Redline - Data Dictionary Appendices

T-MSIS Data Dictionary Appendices
December 04, 2020
Version: v2.4v4.0.0

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Table of Contents

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Preface .......................................................................................................................................................... 4
Appendix A: Valid Values .............................................................................................................................. 5
Appendix B: Home and Community-Based Services (HCBS) Taxonomy ...................................................... 8
Appendix C: Comprehensive Eligibility Crosswalk ...................................................................................... 26
Appendix D: Types of Service (TOS) Reference .......................................................................................... 62
Appendix E: Program Type Reference ........................................................................................................ 86
Appendix F: Eligibility Group Table............................................................................................................. 95
Appendix G: ISO 639 Language Codes Reference .................................................................................... 114
Appendix H: Benefit Types ....................................................................................................................... 126
Appendix I: MBES CBES Category of Service Line Definitions for the 64.9 Base Form ............................ 154
Appendix J: MBES CBES Category of Service Line Definitions for the 21 Form ........................................ 191
Appendix K: Crosswalk of T-MSIS to MSIS Type of Service Values ........................................................... 198
Appendix L: Crosswalk of WPC Provider Taxonomy Codes to Provider Facility Type Categories ............ 204
Appendix M .............................................................................................................................................. 272
Appendix N: Coding Specific Data Elements for Claim Files ..................................................................... 273
Appendix O ............................................................................................................................................... 276
Appendix P: CMS Guidance Library .......................................................................................................... 278
Appendix P.01: Submitting Adjustment Claims to T-MSIS ....................................................................... 279
Appendix P.02: Reporting Financial Transactions in T-MSIS .................................................................... 288
Appendix P.03 CMS Guidance: Revised and Consolidated Guidance for Building Non-Claims T-MSIS Files297
Appendix P.04 ........................................................................................................................................... 299
Appendix P.05: Populating Qualifier Fields and Their Associated Value Fields ....................................... 300
Appendix P.06 ........................................................................................................................................... 308
Appendix P.07: Finding Provider Roles on Standard Transactions........................................................... 309
Appendix Q: Terms and Abbreviations..................................................................................................... 330

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Preface
Appendices B, C, G, I, and J have been retired from the T-MSIS specifications Appendix artifact in v4.0.0 because
they were redundant to the Valid Value List (VVL) artifact. Appendices H, K, L, and P.02 have been retired from
the T-MSIS specifications Appendix artifact in v4.0.0 because they have been determined to be outdated and/or
obsolete. Appendices A, M, O, P.04, and P.06 were retired from previous versions of the T-MSIS specifications
Appendix artifact.
TMSIS is moving along the transition path of creating a comprehensive, integrated, and contextual Data Guide
approach to supporting states and territories in their data submission quality improvement initiatives.
As part of this on-going process, the Data Dictionary Appendix approach will be undergoing significant changes
over time to better meet these needs. This version 2.4.x release contains minimal changes from previous
versions while this transformational work is being undertaken in parallel.

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Appendix AB

Appendix A: Valid Values
*This Section Intentionally Left Blank*

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Appendix AB

NOTE
The content that previously has been included here in Data
Dictionary Appendix A has been removed from this document and
moved to a separate Excel-based file.
The purpose of this change was in response to feedback requesting
to provide Valid Value Lists in a discrete data format which could be
end-user manipulated, as well as to facilitate loading the data into a
system. This is the first of many changes coming to the existing Data
Dictionary Appendices approach as mentioned in the Preface section
above.

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Appendix AB

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Appendix AB

Appendix B: Home and Community-Based Services (HCBS) Taxonomy
The following table defines categories and services in the HCBS Taxonomy. It was approved by CMS in August
2012.
To acknowledge state variation, services and categories are defined based on the minimum definition necessary
to establish mutually distinct categories and services. Some services are defined in part by characteristics that
are NOT in that service. For example, the difference between companion services and personal care is that
companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing,
eating, and toileting.
Some of the services reflected below, including, but not limited to personal care, case management, home
health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State
Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan
Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting
services as “extended state plan” services must offer them in accordance with state plan service definitions.
Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment.
The services and categories are arranged in order of consideration for placing a particular state service in the
taxonomy. If one is not sure how to map a state’s service to the taxonomy, one should first consider Case
Management, then Round-the-Clock Services, then Supported Employment, etc.

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Appendix CAppendix B
HCBS Service Taxonomy Values:
CategoryTerm Sub-Category (where
Service
applicable)Description

Common Names

Definition

Deleted Cells
Deleted Cells

(where applicable)

Deleted Cells

01 – Case
Management

N/A

N/A

N/A

The development of a
comprehensive, written
individualized support plan. In
addition, case management often
includes assisting people in gaining
access to necessary services,
assessment of a person's needs,
ongoing monitoring of service
provision and/or a person's health
and welfare, assistance in
accessing supports to transition
from an institutional setting (but
not the transition services
themselves); and development of a
24-hour individual back-up plan
with formal and informal supports

N/A

01010 case
management

N/A

care management
supports
coordination

Same definition as category 01.

02 Round-theClock Services

N/A

N/A

N/A

Services by a provider that has
round-the-clock responsibility for
the health and welfare of
residents, except during the time
other services (e.g., day services)
are furnished. If these services are
provided in a 1915(c) waiver, the
state must complete Appendix G-3
of the 1915(c) waiver application
regarding medication management
and administration.

N/A

0201 group
living

N/A

assisted living
group home services

Round-the-clock services provided
in a residence that is NOT a
person’s home or apartment or a
single family residence where one
or more people with a disability
live with a person or family who
furnishes services

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Appendix CAppendix B
N/A

N/A

02011 group
living,
residential
habilitation

N/A

Assistance in acquiring, retaining,
and improving self-help,
socialization, and/or adaptive skills
by a provider with round-the-clock
responsibility for the residents’
health and welfare in a residence
that is NOT a person’s own home
or apartment or a single family
residence where one or more
people with a disability live with a
person or family who furnishes
services.

N/A

N/A

02012 group
living, mental
health
services

N/A

Mental health services by a
provider with round-the-clock
responsibility for the residents’
health and welfare in a residence
that is NOT a person’s own home
or apartment or a single family
residence where one or more
people with a disability live with a
person or family who furnishes
services.

N/A

N/A

02013 group
living, other

N/A

Health and social services not
identified elsewhere in
subcategory 0201 by a provider
with round-the-clock responsibility
for the residents’ health and
welfare in a residence that is NOT a
person’s own home or apartment
or a single family residence where
one or more people with a
disability live with a person or
family who furnishes services.

N/A

0202 shared
living

N/A

adult foster care
family living
host homes

Round-the-clock services provided
in a single family residence where
one or more people with a
disability live with a person or
family who furnishes services.

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Appendix CAppendix B
N/A

N/A

02021 shared
living,
residential
habilitation

N/A

Assistance in acquiring, retaining,
and improving self-help,
socialization, and/or adaptive skills
provided in a single family
residence where one or more
people with a disability live with a
person or family who furnishes
services and has round-the-clock
responsibility for the residents’
health and welfare.

