET

X(100)

665

764

1. Value must be 100 characters or less
2. CondiLonal
3. If Oﬀset TransacLon Type equals "1", value
must be populated

FTX172

FTX.005.172

INSURANCEPLAN-ID

Insurance Plan
IdenLﬁer

N/A

FTX00005

COSTSHARINGOFFSET

X(20)

765

784

1. Value must not contain a pipe or asterisk
symbol
2. Value must be 20 characters or less
3. CondiLonal

Managed care plan contract ID

FTX173

FTX.005.173

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

Mandatory

A state-assigned unique idenLﬁcaLon number
used to idenLfy a Medicaid/CHIP enrolled
individual. Value may be an SSN, temporary SSN
or State-assigned eligible individual idenLﬁer.
MSIS IdenLﬁcaLon Numbers are a unique “key”
value used to maintain referenLal integrity of
data distributed over mulLples ﬁles, segments
and reporLng periods. See T-MSIS Guidance
Document, "CMS Guidance: ReporLng Shared
MSIS IdenLﬁcaLon Numbers" for informaLon on
reporLng the MSIS IdenLﬁcaLon Numbers ID for
pregnant women, unborn children, mothers,
and their deemed newborns younger than 1
year of age who share the same MSIS
IdenLﬁcaLon Number.
haps://www.medicaid.gov/tmsis/dataguide/tmsis-coding-blog/reporLng-shared-msisidenLﬁcaLon-numbers-eligibility/

N/A

FTX00005

COSTSHARINGOFFSET

X(20)

785

804

1. Value must be 20 characters or less
2. Mandatory
3. Value must match MSIS IdenLﬁcaLon
Number (ELG.021.019)
4. When Adjustment Indicator does not equal
"1", there must be a valid record of type
Enrollment Time Span where the Coverage
Period Start Date is equal to or greater than
Enrollment Start Date and Coverage Period
End Date is less than or equal to Enrollment
End Date

FTX174

FTX.005.174

COVERAGEPERIOD-STARTDATE

Coverage Period Mandatory
Start Date

The date represenLng the beginning of the
period covered by the capitaLon payment or
premium payment that the beneﬁciary is
oﬀseeng; for example, the ﬁrst day of the
calendar month of beneﬁciary enrollment in the
managed care plan to which the oﬀ-seeng
amount is applied. If returning money to the
beneﬁciary, this is the date represenLng the
beginning of the period for which the
beneﬁciary had previously made an oﬀseeng
payment that is now being returned to them.

N/A

FTX00005

COSTSHARINGOFFSET

9(8)

805

812

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Cost Sealement Period End Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX175

FTX.005.175

COVERAGEPERIOD-ENDDATE

Coverage Period Mandatory
End Date

The date represenLng the end of the period
N/A
covered by the capitaLon payment or premium
payment that the beneﬁciary is oﬀseeng; for
example, the last day of the calendar month of
beneﬁciary enrollment in the managed care plan
to which the oﬀ-seeng amount is applied. If
returning money to the beneﬁciary, this is the
date represenLng the end of the period for
which the beneﬁciary had previously made an
oﬀseeng payment that is now being returned
to them.

FTX00005

COSTSHARINGOFFSET

9(8)

813

820

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be afer or the same as the
associated Cost Sealement Period Start Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX176

FTX.005.176

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

A code to indicate the Federal funding source
for the payment.

FTX00005

COSTSHARINGOFFSET

X(2)

821

822

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

Mandatory

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX177

FTX.005.177

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00005

COSTSHARINGOFFSET

X(5)

874

878

FTX178

FTX.005.178

MBESCBESFORM

MBESCBES
Form

Mandatory

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00005

COSTSHARINGOFFSET

X(50)

824

873

FTX179

FTX.005.179

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

FTX180

FTX.005.180

WAIVER-ID

Waiver ID

FTX181

FTX.005.181

WAIVER-TYPE

FTX182

FTX.005.182

FUNDING-CODE

MBESCBESFORM-GROUP

FTX00005

COSTSHARINGOFFSET

X(1)

823

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

N/A

FTX00005

COSTSHARINGOFFSET

X(20)

879

898

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00005

COSTSHARINGOFFSET

X(2)

899

900

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. CondiLonal

Funding Code

Mandatory

FUNDINGCODE

FTX00005

COSTSHARINGOFFSET

X(2)

901

902

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

A code to indicate the source of non-federal
share funds.

FTX183

FTX.005.183

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FTX184

FTX.005.184

OFFSET-TRANSTYPE

Oﬀset Trans
Type

FTX185

FTX.005.185

SOURCELOCATION

FTX186

FTX.005.186

SPA-NUMBER

FUNDINGSOURCENONFEDERALSHARE

FTX00005

COSTSHARINGOFFSET

X(2)

903

904

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share (VVL)
3. Mandatory

CondiLonal This indicates the type of payment that the
beneﬁciary cost-sharing is/was oﬀseeng.