N/A

N/A

02022 shared
living, mental
health
services

N/A

Mental health services provided in
a single family residence where
one or more people with a
disability live with a person or
family who furnishes services and
has round-the-clock responsibility
for the residents’ health and
welfare.

N/A

N/A

02023 shared
living, other

N/A

Health and social services not
identified elsewhere in
subcategory 0202 provided in a
single family residence where one
or more people with a disability
live with a person or family who
furnishes services and has roundthe-clock responsibility for the
residents’ health and welfare.

N/A

0203 inhome roundthe-clock
services

N/A

supported living

Round-the-clock services provided
in a person's home or apartment
where a provider has round-theclock responsibility for the person's
health and welfare.

N/A

N/A

02031 inhome
residential
habilitation

N/A

Assistance in acquiring, retaining,
and improving self-help,
socialization, and/or adaptive skills
provided in a person's home or
apartment where a provider has
round-the-clock responsibility for
the person's health and welfare.

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Appendix CAppendix B
N/A

N/A

02032 inhome roundthe-clock
mental health
services

N/A

Mental health services provided in
a person's home or apartment
where a provider has round-theclock responsibility for the person's
health and welfare.

N/A

N/A

02033 inhome roundthe-clock
services, other

N/A

Health and social services not
identified elsewhere in
subcategory 0203 provided in a
person's home or apartment
where a provider has round-theclock responsibility for the person's
health and welfare.

03 Supported
Employment

N/A

N/A

N/A

Assistance to help a person obtain
or maintain paid employment or
self-employment.

N/A

0301 job
03010 job
development development

N/A

Assistance to locate and obtain
paid employment or selfemployment.

N/A

0302
ongoing
supported
employment

N/A

N/A

Assistance to maintain paid
employment or self-employment.

N/A

N/A

03021
ongoing
supported
employment,
individual

N/A

Assistance to maintain selfemployment or paid employment
in an individual job placement (i.e.,
person is working with people
without disabilities).

N/A

N/A

03022
ongoing
supported
employment,
group

N/A

Assistance to maintain paid
employment in a group placement
(i.e., person is working on a team
of people with disabilities).

N/A

0303 career
planning

03030 career
planning

N/A

Focused, time-limited assistance to
identify a career direction and
develop a plan to achieve
employment.

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Appendix CAppendix B
04 Day
Services

N/A

N/A

N/A

Services other than supported
employment typically provided
outside the person's home during
the working day (i.e., Monday
through Friday between 8 a.m. and
5 p.m.). These services provide a
range of supports and are often,
but not always, provided on a
regularly scheduled basis at a site
specifically established to provide
day services.

N/A

N/A

04010
prevocational
services

N/A

Time-limited services to provide
learning and work experiences,
including volunteer work, to
acquire general skills that help a
person obtain paid employment in
integrated community settings.

N/A

N/A

04020 day
habilitation

N/A

Regularly scheduled activities in
settings separate from the
participant’s residence, including
assistance in acquiring, retaining,
and improving self-help,
socialization, and/or adaptive skills.
This service includes communitybased volunteer activities that
include acquiring, retaining, and
improving self-help, socialization,
and adaptive skills. This service can
include the supports offered in
adult day health, adult day services
(social model), and community
integration if these supports are
provided along with assistance in
acquiring, retraining, and
improving self-help, socialization,
and/or adaptive skills.

N/A

N/A

04030
education
services

N/A

Services to help a person access
post-secondary education.

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Appendix CAppendix B
N/A

N/A

04040 day
treatment/
partial
hospitalization

N/A

Services necessary for the
diagnosis or treatment of the
person's mental illness provided in
a fixed site facility during the
working day.

N/A

N/A

04050 adult
day health

N/A

Skilled health services and other
support services, NOT including
habilitation (i.e., assistance in
acquiring, retaining, and improving
self-help, socialization, and/or
adaptive skills), provided to adults
in a fixed site facility during the
working day. This service can
include the supports offered in
adult day services (social model) if
these supports are provided along
with skilled health services.

N/A

N/A

04060 adult
day services
(social model)

N/A

Support services, NOT including
skilled health services and not
including habilitation (i.e.,
assistance in acquiring, retaining,
and improving self-help,
socialization, and/or adaptive
skills), provided to adults in a fixed
site facility during the working day.

N/A

N/A

04070
community
integration

escort

Assistance in participating in
community activities, NOT
including assistance with activities
of daily living or assistance in
acquiring, retraining, and
improving self-help, socialization,
and/or adaptive skills. This service
can include supports furnished in
the person’s residence related to
community participation.

N/A

N/A

04080 medical
day care for
children

N/A

Medical services beyond typical
day care responsibilities provided
during the working day for infants,
toddlers, and pre-school age
children.

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Appendix CAppendix B
05 Nursing

N/A

N/A

N/A

Services within the scope of the
state's nurse practices act provided
by a licensed nurse.

N/A

N/A

05010 private
duty nursing

N/A

Licensed nursing services provided
on a continuous or full-time basis
(e.g., for more than 4 consecutive
hours per day and for more than
60 days). This service can include
the supports offered in health
assessment, health monitoring,
and medication assessment if the
service also includes other services
within the scope of the state’s
nurse practices act.

N/A

N/A

05020 skilled
nursing

N/A

Licensed nursing services provided
on a part-time or intermittent
basis. This service can include the
supports offered in health
assessment, health monitoring,
and medication assessment if the
service also includes other services
within the scope of the state’s
nurse practices act.

06 Home
delivered
meals

N/A

N/A

N/A

Prepared meals sent to a person's
home, which may not comprise a
full nutritional regimen.

N/A

N/A

06010 home
delivered
meals

N/A

Same definition as category 06.

07 Rent and
Food Expenses
for Live-In
Caregiver

N/A

N/A

N/A

Payment for the additional costs of
rent and food that can be
attributed to an unrelated direct
support worker living with the
person. This service does not
include payment for the direct
support worker’s services, which
may be covered as part of other
services such as personal care.

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Appendix CAppendix B
N/A

N/A

07010 rent
and food
expenses for
live-in
caregiver

N/A

Same definition as category 07.

08 HomeBased Services

N/A

N/A

N/A

Services that support a person in
his or her home or apartment,
when the provider does not have
round-the-clock responsibility for
the person's health and welfare.
These services can be provided in
other community settings, but are
primarily furnished in a person’s
home or apartment.

N/A

N/A

08010 homebased
habilitation

supported living
(provided on an
hourly basis)

Assistance in acquiring, retaining,
and improving self-help,
socialization, and/or adaptive skills
provided in the person's home
when the provider does NOT have
round-the-clock responsibility for
the person's health and welfare.
This service can include the
supports offered in community
integration, home health aide,
personal care, companion, and
homemaker if these supports are
provided along with assistance in
acquiring, retraining, and
improving self-help, socialization,
and/or adaptive skills.

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Appendix CAppendix B
N/A

N/A

08020 home
health aide

N/A

Assistance with activities of daily
living (ADLs) and/or health-related
tasks provided in a person's home
and possibly other community
settings that are supervised by a
registered nurse or licensed
therapist and provided by a
licensed home health agency.
Home health aide may include
assistance with instrumental
activities of daily living (IADLs).
Home health aide may include the
supports offered in companion and
homemaker if these supports are
provided along with assistance
with ADLs and/or health-related
tasks. Home health aide does NOT
include habilitation (assistance in
acquiring, retaining, and improving
self-help, socialization, and/or
adaptive skills).

N/A

N/A

08030
personal care

attendant care
personal assistance
personal attendant
services

Assistance with ADLs and/or
health-related tasks provided in a
person's home and possibly other
community settings, NOT including
both provision by a licensed home
health agency and a requirement
for supervision by a licensed nurse
or therapist. Personal care may
include assistance with IADLs.
Personal care may include the
supports offered in companion and
homemaker if these supports are
provided along with assistance
with ADLs and/or health-related
tasks. Personal care does NOT
include habilitation (assistance in
acquiring, retaining, and improving
self-help, socialization, and/or
adaptive skills).

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Appendix CAppendix B
N/A

N/A

08040
companion

adult companion
night supervision

Supervision and/or social support
provided in a person's home and
possibly other community settings.
Companion may also include
performance of light housekeeping
tasks (the supports offered in
homemaker). Companion does
NOT include assistance with ADLs
or habilitation (assistance in
acquiring, retaining, and improving
self-help, socialization, and/or
adaptive skills).

N/A

N/A

08050
homemaker

N/A

Performance of light housekeeping
tasks provided in a person's home
and possibly other community
settings NOT including supervision
and social support, assistance with
ADLs, or habilitation (assistance in
acquiring, retaining, and improving
self-help, socialization, and/or
adaptive skills).

N/A

N/A

08060 chore

N/A

Performance of heavy household
chores provided in a person's
home and possibly other
community settings NOT including
supervision and social support,
assistance with ADLs, or
habilitation (assistance in
acquiring, retaining, and improving
self-help, socialization, and/or
adaptive skills).

09 Caregiver
Support

N/A

N/A

N/A

Assistance to people who provide
ongoing support to the person with
a disability when assisting the
support person is the primary
purpose of the service. In most
cases, the support person is
unpaid. However, respite can be
provided to relieve providers who
furnish shared living.

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Appendix CAppendix B
N/A

0901 respite

N/A

N/A

Short-term services provided
because a support person is absent
or needs relief when relieving the
support person is the primary
purpose of the service.

N/A

N/A

09011 respite,
out-of-home

N/A

Short-term services provided
because a support person is absent
or needs relief NOT provided in a
person's home or apartment when
relieving the support person is the
primary purpose of the service.

N/A

N/A

09012 respite,
in-home

N/A

Short-term services provided
because a support person is absent
or needs relief provided in a
person's home or apartment when
relieving the support person is the
primary purpose of the service.

N/A

0902
caregiver
counseling
and/or
training

09020
caregiver
counseling
and/or
training

N/A

Counseling, emotional support,
and/or training provided to a
family member or friend providing
support when providing counseling
or training to the support person is
the primary purpose of the service.
Examples of training topics include
a) skills to provide specific
treatment regimens or help the
person improve function, b)
information about the person's
disability or conditions, and c)
navigation of the service system.

10 Other
Mental Health
and Behavioral
Services

N/A

N/A

N/A

Services NOT identified in previous
categories that support people in
improving or maintaining mental
or behavioral health.

N/A

N/A

10010 mental
health
assessment

N/A

Assessment or evaluation of
mental health status when the
assessment is the primary purpose
of the service. This service can
include medication assessment if
the assessment includes other
mental health information.

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Appendix CAppendix B
N/A

N/A

10020
assertive
community
treatment

N/A

A range of mental health supports
characterized by assertive
engagement of the person,
availability 24 hours a day, and
support by an interdisciplinary
team.

N/A

N/A

10030 crisis
intervention

crisis support

Response to stabilize a person
exhibiting behavior that puts the
person at risk of hospitalization or
institutionalization.

N/A

N/A

10040
behavior
support

behavior analysis
behavior therapy

Services specifically to encourage
positive behaviors and to decrease
challenging behaviors, including a)
assessment to identify antecedents
to behaviors and b) development
of a plan to improve behaviors.

N/A

N/A

10050 peer
specialist

peer support

Mental health support services
provided by a trained and
credentialed person with a mental
illness.

N/A

N/A

10060
counseling

N/A

Individual or group therapy to
develop coping skills or improve
mental health function.

N/A

N/A

10070
psychosocial
rehabilitation

N/A

Assistance to improve or restore
function in ADLs, IADLs, and social
or adaptive skills NOT identified in
previous categories or services.

N/A

N/A

10080 clinic
services

N/A

Services for individuals with
chronic mental illness furnished in
a clinic or based in a clinic NOT
identified in previous categories or
services.

N/A

N/A

10090 other
mental health
and
behavioral
services

N/A

Services NOT identified elsewhere
in category 10 that support people
in improving or maintaining mental
or behavioral health.

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Appendix CAppendix B
11 Other
Health and
Therapeutic
Services

N/A

N/A

N/A

Services NOT identified in previous
categories that support people in
improving or maintaining health or
functional capacity.

N/A

N/A

11010 health
monitoring

N/A

Ongoing monitoring of physical
health status when monitoring is
the primary purpose of the service.
This service can include medication
monitoring if other aspects of a
person’s health also are
monitored.

N/A

N/A

11020 health
assessment

N/A

Assessment or evaluation of
physical health status when the
assessment is the primary purpose
of the service. This service can
include medication assessment if
the assessment includes other
health information.

N/A

N/A

11030
medication
assessment
and/or
management

N/A

Assessment of medication
administration and/or possible
drug interactions—and/or
oversight of ongoing medication
administration—when the
management of medications is the
primary purpose of the service.

N/A

N/A

11040
nutrition
consultation

N/A

Assistance to a person to help him
or her plan and implement changes
to nutritional intake.

N/A

N/A

11050
physician
services

N/A

Services by a licensed physician.
This service can include health
assessment, medication
assessment, and/or mental health
assessment if other physician
services are also provided.

N/A

N/A

11060
prescription
drugs

N/A

Prescription drugs.

N/A

N/A

11070 dental
services

N/A

Services by a licensed dentist.

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Appendix CAppendix B
N/A

N/A

11080
occupational
therapy

N/A

Services by a licensed occupational
therapist.

N/A

N/A

11090
physical
therapy

N/A

Services by a licensed physical
therapist.

N/A

N/A

11100 speech,
hearing, and
language
therapy

N/A

Services by a licensed speech,
hearing, and language therapist.
This service includes services by a
speech pathologist or a qualified
audiologist.

N/A

N/A

11110
respiratory
therapy

N/A

Services by a licensed respiratory
therapist.