OFFSET-TRANSTYPE

FTX00005

COSTSHARINGOFFSET

X(1)

905

1. Value must be 1 character
2. Value must be in Oﬀset TransacLon Type
List (VVL)
3. CondiLonal

Source LocaLon

Mandatory

SOURCELOCATION

FTX00005

COSTSHARINGOFFSET

X(2)

906

907

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00005

COSTSHARINGOFFSET

X(15)

908

922

1. Value must be 15 characters or less
2. CondiLonal

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

FTX187

FTX.005.187

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

FTX00005

COSTSHARINGOFFSET

X(2)

923

924

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

FTX188

FTX.005.188

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00005

COSTSHARINGOFFSET

X(100)

925

1024

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

FTX189

FTX.005.189

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00005

COSTSHARINGOFFSET

X(500)

1025

1524

1. Value must be 500 characters or less
2. CondiLonal

FTX190

FTX.005.190

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00005

COSTSHARINGOFFSET

X(500)

1525

2024

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX192

FTX.006.192

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00006

VALUE-BASEDPAYMENT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00005"

segment idenLﬁer padded with leading zeros
(e.g., 00001, 00002, 00003, etc.).

FTX193

FTX.006.193

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00006

VALUE-BASEDPAYMENT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX194

FTX.006.194

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00006

VALUE-BASEDPAYMENT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX195

FTX.006.195

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX196

FTX.006.196

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(50)

121

FTX198

FTX.006.198

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00006

VALUE-BASEDPAYMENT

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX199

FTX.006.199

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00006

VALUE-BASEDPAYMENT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX200

FTX.006.200

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00006

VALUE-BASEDPAYMENT

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX201

FTX.006.201

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00006

VALUE-BASEDPAYMENT

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX202

FTX.006.202

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX203

FTX.006.203

PAYER-ID

Payer ID

Mandatory

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00006

VALUE-BASEDPAYMENT

X(2)

197

198

N/A

FTX00006

VALUE-BASEDPAYMENT

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

The payer is the subject taking the acLon of
either making a payment or taking a
recoupment, as opposed to the payee who is
the object of the transacLon.
The payer is the enLty that is either making a
payment or recouping a payment from another
enLty or individual. The payee is the individual
or enLty that is either receiving a payment or
having a previous payment recouped.
FTX204

FTX.006.204

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX205

FTX.006.205

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

FTX206

FTX.006.206

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00006

VALUE-BASEDPAYMENT

X(30)

299

328

1. Value must be 30 characters or less
2. Mandatory

FTX207

FTX.006.207

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

PAYEE-ID-TYPE

FTX00006

VALUE-BASEDPAYMENT

X(2)

329

330

FTX208

FTX.006.208

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00006

VALUE-BASEDPAYMENT

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX209

FTX.006.209

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

MANAGEDCARE-PLANTYPE

FTX00006

VALUE-BASEDPAYMENT

X(2)

431

432

FTX210

FTX.006.210

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00006

VALUE-BASEDPAYMENT

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX211

FTX.006.211

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00006

VALUE-BASEDPAYMENT

X(30)

533

562

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00006

VALUE-BASEDPAYMENT

X(2)

563

564

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

N/A

FTX00006

VALUE-BASEDPAYMENT

X(100)

565

664

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system.
The payee is the individual or enLty that is
either receiving a payment or having a previous
payment recouped. The payee is the object of
the transacLon, as opposed to the payer who is
the subject taking the acLon of either making a
payment or taking a recoupment.

FTX212

FTX.006.212

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX213

FTX.006.213

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

FTX214

FTX.006.214

CONTRACT-ID

Contract
IdenLﬁer

CondiLonal

FTX215

FTX.006.215

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

FTX216

FTX.006.216

PERFORMANCEPERIOD-STARTDATE

Performance
Period Start
Date

Managed care plan contract ID

N/A

FTX00006

VALUE-BASEDPAYMENT

X(100)

665

764

1. Value must be 100 characters or less
2. CondiLonal
3. If Payee ID Type is in [02,03], then value
must be populated

N/A

FTX00006

VALUE-BASEDPAYMENT

X(20)

765

784

1. Value must be 20 characters or less
2. CondiLonal
3. When populated, value must match MSIS
IdenLﬁcaLon Number (ELG.002.019)
4. When Adjustment Indicator does not equal
"1", there must be a valid record of type
Enrollment Time Span where the
Performance Period Start Date is equal to or
greater than Enrollment Start Date and
Performance Period End Date is less than or
equal to Enrollment End Date

Mandatory

N/A

FTX00006

VALUE-BASEDPAYMENT

9(8)

785

792

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Performance Period End Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

The date represenLng the beginning of the
performance period that the value-based dollar
amount is rewarding or penalizing.

FTX217

FTX.006.217

PERFORMANCEPERIOD-ENDDATE

Performance
Period End Date

Mandatory

The date represenLng the end of the
performance period that the value-based dollar
amount is rewarding or penalizing.

N/A

FTX00006

VALUE-BASEDPAYMENT

9(8)

793

800

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be afer or the same as the
associated Performance Period Start Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX218

FTX.006.218

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

A code to indicate the Federal funding source
for the payment.

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00006

VALUE-BASEDPAYMENT

X(2)

801

802

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

FTX219

FTX.006.219

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00006

VALUE-BASEDPAYMENT

X(5)

854

858

FTX220

FTX.006.220

MBESCBESFORM

MBESCBES
Form

Mandatory

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00006

VALUE-BASEDPAYMENT

X(50)

804

853

FTX221

FTX.006.221

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

MBESCBESFORM-GROUP

FTX00006

VALUE-BASEDPAYMENT

X(1)

803

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

FTX222

FTX.006.222

WAIVER-ID

Waiver ID

N/A

FTX00006

VALUE-BASEDPAYMENT

X(20)

859

878

FTX223

FTX.006.223

WAIVER-TYPE

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00006

VALUE-BASEDPAYMENT

X(2)

879

880

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. CondiLonal

FTX224

FTX.006.224

FUNDING-CODE

Funding Code

Mandatory

A code to indicate the source of non-federal
share funds.