N/A

N/A

11120
cognitive
rehabilitative
therapy

N/A

Assistance to manage or restore
cognitive function.

N/A

N/A

11130 other
therapies

N/A

Therapeutic interventions to
maintain or improve function NOT
identified in previous categories or
services. This service includes
specialized interventions such as
those using art, music, dance, or
trained animals.

12 Services
Supporting
Participant
Direction

N/A

N/A

N/A

Services that assist a person and/or
his or her representative in
managing participant-directed
services, as identified in the
Participant Direction of Services
section of the 1915(c) waiver or
1915(i) State Plan Amendment
application.

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Appendix CAppendix B
N/A

N/A

12010
financial
management
services in
support of
participant
direction

N/A

Assistance to help a person and/or
representative manage participantdirected services by a) performing
financial tasks to facilitate the
employment of staff; b) managing
the disbursement of funds in a
participant-directed budget;
and/or c) performing fiscal
accounting and making
expenditure reports to the person,
representative, and/or state
authorities.

N/A

N/A

12020
information
and assistance
in support of
participant
direction

N/A

Training the person and/or
representative in directing or
managing services. Topics include:
a) the person's rights and
responsibilities in participant
direction; b) recruiting and hiring
staff; c) managing staff and solving
problems regarding services; and
d) managing a participant-directed
budget.

13 Participant
Training

N/A

N/A

N/A

Training provided to a participant
when training the participant is the
primary purpose of the service.
Topics may include: a) specific
treatment regimens, b) the
person's disability or condition,
and c) navigation of the service
system.

N/A

N/A

13010
participant
training

N/A

The same definition as category 13.

14 Equipment,
Technology,
and
Modifications

N/A

N/A

N/A

Material goods to help a person
improve or maintain function.

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23

Appendix CAppendix B
N/A

1401
personal
emergency
response
system
(PERS)

14010
personal
emergency
response
system (PERS)

N/A

Devices that enable participants to
signal a response center to secure
help in an emergency. This service
can include installation,
maintenance, and monthly
response center fees.

N/A

1402 home
and/or
vehicle
accessibility
adaptations

14020 home
and/or vehicle
accessibility
adaptations

home and/or vehicle
modifications

Physical changes to a private
residence, automobile, or van, to
accommodate the participant or
improve his or her function.

N/A

1403
equipment,
technology,
and supplies

N/A

N/A

The purchase or rent of items,
devices, product systems, and/or
disposable medical supplies.

N/A

N/A

14031
equipment
and
technology

assistive
The purchase or rent of items,
technologyspecialized devices, or product systems to
medical equipment
increase or maintain a person's
functional status. This service can
include designing, fitting, adapting,
and maintaining equipment, as
well as training or technical
assistance to use equipment.

N/A

N/A

14032
supplies

N/A

The purchase of disposable
medical supplies, including
nutritional supplements.

N/A

N/A

Transportation not provided as
part of another service such as a
round-the-clock service or a day
service. This service may include: a)
transportation to and from other
HCBS services; b) transportation to
community activities where HCBS
services are not provided; and/or
c) the purchase of public transit
tokens or passes.

15 NonN/A
Medical
Transportation

N/A

December 2020v4.0.0

N/A

15010 nonmedical
transportation

N/A

Same definition as category 15.

24

Deleted Cells
Deleted Cells
Deleted Cells
Deleted Cells

Appendix CAppendix B
16 Community
Transition
Services

N/A

N/A

N/A

Non-recurring set-up expenses for
moving to a residence where the
person is responsible for living
expenses.

N/A

N/A

16010
community
transition
services

N/A

Same definition as category 16.

17 Other
Services

N/A

N/A

N/A

Services NOT identified in previous
categories.

N/A

N/A

17010 goods
and services

Individually directed
goods and services

Services, equipment, or supplies in
the person's support plan NOT
otherwise provided in the
Medicaid program.

N/A

N/A

17020
interpreter

N/A

Services provided by an individual
to support communication by
someone who has limited English
proficiency or verbal skills, such as
a sign language interpreter or
communicator.

N/A

N/A

17030 housing N/A
consultation

Information and assistance to help
a person identify and select
housing.

N/A

N/A

17990 other

Services NOT identified in previous
categories and services.

December 2020v4.0.0

N/A

25

Appendix CAppendix B

Appendix C: Comprehensive Eligibility Crosswalk
MAS/BOE - INDIVIDUALS COVERED UNDER SEPARATE CHILDREN’S
HEALTH INSURANCE PROGRAMS (Separate-CHIP)

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26

Appendix CAppendix B

ITEM

DESCRIPTION

CFR/PL CITATIONS

1

Children covered under a Title XXI
separate CHIP)

42 CFR 457.310,
§2110 (b) of the Act.

Legal immigrant children and
pregnant women covered under a
Title XXI separate CHIP
Children receiving dental-only
coverage under a separate CHIP

§2107(e)(1) of the Act,
P.L. 111-3.

Targeted low-income pregnant
women covered under a Title XXI
separate CHIP
Infants under age 1 born to targeted
low-income pregnant women made
eligible under a Title XXI separate
CHIP
Children who have been granted
presumptive eligibility under a Title
XXI separate CHIP
Pregnant women who have been
granted presumptive eligibility
under a Title XXI separate CHIP

§2112 of the Act, PL
111-3.

2

3

4

5

6

7

December 2020v4.0.0

§2102 and 2110 (b) of
the Act, PL 111-3.

§2112 of the Act, PL
111-3.

42 CFR 457.355,
§2105 of the Act.
§2112 of the Act, PL
111-3.

27

Appendix CAppendix B

8

Caretaker relatives and children
covered under the authority of an
1115 waiver and a Title XXI separate
CHIP

§2107(e) of the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE
UNDER SECTION 1931 OF THE ACT-AGED MSIS Coding (MAS-1, BOE1)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Aged individuals receiving SSI, eligible
42 CFR 435.120,
1
spouses or persons receiving SSI
§1619(b) of the Act,
pending a final determination of
§1902(a)(10)(A)(I)(II) of
disposal of resources exceeding SSI the Act, PL 99-643, §2.
dollar limits; and persons considered
to be receiving SSI under §1619(b) of
the Act.
Aged individuals who meet more
42 CFR 435.121,
2 restrictive requirements than SSI and §1619(b)(3) of the Act,
who are either receiving or not
§1902(f) of the Act, PL
receiving SSI; or who qualify under
99-643, §7.
§1619 of the Act.
Aged individuals receiving mandatory
42 CFR 435.130.
3
State supplements.
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Appendix CAppendix B

ITE
M
4

DESCRIPTION

CFR/PL CITATIONS

Aged individuals who receive a State
supplementary payment (but not SSI)
based on need.