FUNDINGCODE

FTX00006

VALUE-BASEDPAYMENT

X(2)

881

882

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

FTX225

FTX.006.225

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00006

VALUE-BASEDPAYMENT

X(2)

883

884

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share (VVL)
3. Mandatory

FTX226

FTX.006.226

SDP-IND

State Directed
Payment
Indicator

Mandatory

Indicates whether the ﬁnancial transacLon from
an MC plan to a provider or other enLty is a
type of State Directed Payment.

SDP-IND

FTX00006

VALUE-BASEDPAYMENT

X(1)

885

1. Value must be 1 character
2. Value must be in State Directed Payment
Indicator List (VVL)
3. Mandatory

FTX227

FTX.006.227

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00006

VALUE-BASEDPAYMENT

X(2)

886

887

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX228

FTX.006.228

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00006

VALUE-BASEDPAYMENT

X(15)

888

902

1. Value must be 15 characters or less
2. CondiLonal

YY = Calendar Year (last two characters of the
calendar year of the state plan amendment);
NNNN = SPA number (a four character number
beginning with 0001) States should track their
submissions to assign sequenLal numbers to
their submissions. The system will not permit
reuse of a previously used SPA ID for a package
that has been formally = an SituaLonal entry for
speciﬁc SPA types
FTX229

FTX.006.229

VALUE-BASEDPAYMENTMODEL-TYPE

Value Based
Payment Model
Type

CondiLonal This is the type of value-based payment model
to which the ﬁnancial transacLon applies. These
values come from the “AlternaLve Payment
Model (APM) Framework Final White Paper”,
produced by the Healthcare Learning and AcLon
Network.
haps://hcp-lan.org/work products/apmwhitepaper.pdf

VALUE-BASEDPAYMENTMODEL-TYPE

FTX00006

VALUE-BASEDPAYMENT

X(2)

903

904

1. Value must be 2 characters
2. Value must be in Value Based Payment
Model Type List (VVL)
3. CondiLonal

FTX230

FTX.006.230

PAYMENT-CATXREF

Payment Cat
Xref

CondiLonal Cross-reference to the applicable payment
category in the managed care plan's contract
with the state Medicaid/CHIP agency or their
ﬁscal intermediary.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(50)

905

954

1. Value must be 50 characters or less
2. CondiLonal

FTX231

FTX.006.231

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

FTX00006

VALUE-BASEDPAYMENT

X(2)

955

956

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

FTX232

FTX.006.232

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(100)

957

1056

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

FTX233

FTX.006.233

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(500)

1057

1556

1. Value must be 500 characters or less
2. CondiLonal

FTX234

FTX.006.234

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00006

VALUE-BASEDPAYMENT

X(500)

1557

2056

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX236

FTX.007.236

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00007"

segment idenLﬁer padded with leading zeros
(e.g., 00001, 00002, 00003, etc.).

FTX237

FTX.007.237

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX238

FTX.007.238

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX239

FTX.007.239

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX240

FTX.007.240

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(50)

121

FTX242

FTX.007.242

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX243

FTX.007.243

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX244

FTX.007.244

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX245

FTX.007.245

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX246

FTX.007.246

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX247

FTX.007.247

PAYER-ID

Payer ID

Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

197

198

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system.
The payer is the subject taking the acLon of
either making a payment or taking a
recoupment, as opposed to the payee who is
the object of the transacLon.
The payer is the enLty that is either making a
payment or recouping a payment from another
enLty or individual. The payee is the individual
or enLty that is either receiving a payment or
having a previous payment recouped.

FTX248

FTX.007.248

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX249

FTX.007.249

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX250

FTX.007.250

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(30)

299

328

1. Value must be 30 characters or less
2. Mandatory

FTX251

FTX.007.251

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

PAYEE-ID-TYPE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

329

330

(ELG.002.019)
9. Mandatory

FTX252

FTX.007.252

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX253

FTX.007.253

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

MANAGEDCARE-PLANTYPE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

431

432

FTX254

FTX.007.254

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX255

FTX.007.255

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(30)

533

562

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

563

564

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system.
The payee is the individual or enLty that is
either receiving a payment or having a previous
payment recouped. The payee is the object of
the transacLon, as opposed to the payer who is
the subject taking the acLon of either making a
payment or taking a recoupment.

FTX256

FTX.007.256

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX257

FTX.007.257

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

565

664

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX258

FTX.007.258

CONTRACT-ID

Contract
IdenLﬁer

Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

665

764

1. Value must be 100 characters or less
2. Mandatory

Managed care plan contract ID

FTX259

FTX.007.259

PAYMENTPERIOD-STARTDATE

Payment Period
Start Date

Mandatory

The date represenLng the start of the Lme
period that the payment is expected to be used
by the provider.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

9(8)

765

772

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Payment Period End Date
3. Mandatory
4. Value of the CC component must be equal
to "20"

FTX260

FTX.007.260

PAYMENTPERIOD-ENDDATE

Payment Period
End Date

Mandatory

The date represenLng the end of the Lme
period that the payment is expected to be used
by the provider.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

9(8)

773

780

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be afer or the same as the
associated Payment Period Start Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX261

FTX.007.261

PAYMENTPERIOD-TYPE

Payment Period
Type

Mandatory

A qualiﬁer that idenLﬁes what the payment
period begin and end dates represent. For
example, the payment period begin an end
dates may correspond to a range of service
dates from claims or encounters or they may
represent a period of beneﬁciary eligibility or
enrollment.

PAYMENTPERIOD-TYPE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

781

782

1. Value must be 2 characters
2. Value must be in Payment Period Type List
(VVL)
3. Mandatory

FTX262

FTX.007.262

PAYMENTPERIOD-TYPEOTHER-TEXT

Payment Period
Type Other Text

CondiLonal This is a descripLon of the type of ﬁnancial
transacLon when the PAYMENT-PERIOD-TYPE is
"Other".

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

783

882

1. Value must be 100 characters or less
2. Value must be populated when Payment
Period Type equals "95"
3. CondiLonal

FTX263

FTX.007.263

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

883

884

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

A code to indicate the Federal funding source
for the payment.

FTX264

FTX.007.264

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(5)

936

940

FTX265

FTX.007.265

MBESCBESFORM

MBESCBES
Form

Mandatory

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(50)

886

935

FTX266

FTX.007.266

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

FTX267

FTX.007.267

WAIVER-ID

Waiver ID

FTX268

FTX.007.268

WAIVER-TYPE

FTX269

FTX.007.269

FUNDING-CODE

MBESCBESFORM-GROUP

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(1)

885

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(20)

941

960

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

961

962

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. CondiLonal

Funding Code

Mandatory

FUNDINGCODE

FTX00007

STATEDIRECTEDPAYMENTSEPARATE-

X(2)

963

964

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

A code to indicate the source of non-federal
share funds.

PAYMENTTERM

FTX270

FTX.007.270

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

965

966

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share (VVL)
3. Mandatory

FTX271

FTX.007.271

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

967

968

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX272

FTX.007.272

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(15)

969

983

1. Value must be 15 characters or less
2. CondiLonal

FTX273

FTX.007.273

PAYMENT-CATXREF

Payment Cat
Xref

CondiLonal Cross-reference to the applicable payment
category in the managed care plan's contract
with the state Medicaid/CHIP agency or their
ﬁscal intermediary.

FTX274

FTX.007.274

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

FTX275

FTX.007.275

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

FTX276

FTX.007.276

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(50)

984

1033

1. Value must be 50 characters or less
2. CondiLonal

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(2)

1034

1035

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(100)

1036

1135

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(500)

1136

1635

1. Value must be 500 characters or less
2. CondiLonal

FTX277

FTX.007.277

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00007

STATEDIRECTEDPAYMENTSEPARATEPAYMENTTERM

X(500)

1636

2135

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX279

FTX.008.279

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00008

COSTSETTLEMENTPAYMENT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00008"

FTX280

FTX.008.280

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX281

FTX.008.281

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00008

COSTSETTLEMENTPAYMENT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX282

FTX.008.282

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX283

FTX.008.283

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(50)

121

FTX285

FTX.008.285

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00008

COSTSETTLEMENTPAYMENT

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX286

FTX.008.286

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX287

FTX.008.287

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX288

FTX.008.288

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX289

FTX.008.289

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX290

FTX.008.290

PAYER-ID

Payer ID

Mandatory

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

197

198

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system.
The payer is the subject taking the acLon of
either making a payment or taking a
recoupment, as opposed to the payee who is
the object of the transacLon.
The payer is the enLty that is either making a
payment or recouping a payment from another
enLty or individual. The payee is the individual
or enLty that is either receiving a payment or
having a previous payment recouped.

FTX291

FTX.008.291

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX292

FTX.008.292

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX293

FTX.008.293

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(30)

299

328

1. Value must be 30 characters or less
2. Mandatory

FTX294

FTX.008.294

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

PAYEE-ID-TYPE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

329

330

FTX295

FTX.008.295

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX296

FTX.008.296

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

MANAGEDCARE-PLANTYPE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

431

432

FTX297

FTX.008.297

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX298

FTX.008.298

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(30)

533

562

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

563

564

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system.
The payee is the individual or enLty that is
either receiving a payment or having a previous
payment recouped. The payee is the object of
the transacLon, as opposed to the payer who is
the subject taking the acLon of either making a
payment or taking a recoupment.

FTX299

FTX.008.299

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX300

FTX.008.300

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(100)

565

664

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX301

FTX.008.301

COSTSETTLEMENTPERIOD-STARTDATE

Cost Sealement
Period Start
Date

Mandatory

The date represenLng the beginning of the costsealement period. For example, if the costsealement is for the ﬁrst calendar quarter of the
year, then the cost sealement begin date would
be March 1 of that year.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

9(8)

665

672

FTX302

FTX.008.302

COSTSETTLEMENTPERIOD-ENDDATE

Cost Sealement
Period End Date

Mandatory

The date represenLng the end of the costsealement period. For example, if the costsealement is for the ﬁrst calendar quarter of the
year, then the cost sealement end date would
be March 31 of that year.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

9(8)

673

680

FTX303

FTX.008.303

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

A code to indicate the Federal funding source
for the payment.