42 CFR 435.230,
§1902(a)(10)(A)(ii) of
the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE
UNDER SECTION 1931 OF THE ACT - BLIND/DISABLED MSIS Coding
(MAS-1, BOE-2)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Blind and/or disabled individuals
42 CFR 435.120,
1
receiving SSI, eligible spouses or
§1619(b) of the Act,
persons receiving SSI pending a final §1902(a)(10)(A)(I)(II) of
determination of blindness, disability, the Act, PL 99-643, §2.
and/or disposal of resources
exceeding SSI dollar limits; and
persons considered to be receiving
SSI under §1619(b) of the Act.
Blind and/or disabled individuals who
42 CFR 435.121,
2 meet more restrictive requirements §1619(b)(3) of the Act,
than SSI and who are either receiving §1902(f) of the Act, PL
or not receiving SSI; or who qualify
99-643, §7.
under §1619.
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Appendix CAppendix B

ITE
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3

4

DESCRIPTION

CFR/PL CITATIONS

Blind and/or disabled individuals
receiving mandatory State
supplements.
Blind and/or disabled individuals who
receive a State supplementary
payment (but not SSI) based upon
need.

42 CFR 435.130.

42 CFR 435.230,
§1902(a)(10)(A)(ii) of
the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE
UNDER SECTION 1931 OF THE ACT – CHILDREN MSIS Coding (MAS-1,
BOE-4)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Low Income Families with Children
42 CFR 435.110,
1
qualified under §1931 of the Act.
§1902(a)(10)(A)(I)(I) of
the Act, §1931 of the
Act.
2

Children age 18 who are regularly
attending a secondary school or the
equivalent of vocational or technical
training.

December 2020v4.0.0

42 CFR 435.110,
§1902(a)(10)(A)(I)(I).

30

Appendix CAppendix B

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE
UNDER SECTION 1931 OF THE ACT – ADULTS MSIS Coding (MAS-1,
BOE-5)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Adults deemed essential for well42 CFR 435.110,
1
being of a recipient [see 45 CFR
§1902(a)(10)(A)(I)(I) of
233.20(a)(2)(vi)] qualified for
the Act, §1931 of the
Medicaid under §1931 of the Act.
Act.
1

2
2

Pregnant women who have no
other eligible children.
Other adults in "adult only"
units.

42 CFR 435.110,
§1902(a)(10)(A)(I)(I) of
the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE
UNDER SECTION 1931 -U CHILDREN MSIS Coding (MAS-1, BOE-6) (OPTIONAL)

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31

Appendix CAppendix B

ITE
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1

2

DESCRIPTION

CFR/PL CITATIONS

Unemployed Parent Program - Cash
assistance benefits to low income
individuals in two parent families
where the principle wage earner is
employed fewer than 100 hours a
month.
Children age 18 who are regularly
attending a secondary school or the
equivalent of vocational or technical
training.

42 CFR 435.110,
§1902(a)(10)(A)(I)(I) of
the Act, §1931 of the
Act.

42 CFR 435.110,
§1902(a)(10)(A)(I)(I) of
the Act.

MAS/BOE - INDIVIDUALS RECEIVING CASH ASSISTANCE OR ELIGIBLE
UNDER SECTION 1931 - U ADULTS MSIS Coding (MAS-1, BOE-7) (OPTIONAL)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Adults deemed essential for well42 CFR 435.110,
1
being of a recipient (see 45 CFR
§1902(a)(10)(A)(I)(I) of
233.20(a)(2)(vi)) qualified under
the Act, §1931 of the
§1931 of the Act (Low Income
Act.
Families with Children).

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Appendix CAppendix B

ITE
M

DESCRIPTION
3

2
4

Pregnant women who have no
other eligible children.
Other Adults in "adult only"
units.

CFR/PL CITATIONS
42 CFR 435.110,
§1902(a)(10)(A)(I)(I) of
the Act.

MAS/BOE - MEDICALLY NEEDY – AGED MSIS Coding (MAS-2, BOE-1)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Aged individuals who would be
42 CFR 435.326.
1
ineligible if not enrolled in an HMO.
Categorically needy individuals are
covered under 42 CFR 435.212, and
the same rules apply to medically
needy individuals.
Aged
42 CFR 435.320, 42
2
CFR 435.330.

MAS/BOE - MEDICALLY NEEDY - BLIND/DISABLED MSIS Coding (MAS2, BOE-2)

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33

Appendix CAppendix B

ITE
M
1

DESCRIPTION

CFR/PL CITATIONS

Blind and/or disabled individuals who
would be ineligible if not enrolled in
an HMO. Categorically needy
individuals are covered under 42 CFR
435.212 and the same rules apply to
medically needy individuals.
Blind/Disabled

42 CFR 435.326.

2

3

Blind and/or disabled individuals who
meet all Medicaid requirements
except current blindness and/or
disability criteria, and have been
continuously eligible since 12/73
under the State's requirements.

42 CFR 435.322, 42
CFR 435.324, 42 CFR
435.330.
42 CFR 435.340.

MAS/BOE - MEDICALLY NEEDY – CHILDREN MSIS Coding (MAS-2,
BOE-4)

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Appendix CAppendix B

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M
1

2

3

4

DESCRIPTION

CFR/PL CITATIONS

Individuals under age 18 who, but for
income and resources, would be
eligible.

§1902(a)(10)(C)(ii)(I)
of the Act, PL 97-248,
§137.

Infants under the age of 1 and who
were born after 9/30/84 to and living
in the household of medically needy
women.
Other financially eligible individuals
under age 18-21, as specified by the
State.
Children who would be ineligible if not
enrolled in an HMO. Categorically
needy individuals are covered under
42 CFR 435.212 and the same rules
apply to medically needy individuals.

§1902(e)(4) of the
Act, PL 98-369,
§2362.
42 CFR 435.308.

42 CFR 435.326.

MAS/BOE - MEDICALLY NEEDY – ADULTS MSIS Coding (MAS-2, BOE-5)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Pregnant women.
42 CFR 435.301.
1
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Appendix CAppendix B

ITE
M
2

3

DESCRIPTION

CFR/PL CITATIONS

Caretaker relatives who, but for
income and resources, would be
eligible.
Adults who would be ineligible if not
enrolled in an HMO. Categorically
needy individuals are covered under
42 CFR 435.212 and the same rules
apply to medically needy individuals.

42 CFR 435.310.

42 CFR 435.326.

MAS/BOE - POVERTY RELATED ELIGIBLES – AGED MSIS Coding (MAS3, BOE-1)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Qualified Medicare Beneficiaries
§§1902(a)(10)(E)(I)
1 (QMBs) who are entitled to Medicare and 1905(p)(1) of the
Part A, whose income does not exceed
Act, PL 100-203,
100% of the Federal poverty level, and §4118(p)(8), PL 100whose resources do not exceed twice 360, §301(a) & (e), PL
the SSI standard.
100-485, §608(d)(14),
PL 100-647, §8434.