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

681

682

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

FTX304

FTX.008.304

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00008

COSTSETTLEMENTPAYMENT

X(5)

734

738

FTX305

FTX.008.305

MBESCBESFORM

MBESCBES
Form

Mandatory

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00008

COSTSETTLEMENTPAYMENT

X(50)

684

733

FTX306

FTX.008.306

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

FTX307

FTX.008.307

WAIVER-ID

Waiver ID

FTX308

FTX.008.308

WAIVER-TYPE

FTX309

FTX.008.309

FUNDING-CODE

MBESCBESFORM-GROUP

FTX00008

COSTSETTLEMENTPAYMENT

X(1)

683

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(20)

739

758

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

759

760

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. CondiLonal

Funding Code

Mandatory

FUNDINGCODE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

761

762

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

A code to indicate the source of non-federal
share funds.

FTX310

FTX.008.310

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

763

764

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share (VVL)
3. Mandatory

FTX311

FTX.008.311

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

765

766

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX312

FTX.008.312

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(15)

767

781

1. Value must be 15 characters or less
2. CondiLonal

FTX313

FTX.008.313

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

FTX00008

COSTSETTLEMENTPAYMENT

X(2)

782

783

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

FTX314

FTX.008.314

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(100)

784

883

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

FTX315

FTX.008.315

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(500)

884

1383

1. Value must be 500 characters or less
2. CondiLonal

FTX316

FTX.008.316

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00008

COSTSETTLEMENTPAYMENT

X(500)

1384

1883

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX318

FTX.009.318

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00009

FQHC-WRAPPAYMENT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00009"

segment idenLﬁer padded with leading zeros
(e.g., 00001, 00002, 00003, etc.).

FTX319

FTX.009.319

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00009

FQHC-WRAPPAYMENT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX320

FTX.009.320

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00009

FQHC-WRAPPAYMENT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX321

FTX.009.321

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX322

FTX.009.322

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(50)

121

FTX324

FTX.009.324

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00009

FQHC-WRAPPAYMENT

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX325

FTX.009.325

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00009

FQHC-WRAPPAYMENT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX326

FTX.009.326

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00009

FQHC-WRAPPAYMENT

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX327

FTX.009.327

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00009

FQHC-WRAPPAYMENT

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX328

FTX.009.328

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX329

FTX.009.329

PAYER-ID

Payer ID

Mandatory

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00009

FQHC-WRAPPAYMENT

X(2)

197

198

N/A

FTX00009

FQHC-WRAPPAYMENT

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX.009.330

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX331

FTX.009.331

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

FTX332

FTX.009.332

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00009

FQHC-WRAPPAYMENT

X(30)

299

328

1. Value must be 30 characters or less
2. Mandatory

FTX333

FTX.009.333

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

PAYEE-ID-TYPE

FTX00009

FQHC-WRAPPAYMENT

X(2)

329

330

FTX334

FTX.009.334

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00009

FQHC-WRAPPAYMENT

X(100)

331

430

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX335

FTX.009.335

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

MANAGEDCARE-PLANTYPE

FTX00009

FQHC-WRAPPAYMENT

X(2)

431

432

FTX336

FTX.009.336

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00009

FQHC-WRAPPAYMENT

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX337

FTX.009.337

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00009

FQHC-WRAPPAYMENT

X(30)

533

562

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00009

FQHC-WRAPPAYMENT

X(2)

563

564

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

N/A

FTX00009

FQHC-WRAPPAYMENT

X(100)

565

664

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system.
The payee is the individual or enLty that is
either receiving a payment or having a previous
payment recouped. The payee is the object of
the transacLon, as opposed to the payer who is
the subject taking the acLon of either making a
payment or taking a recoupment.

FTX338

FTX.009.338

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX339

FTX.009.339

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

FTX340

FTX.009.340

WRAP-PERIODSTART-DATE

Wrap Period
Start Date

Mandatory

The date represenLng the beginning of the
FQHC wrap payment or recoupment period. For
example, if the FQHC wrap payment is for the
ﬁrst calendar quarter of the year, then the FQHC
wrap payment begin date would be March 1 of
that year.

N/A

FTX00009

FQHC-WRAPPAYMENT

9(8)

665

672

FTX341

FTX.009.341

WRAP-PERIODEND-DATE

Wrap Period
End Date

Mandatory

The date represenLng the end of the FQHC wrap N/A
payment period. For example, if the FQHC wrap
payment is for the ﬁrst calendar quarter of the
year, then the FQHC wrap payment end date
would be March 31 of that year.

FTX00009

FQHC-WRAPPAYMENT

9(8)

673

680

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be afer or the same as the
associated Wrap Period Start Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX342

FTX.009.342

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

A code to indicate the Federal funding source
for the payment.

FTX00009

FQHC-WRAPPAYMENT

X(2)

681

682

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX343

FTX.009.343

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00009

FQHC-WRAPPAYMENT

X(5)

734

738

FTX344

FTX.009.344

MBESCBESFORM

MBESCBES
Form

Mandatory

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00009

FQHC-WRAPPAYMENT

X(50)

684

733

FTX345

FTX.009.345

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

FTX346

FTX.009.346

WAIVER-ID

Waiver ID

FTX347

FTX.009.347

WAIVER-TYPE

FTX348

FTX.009.348

FUNDING-CODE

MBESCBESFORM-GROUP

FTX00009

FQHC-WRAPPAYMENT

X(1)

683

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

N/A

FTX00009

FQHC-WRAPPAYMENT

X(20)

739

758

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00009

FQHC-WRAPPAYMENT

X(2)

759

760

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. CondiLonal

Funding Code

Mandatory

FUNDINGCODE

FTX00009

FQHC-WRAPPAYMENT

X(2)

761

762

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

A code to indicate the source of non-federal
share funds.

FTX349

FTX.009.349

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00009

FQHC-WRAPPAYMENT

X(2)

763

764

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share (VVL)
3. Mandatory

FTX350

FTX.009.350

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00009

FQHC-WRAPPAYMENT

X(2)

765

766

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX351

FTX.009.351

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00009

FQHC-WRAPPAYMENT

X(15)

767

781

1. Value must be 15 characters or less
2. CondiLonal

FTX352

FTX.009.352

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

FTX00009

FQHC-WRAPPAYMENT

X(2)

782

783

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

FTX353

FTX.009.353

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(100)

784

883

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

FTX354

FTX.009.354

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(500)

884

1383

1. Value must be 500 characters or less
2. CondiLonal

FTX355

FTX.009.355

STATE-NOTATION

State NotaLon

SituaLonal

A free text ﬁeld for the submieng state to enter
whatever informaLon it chooses.

N/A

FTX00009

FQHC-WRAPPAYMENT

X(500)

1384

1883

1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. SituaLonal

FTX357

FTX.095.357

RECORD-ID

Record ID

Mandatory

RECORD-ID

FTX00095

MISCELLANEO
US-PAYMENT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "FTX00095"

segment idenLﬁer padded with leading zeros
(e.g., 00001, 00002, 00003, etc.).

FTX358

FTX.095.358

SUBMITTINGSTATE

Submieng
State

Mandatory

A code that uniquely idenLﬁes the U.S. State or
Territory from which T-MSIS system data
resources were received.

STATE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

FTX359

FTX.095.359

RECORDNUMBER

Record Number

Mandatory

N/A

FTX00095

MISCELLANEO
US-PAYMENT

9(11)

1. Value must be 11 digits or less
2. Value must be unique within record
segment over all records associated with a
given Record ID
3. Mandatory

FTX360

FTX.095.360

ICN-ORIG

Original ICN

Mandatory

A unique item control number assigned by the
states payment system that idenLﬁes an original
or adjustment claim/transacLon.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(50)

1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. Mandatory

FTX361

FTX.095.361

ICN-ADJ

Adjustment ICN

CondiLonal A unique claim/transacLon number assigned by
the state’s payment system that idenLﬁes the
adjustment claim/transacLon for an original
item control number.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(50)

121

FTX363

FTX.095.363

ADJUSTMENTIND

Adjustment
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

FTX00095

MISCELLANEO
US-PAYMENT

X(1)

122

1. Value must be 1 character
2. Value must be in Adjustment Indicator List
(VVL)
3. Mandatory

FTX364

FTX.095.364

PAYMENT-ORRECOUPMENTDATE

Payment Or
Recoupment
Date

Mandatory

The date that the payment or recoupment was
executed by the payer.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

9(8)

123

130

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value of the CC component must be equal
to "20"

FTX365

FTX.095.365

PAYMENT-ORRECOUPMENTAMOUNT

Payment Or
Recoupment
Amount

Mandatory

The dollar amount being paid to the payee or
recouped from the payee for a previous
payment. A recoupment should be reported as a
negaLve amount.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

S9(11)
V99

131

143

1. Value must be between -99999999999.99
and 99999999999.99
2. Value must be expressed as a number with
2-digit precision (e.g. 100.50)
3. Mandatory

FTX366

FTX.095.366

CHECK-EFF-DATE

Check EﬀecLve
Date

CondiLonal The date a check is issued to the payee. In the
case of electronic funds transfer, it is the date
the transfer is made.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

9(8)

144

151

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Must have an associated Check Number
3. CondiLonal
4. Value of the CC component must be equal
to "20"

FTX367

FTX.095.367

CHECK-NUM

Check Number

CondiLonal The check or electronic funds transfer number.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(15)

152

166

1. Value must be 15 characters or less
2. When populated. value must have an
associated Check EﬀecLve Date
3. Value must not contain a pipe or asterisk
symbols
4. CondiLonal

FTX368

FTX.095.368

PAYER-ID

Payer ID

Mandatory

This is the idenLﬁer that corresponds with the
payer's role in relaLon to the Medicaid/CHIP
system.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(30)

167

196

1. Value must be 30 characters or less
2. Mandatory

PAYER-ID-TYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

197

198

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

199

298

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

FTX.095.369

PAYER-ID-TYPE

Payer ID Type

Mandatory

FTX370

FTX.095.370

PAYER-ID-TYPEOTHER-TEXT

Payer ID Type
Other Text

CondiLonal This is a descripLon of what the payer ID
represents when the payer ID was reported with
a payer type of "Other".

FTX371

FTX.095.371

PAYER-MCRPLAN-TYPE

Payer MCR Plan
Type

MANAGEDCARE-PLANTYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

299

300

FTX372

FTX.095.372

PAYER-MCRPLAN-TYPEOTHER-TEXT

Payer MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payer
ID was reported with a PAYER-MCR-PLAN-OROTHER-TYPE of "Other".

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

301

400

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX373

FTX.095.373

PAYEE-ID

Payee IdenLﬁer

Mandatory

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(30)

401

430

1. Value must be 30 characters or less
2. Mandatory

FTX374

FTX.095.374

PAYEE-ID-TYPE

Payee IdenLﬁer
Type

Mandatory

FTX375

FTX.095.375

PAYEE-ID-TYPEOTHER-TEXT

Payee ID Type
Other Text

FTX376

FTX.095.376

PAYEE-MCRPLAN-TYPE

Payee MCR Plan
Type

PAYEE-ID-TYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

431

432

CondiLonal This is a descripLon of what the PAYEE-ID-TYPE
represents when the PAYEE-ID-TYPE was
reported with a payee ID type of "Other".