December 2020v4.0.0

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Appendix CAppendix B

ITE
M
2

3

4

DESCRIPTION

CFR/PL CITATIONS

Specified Low-Income Medicare
§4501(b) of OBRA 90,
Beneficiaries (SLMBs) who meet all of
as amended in
the eligibility requirements for QMB
§1902(a)(10)(E) of
status, except for the income in excess
the Act.
of the QMB income limit, but not
exceeding 120% of the Federal
poverty level.
Qualifying individuals having higher §1902(a)(10)(E)(iv) of
income than allowed for QMBs or
the Act.
SLMBs.
Aged individual not described in S
§1902(a)(10)(A)(ii)(X),
1902(a)(10)(A)(1) of the Act, with
1902(m)(1) of the
income below the poverty level and
Act, PL 99-509,
resources within state limits, who are
§§9402 (a) and (b).
entitled to full Medicaid benefits.

MAS/BOE - POVERTY RELATED ELIGIBLES - BLIND/DISABLED MSIS
Coding (MAS-3, BOE-2)

December 2020v4.0.0

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Appendix CAppendix B

ITE
M
1

2

3

4

DESCRIPTION

CFR/PL CITATIONS

Qualified Medicare Beneficiaries
§§1902(a)(10)(E)(I)
(QMBs) who are entitled to Medicare and 1905(p)(1) of the
Part A, whose income does not exceed
Act, PL 100-203,
100% of the Federal poverty level, and §4118(p)(8), PL 100whose resources do not exceed twice 360, §301(a) & (e), PL
the SSI standard.
100-485, §608(d)(14),
PL 100-647, §8434.
Specified Low-Income Medicare
§4501(b) of OBRA 90
Beneficiaries (SLMBs) who meet all of
as amended in
the eligibility requirements for QMB
§1902(a)(10)(E)(I) of
status, except for the income in excess
the Act.
of the QMB income limit, but not
exceeding 120% of the Federal
poverty level.
Qualifying individuals having higher §1902(a)(10)(E)(iv) of
income than allowed for QMBs or
the Act.
SLMBs.
Qualified Disabled Working Individuals §§1902(a)(10)(E)(ii)
(QDWIs) who are entitled to Medicare
and 1905(s) of the
Part A.
Act.

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38

Appendix CAppendix B

ITE
M
5

DESCRIPTION

CFR/PL CITATIONS

Disabled individuals not described in
§1902(a)(10)(A)(1) of the Act, with
income below the poverty level and
resources within state limits, which
are entitled to full Medicaid benefits.

§§1902(a)(10)(A)(ii)(X
), 1902(m)(1) and (3)
of the Act, P.L. 99509, §§9402 (a) and
(b).

MAS/BOE - POVERTY RELATED ELIGIBLES – CHILDREN MSIS Coding
(MAS-3, BOE-4)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Infants and children up to age 6 with §§1902(a)(10)(A)(I)(IV
1
income at or below 133% of the
) & (VI), 1902(l)(1)(A),
Federal Poverty Level (FPL).
(B), & (C) of the Act,
PL 100-360,
§302(a)(1), PL 100485, §608(d)(15).

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39

Appendix CAppendix B

ITE
M
2

3

4

5

DESCRIPTION

CFR/PL CITATIONS

Children under age 19 (born after
§1902(a)(10)(A)(I)
9/30/83) whose income is at or below
(VII) of the Act.
100% of the Federal poverty level
within the State's resource
requirements.
Infants under age 1 whose family
§§1902(a)(10)(A)(ii)
income is below 185% of the poverty (IX) and 1902(l)(1)(D)
level and who are within any optional of the Act, PL 99-509,
State resource requirements.
§§9401(a) & (b), PL
100-203, §4101.
Children made eligible under the more
liberal income and resource
requirements as authorized under
§1902(r)(2) of the Act when used to
disregard income on a poverty-levelrelated basis.
Children made eligible by a Title XXI
Medicaid expansion under the Child
Health Insurance Program (CHIP)

§1902(r)(2) of the
Act.

P.L. 105-100.

MAS/BOE - POVERTY RELATED ELIGIBLES – ADULTS MSIS Coding
(MAS-3, BOE-5)
December 2020v4.0.0

40

Appendix CAppendix B

ITE
M
1

2

3

4

DESCRIPTION

CFR/PL CITATIONS

Pregnant women with incomes at or
below 133% of the Federal Poverty
Level.

§1902(a)(10)(A)(I),
(IV) and (VI);
§1902(l)(1)(A), (B), &
(C) of the Act, PL 100360, §302(a)(1), PL
100-485, §608(d)(15).

Women who are eligible until 60 days §§1902(a)(10)(A)(ii)(I
after their pregnancy, and whose
X) and 1902(l)(1)(D)
incomes are below 185% of the FPL of the Act, PL 99-509,
and have resources within any
§§9401(a) & (b), PL
optional State resource requirements.
100-203, §4101.
Caretaker relatives and pregnant
§1902(r)(2) of the
women made eligible under more
Act.
liberal income and resource
requirements of §1902(r)(2) of the Act
when used to disregard income on a
poverty-level related basis.
Adults made eligible by a Title XXI
Title XXI of the Social
Medicaid expansion under the Child
Security Act.
Health Insurance Program (CHIP).

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41

Appendix CAppendix B

MAS/BOE - POVERTY RELATED ELIGIBLES – ADULTS MSIS Coding
(MAS-3, BOE-A)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Women under age 65 who are found §1902(a)(10)(a)(ii)(XV
1
to have breast or cervical cancer, or
III), P.L. 106-354.
have precancerous conditions.

MAS/BOE - OTHER ELIGIBLES – AGED MSIS Coding (MAS-4, BOE-1)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Aged individuals who meet more
42 CFR 435.121,
1 restrictive requirements than SSI and
§1619(b)(3) of the
who are either receiving or not
Act, §1902(f) of the
receiving SSI; or who qualify under
Act, PL 99-643, §7.
§1619 of the Act.
Aged individuals who are ineligible for
42 CFR 435.122.
2 optional State supplements or SSI due
to requirements that do not apply
under title XIX.

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Appendix CAppendix B

ITE
M
3

4

5

6

7

DESCRIPTION

CFR/PL CITATIONS

Aged essential spouses considered
continuously eligible since 12/73; and
some spouses who share hospital or
nursing facility rooms for 6 months or
more.
Institutionalized aged individuals who
have been continuously eligible since
12/73 as inpatients or residents of
Title XIX facilities.
Aged individuals who would be SSI/SSP
eligible except for the 8/72 increase in
OASDI benefits.
Aged individuals who would be eligible
for SSI but for title II cost-of-living
adjustment(s).
Aged aliens who are not lawful,
permanent residents or who do not
have PRUCOL status, but who are
otherwise qualified, and who require
emergency care.

42 CFR 435.131.

December 2020v4.0.0

42 CFR 435.132.

42 CFR 435.134.

42 CFR 435.135.

PL 99-509, §9406.

43

Appendix CAppendix B

ITE
M
8

9

10

DESCRIPTION

CFR/PL CITATIONS

Aged individuals who would be eligible
for AFDC, SSI, or an optional State
supplement if not in a medical
institution.

42.CFR 435.211,
§1902(a)(10)(A)(ii)
and §1905(a) of the
Act.

Aged individuals who meet income
and resource requirements for AFDC,
SSI, or an optional State supplement.

42 CFR 435.210,
§1902(a)(10)(A)(ii)
and §1905 of the Act.

Aged individuals who have become
ineligible and who are enrolled in a
qualified HMO or "§1903(m)(2)(G)
entity" that has a risk contract.

42 CFR 435.212,
§1902(e)(2), PL 99272, §9517, PL 100203, §4113(d).

Aged individuals who, solely because
42 CFR 435.217,
11
of coverage under a home and
§1902(a)(10)(A)(ii),
community based waiver, are not in a
(VI); 50 PL 100-13.
medical institution, but who would be
eligible if they were.
Aged individuals who elect to receive
§1902(a)(10)(A)(ii),
12 hospice care who would be eligible if (VII) of the Act, PL 99in a medical institution.
272, §9505.

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44

Appendix CAppendix B

ITE
M
13

DESCRIPTION

CFR/PL CITATIONS

Aged individuals in institutions who
are eligible under a special income
level specified in Supplement 1 to
Attachment 2.6-A of the State's title
XIX Plan.

42 CFR 435.236,
§1902(a)(10)(A)(ii) of
the Act.

MAS/BOE - OTHER ELIGIBLES - BLIND/DISABLED MSIS Coding (MAS-4,
BOE-2)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Blind and/or disabled individuals who
42 CFR 435.121,
1
meet more restrictive requirements
§1619(b)(3) of the
than SSI, including both those
Act, §1902(f) of the
receiving and not receiving SSI
Act, PL 99-643, §7.
payments
Blind and/or disabled individuals who
42 CFR 435.122.
2
are ineligible for optional State
supplements or SSI due to
requirements that do not apply under
title XIX.

December 2020v4.0.0

45

Appendix CAppendix B

ITE
M
3

4

5

6

7

DESCRIPTION

CFR/PL CITATIONS

Blind and/or disabled essential
42 CFR 435.131.
spouses considered continuously
eligible since 12/73; and some spouses
who share hospital or nursing facility
rooms for 6 months or more.
Institutionalized blind and/or disabled
42 CFR 435.132.
individuals who have been
continuously eligible since 12/73 as
inpatients or residents of Title XIX
facilities.
Blind and/or disabled individuals who
42 CFR 435.134.
would be SSI/SSP, eligible except for
the 8/72 increase in OASDI benefits.
Blind and/or disabled individuals who 42 CFR 435.135, §503
would be eligible for SSI but for title II
PL 94-566.
cost-of-living adjustment(s).
Blind and/or disabled aliens who are
PL 99-509, §9406.
not lawful, permanent residents or
who do not have PRUCOL status, but
who are otherwise qualified, and who
require emergency care.

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46

Appendix CAppendix B

ITE
M
8

9

10

11

DESCRIPTION

CFR/PL CITATIONS

Blind and/or disabled individuals who
meet all Medicaid requirements
except current blindness, or disability
criteria, who have been continuously
eligible since 12/73 under the State's
12/73 requirements.
Blind and/or disabled individuals, age
18 or older, who became blind or
disabled before age 22 and who lost
SSI or State supplementary payments
eligibility because of an increase in
their OASDI (childhood disability)
benefits.
Blind and/or disabled individuals who
would be eligible for AFDC, SSI, or an
optional State supplement if not in a
medical institution.

42 CFR 435.133.

Qualified severely impaired blind or
disabled individuals under age 65,
who, except for earnings, are eligible
for SSI.

December 2020v4.0.0

§1634(c) of the Act;
PL 99-643, §6.

42 CFR 435.211,
§§1902(a)(10)(A)(ii)
and 1905(a) of the
Act.
§§1902(a)(10)(A)(I)(II)
and 1905(q) of the
Act, PL 99-509, §9404
and §1619(b)(8) of
the Act, PL 99-643, §7
47

Appendix CAppendix B

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DESCRIPTION

CFR/PL CITATIONS

Blind and/or disabled individuals who
42 CFR 435.210,
12
meet income and resource
§§1902(a)(10)(A)(ii)
requirements for AFDC, SSI, or an
and 1905 of the Act.
optional State supplement.
Working disabled individuals who buy- §1902(a)(10)(A)(ii)(XII
13
in to Medicaid
I).
Blind and/or disabled individuals who
14
have become ineligible who are
enrolled in a qualified HMO or
Ҥ1903(m)(2)(G) entity" that has a risk
contract.

42 CFR 435.212,
§1902(e)(2) of the
Act; PL 99-272,
§9517; PL 100-203,
§4113(d).

Blind and/or disabled individuals who,
42 CFR 435.217,
15
solely because of coverage under a §1902(a)(10)(A)(ii)(VI)
home and community based waiver, of the Act, 50 PL 100are not in a medical institution and
13.
who would be eligible if they were.
Blind and/or disabled individuals who §1902(a)(10)(A)(ii)(VII
16 elect to receive hospice care, and who ), PL 99-272, §9505
would be eligible if in a medical
institution.

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Appendix CAppendix B

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M
17

18

19

20

DESCRIPTION

CFR/PL CITATIONS

Blind and/or disabled individuals in
42 CFR 435.231.
institutions who are eligible under a §1902(a)(10)(A)(ii) of
special income level specified in
the Act.
Supplement 1 to Attachment 2.6-A of
the State's title XIX Plan.
Blind and/or disabled widows and
§1634 of the Act, PL
widowers who have lost SSI/SSP
101-508, §5103.
benefits but are considered eligible for
Medicaid until they become entitled
to Medicare Part A.
Certain Disabled children, 18 or under,
42 CFR 435.225;
who live at home, but who, if in a
§1902(e)(3) of the
medical institution, would be eligible
Act.
for SSI or a State supplemental
payment.
Continuation of Medicaid eligibility for §1902(a)(10)(A)(ii) of
disabled children who lose SSI benefits the Act; P.L. 15-32,
because of changes in the definition of
§491.
disability.

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ITE
M

DESCRIPTION

CFR/PL CITATIONS

Disabled individuals with medically
§1902(a)(10)(A)(ii)(XV
21
improved disabilities made eligible
) of the Act.
under the Ticket to Work and Work
Incentives Improvement Act (TWWIIA)
of 1999.

MAS/BOE - OTHER ELIGIBLES – CHILDREN MSIS Coding (MAS-4, BOE4)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Children of families receiving up to 12 §1925 of the Act, PL
1 months of extended Medicaid benefits
100-485, §303.
(for those eligible after 4/1/90).
"Qualified children" under age 19 born §§1902(a)(10)(A)(I)(III
2
after 9/30/83 or at an earlier date at
) and 1905(n) of the
State option, who meet the State's
Act, PL 98-369,
AFDC income and resource
§2361, PL 99-272,
requirements.
§9511, PL 100-203,
§4101.