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

433

532

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

MANAGEDCARE-PLANTYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

533

534

FTX377

FTX.095.377

PAYEE-MCRPLAN-TYPEOTHER-TEXT

Payee MCR Plan
Type Other Text

CondiLonal This is a descripLon of what type of managed
care plan or care coordinaLon model the payee
ID was reported with a payee MCR plan or other
care coordinaLon model type of "Other".

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

535

634

1. Value must be 100 characters or less
2. Value must be populated when Payee MCR
Plan Type equals "95"
3. CondiLonal

FTX378

FTX.095.378

PAYEE-TAX-ID

Payee Tax ID

Mandatory

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(30)

635

664

1. Value must be 30 characters or less
2. Mandatory
3. If Payee Tax ID Type equals "01", then
value must be 9-digits and meet the
requirements of a valid SSN per SSA
requirements

PAYEE-TAX-IDTYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

665

666

1. Value must be 2 characters
2. Value must be in Payee Tax ID Type List
(VVL)
3. Mandatory

This is the idenLﬁer that corresponds with the
payee's role in relaLon to the Medicaid/CHIP
system.
The payee is the individual or enLty that is
either receiving a payment or having a previous
payment recouped. The payee is the object of
the transacLon, as opposed to the payer who is
the subject taking the acLon of either making a
payment or taking a recoupment.

FTX379

FTX.095.379

PAYEE-TAX-IDTYPE

Payee Tax ID
Type

Mandatory

FTX380

FTX.095.380

PAYEE-TAX-IDTYPE-OTHERTEXT

Payee Tax ID
Type Other Text

CondiLonal This is a descripLon of what the PAYEE-TAX-IDTYPE represents when the PAYEE-TAX-ID-TYPE
was reported with a payee tax ID type of
"Other".

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

667

766

1. Value must be 100 characters or less
2. Value must be populated when Payee Tax
IdenLﬁer Type equals "95"
3. CondiLonal

FTX381

FTX.095.381

CONTRACT-ID

Contract
IdenLﬁer

CondiLonal

Managed care plan contract ID

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

767

866

1. Value must be 100 characters or less
2. CondiLonal

FTX382

FTX.095.382

INSURANCECARRIER-IDNUM

Insurance
Carrier
IdenLﬁcaLon
Number

CondiLonal

The state-assigned idenLﬁcaLon number of the
Third Party Liability (TPL) EnLty.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(12)

867

878

1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk
symbols
3. CondiLonal

FTX383

FTX.095.383

MSISIDENTIFICATIONNUM

MSIS
IdenLﬁcaLon
Number

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(20)

879

898

1. Value must be 20 characters or less
2. CondiLonal
3. When populated, value must match MSIS
IdenLﬁcaLon Number (ELG.002.019)
4. When Adjustment Indicator does not equal
"1", there must be a valid record of type
Enrollment Time Span where the Payment
Period Start Date is equal to or greater than
Enrollment Start Date and Period End Date is
less than or equal to Enrollment End Date

FTX384

FTX.095.384

PAYMENTPERIOD-STARTDATE

Payment Period
Start Date

Mandatory

The date represenLng the start of the Lme
period that the payment is expected to be used
by the provider.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

9(8)

899

906

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Value must be before or the same as the
associated Payment Period End Date
3. Value of the CC component must be equal
to "20"
4. Mandatory

FTX385

FTX.095.385

PAYMENTPERIOD-ENDDATE

Payment Period
End Date

Mandatory

The date represenLng the end of the Lme
period that the payment is expected to be used
by the provider.

N/A

FTX00095

MISCELLANEO
US-PAYMENT

9(8)

907

914

1. The date must be a valid calendar date in
the form "CCYYMMDD"
2. Mandatory
3. Value must be afer or the same as the
associated Payment Period Start Date
4. Value of the CC component must be equal
to "20"

FTX386

FTX.095.386

PAYMENTPERIOD-TYPE

Payment Period
Type

Mandatory

FTX387

FTX.095.387

PAYMENTPERIOD-TYPEOTHER-TEXT

Payment Period
Type Other Text

FTX388

FTX.095.388

TRANSACTIONTYPE

FTX389

FTX.095.389

FTX390

FTX.095.390

PAYMENTPERIOD-TYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

915

916

1. Value must be 2 characters
2. Value must be in Payment Period Type List
(VVL)
3. Mandatory

CondiLonal This is a descripLon of the type of ﬁnancial
transacLon when the PAYMENT-PERIOD-TYPE is
"Other".

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

917

1016

1. Value must be 100 characters or less
2. Value must be populated when Payment
Period Type equals "95"
3. CondiLonal

TransacLon
Type

CondiLonal This is a code that classiﬁes the type of ﬁnancial
transacLon when the ﬁnancial transacLon does
not ﬁt into any other ﬁnancial transacLon
segment type (e.g., FTX00002, FTX00003,
FTX00004, etc.).

TRANSACTIONTYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1017

1018

1. Value must be 2 characters
2. Value must be in TransacLon Type List
(VVL)
3. CondiLonal

TRANSACTIONTYPE-OTHERTEXT

TransacLon
Type Other Text

CondiLonal This is a descripLon of the type of ﬁnancial
transacLon when the TRANSACTION-TYPE is
"Other".

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

1019

1118

1. Value must be 100 characters or less
2. Value must be populated when Payee
IdenLﬁer Type equals "95"
3. CondiLonal

CATEGORY-FORFEDERALREIMBURSEMEN
T

Category for
Federal
Reimbursement

Mandatory

CATEGORYFOR-FEDERALREIMBURSEME
NT

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1119

1120

1. Value must be 2 characters
2. Value must be in Category for Federal
Reimbursement List (VVL)
3. Mandatory

A code to indicate the Federal funding source
for the payment.

FTX391

FTX.095.391

MBESCBESCATEGORY-OFSERVICE

MBESCBES
Category of
Service

Mandatory

21.P-FORM,
21BASE-FORM,
64.21U-FORM,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASEFORM,
64.21UP-FORM

FTX00095

MISCELLANEO
US-PAYMENT

X(5)

1172

1176

FTX392

FTX.095.392

MBESCBESFORM

MBESCBES
Form

Mandatory

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

FTX00095

MISCELLANEO
US-PAYMENT

X(50)

1122

1171

FTX393

FTX.095.393

MBESCBESFORM-GROUP

MBESCBES
Form Group

Mandatory

FTX394

FTX.095.394

WAIVER-ID

Waiver ID

FTX395

FTX.095.395

WAIVER-TYPE

FTX396

FTX.095.396

FUNDING-CODE

MBESCBESFORM-GROUP

FTX00095

MISCELLANEO
US-PAYMENT

X(1)

1121

1. Value must be 1 character
2. Value must be in MBESCBES Form Group
List (VVL)
3. Mandatory

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(20)

1177

1196

Waiver Type

CondiLonal A code for specifying waiver type under which
the eligible individual is covered during the
month and receiving services/under which
transacLon is submiaed.

WAIVER-TYPE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1197

1198

1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must have a corresponding value in
Waiver ID
4. CondiLonal

Funding Code

Mandatory

FUNDINGCODE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1199

1200

1. Value must be 1 character
2. Value must be in Funding Code List (VVL)
3. Mandatory

A code to indicate the source of non-federal
share funds.

FTX397

FTX.095.397

FUNDINGSOURCENONFEDERALSHARE

Funding Source
Nonfederal
Share

Mandatory

FUNDINGSOURCENONFEDERALSHARE

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1201

1202

1. Value must be 2 characters
2. Value must be in Funding Source
Nonfederal Share (VVL)
3. Mandatory

FTX398

FTX.095.398

SDP-IND

State Directed
Payment
Indicator

Mandatory

Indicates whether the ﬁnancial transacLon from
an MC plan to a provider or other enLty is a
type of State Directed Payment.

SDP-IND

FTX00095

MISCELLANEO
US-PAYMENT

X(1)

1203

1. Value must be 1 character
2. Value must be in State Directed Payment
Indicator List (VVL)
3. Mandatory

FTX399

FTX.095.399

SOURCELOCATION

Source LocaLon

Mandatory

The ﬁeld denotes the claims/transacLon
processing system in which the
claims/transacLons were originally processed.

SOURCELOCATION

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1204

1205

1. Value must be 2 characters
2. Value must be in Source LocaLon List (VVL)
3. Mandatory

FTX400

FTX.095.400

SPA-NUMBER

SPA Number

CondiLonal State plan amendment (SPA) ID number using
the following format: SS-YY-NNNN-xxxx where:
SS = State (use the two character postal
abbreviaLon for your state);

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(15)

1206

1220

1. Value must be 15 characters or less
2. CondiLonal

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(50)

1221

1270

1. Value must be 50 characters or less
2. CondiLonal

YY = Calendar Year (last two characters of the
calendar year of the state plan amendment);
NNNN = SPA number (a four character number
beginning with 0001) States should track their
submissions to assign sequenLal numbers to
their submissions. The system will not permit
reuse of a previously used SPA ID for a package
that has been formally = an SituaLonal entry for
speciﬁc SPA types
FTX401

FTX.095.401

PAYMENT-CATXREF

Payment Cat
Xref

CondiLonal Cross-reference to the applicable payment
category in the managed care plan's contract
with the state Medicaid/CHIP agency or their
ﬁscal intermediary.

FTX402

FTX.095.402

EXPENDITUREAUTHORITYTYPE

Expenditure
Authority Type

Mandatory

FTX403

FTX.095.403

EXPENDITUREAUTHORITYTYPE-OTHERTEXT

Expenditure
Authority Type
Other Text

CondiLonal This ﬁeld is only to be used if Expenditure
Authority Type "Other" valid value is selected.
Enter a speciﬁc text descripLon of the "Other"
expenditure authority type.

FTX404

FTX.095.404

MEMO

Memo

CondiLonal This represents any notes from the state's
ledger/accounLng system associated with the
payment/recoupment.

FTX00095

MISCELLANEO
US-PAYMENT

X(2)

1271

1272

1. Value must be 2 characters
2. Value must be in Expenditure Authority
Type List (VVL)
3. Mandatory

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(100)

1273

1372

1. Value must be 100 characters or less
2. If Expenditure Authority Type equals "95",
then value must be populated
3. CondiLonal

N/A

FTX00095

MISCELLANEO
US-PAYMENT

X(500)

1373

1872

1. Value must be 500 characters or less
2. CondiLonal

File Type	application/pdf
File Modified	2024:07:01 18:15:05Z
File Created	2024:07:01 18:15:05Z