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Appendix CAppendix B

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M
3

4

5

6

DESCRIPTION

CFR/PL CITATIONS

Children of individuals who are
ineligible for AFDC-related Medicaid
because of requirements that do not
apply under title XIX.
Children of individuals who would be
eligible for Medicaid under §1931 of
the Act (Low income families with
children) except for the 7/1/72 (PL 92325) OASDI increase and were entitled
to OASDI and received cash assistance
in 8/72.
Children whose mothers were eligible
for Medicaid at the time of childbirth,
and are deemed eligible for one year
from birth as long as the mother
remained eligible, or would have if
pregnant, and the child remains in the
same household as the mother.
Children of aliens who are not lawful,
permanent residents or who do not
have PRUCOL status, but who are
otherwise qualified, and who require
emergency care.

42 CFR 435.113.

December 2020v4.0.0

42 CFR 435.114.

42 CFR 435.117,
§1902(e)(4) of the
Act, PL 98-369,
§2362.

PL 99-509, §9406.

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Appendix CAppendix B

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M
7

8

9

10

11

DESCRIPTION

CFR/PL CITATIONS

Children who meet income and
resource requirements for AFDC, SSI,
or an optional State supplement

42 CFR 435.210,
§1902(a)(10)(A)(ii)
and §1905 of the Act.

Children who would be eligible for
AFDC, SSI, or an optional State
supplement if not in a medical
institution.

42 CFR 435.211,
§1902(a)(10)(A)(ii)
and §1905(a) of the
Act.

Children who have become ineligible
who are enrolled in a qualified HMO
or "§1903(m)(2)(G) entity" that has a
risk contract.

42 CFR 435.212,
§1902(e)(2) of the
Act, PL 99-272,
§9517, PL 100-203,
§4113(d).

Children of individuals who elect to
receive hospice care, and who would
be eligible if in a medical institution.
Children who would be eligible for
AFDC if work-related child care costs
were paid from earnings rather than
received as a State service.

§1902(a)(10)(A)(ii)(VII
), PL 99-272, §9505.

December 2020v4.0.0

42 CFR 435.220.

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12

DESCRIPTION

CFR/PL CITATIONS

Children of individuals who would be
eligible for AFDC if the State used the
broadest allowable AFDC criteria.

42 CFR 435.223,
§§1902(a)(10)(A)(ii)
and 1905(a) of the
Act.

Children who solely because of
42 CFR 435.217,
13
coverage under a home and
§1902(a)(10)(A)(ii)(VI)
community based waiver, are not in a
of the Act.
medical institution, but who would be
eligible if they were.
Children not described in
§§1902(a)(10)(A)(ii)
14 §1902(a)(10)(A)(I) of the Act, "Ribikoff and 1905(a)(I) of the
Kids", who meet AFDC income and
Act, PL 97-248, §137.
resource requirements, and are under
a State-established age (18-21).

MAS/BOE - OTHER ELIGIBLES – ADULTS MSIS Coding (MAS-4, BOE-5)
ITE
DESCRIPTION
CFR/PL CITATIONS
M
Families receiving up to 12 months of §1925 of the Act, PL
1 extended Medicaid benefits (if eligible
100-485, §303.
on or after 4/1/90).
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ITE
M
2

3

4

5

DESCRIPTION

CFR/PL CITATIONS

Qualified pregnant women whose
pregnancies have been medically
verified and who meet the State's
AFDC income and resource
requirements.

§§1902(a)(10)(A)(I)(III
) and 1905(n) of the
Act, PL 98-369,
§2361, PL 99-272,
§9511, PL 100-203
§4101.

Adults who are ineligible for AFDCrelated Medicaid because of
requirements that do not apply under
title XIX.
Adults who would be eligible for
Medicaid under §1931 of the Act (Low
income families with children) except
for the 7/1/72 (PL 92-325) OASDI
increase; and were entitled to OASDI
and received cash assistance in 8/72.
Women who were eligible while
pregnant, and are eligible for family
planning and pregnancy related
services until the end of the month in
which the 60th day occurs after the
pregnancy

42 CFR 435.113.

December 2020v4.0.0

42 CFR 435.114.

§1902(e)(5) of the
Act, PL 98-369, PL
100-203, §4101, PL
100-360, §302(e).

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Appendix CAppendix B

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6

7

8

9

DESCRIPTION

CFR/PL CITATIONS

Adult aliens who are not lawful,
permanent residents or who do not
have PRUCOL status, but who are
otherwise qualified, and who require
emergency care.
Adults who meet the income and
resource requirements for AFDC, SSI,
or an optional State Supplement.

PL 99-509, §9406.

42 CFR 435.210,
§§1902(a)(10)(A)(ii)
and 1905 of the Act.

Adults who would be eligible for AFDC,
SSI, or an optional State Supplement if
not in a medical institution.

42 CFR 435.211,
§§1902(a)(10)(A)(ii)
and 1905(a) of the
Act.

Adults who have become ineligible
who are enrolled in a qualified HMO
or "§1903(m)(2)(G) entity" that has a
risk contract.

42 CFR 435.212,
§1902(e)(2)(A) of the
Act, PL 99-272,
§9517, PL 100-203,
§4113(d).

Adults who solely because of coverage
42 CFR 435.217,
10 under a home and community based §1902(a)(10)(A)(ii)(VI)
waiver, are not in a medical
of the Act.
institution, but who would be eligible
if they were.
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Appendix CAppendix B

ITE
M
11

DESCRIPTION

CFR/PL CITATIONS

Adults who elect to receive hospice
care, and who would be eligible if in a
medical institution.

§1902(a)(10)(A)(ii),
(VII); PL 99-272,
§9505.

Adults who would be eligible for AFDC
12 if work-related child care costs were
paid from earnings rather than
received as a State service.
Pregnant women who have been
13
granted presumptive eligibility.
Adults who would be eligible for AFDC
14
if the State used the broadest
allowable AFDC criteria.

42 CFR 435.220.

§§1902(a)(47) and
1920 of the Act, PL
99-509, §9407.
42 CFR 435.223,
§§1902(a)(10)(A)(ii)
and 1905(a) of the
Act.

MAS/BOE - OTHER ELIGIBLES - FOSTER CARE CHILDREN MSIS Coding
(MAS-4, BOE-8)

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Appendix CAppendix B

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1

2

DESCRIPTION

CFR/PL CITATIONS

Children for whom the State makes
adoption assistance or foster care
maintenance payments under Title IVE.
Children with special needs covered by
State foster care payments or under a
State adoption assistance agreement
which does not involve Title IV-E.
Children leave foster care due to age.

42 CFR 435.145,
§1902(a)(10)(A)(i)(I)
of the Act.

3

§1902(a)(10)(A)(ii)
(VIII) of the Act, PL
99-272, §9529.
Foster Care
Independence Act of
1999.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-1)
ITE
DESCRIPTION
CFR/PL CITATION
M
Aged individuals made eligible under §1115(a)(1), (a)(2) &
1 the authority of a §1115 waiver due to
(b)(1) of the Act,
poverty-level related eligibility
§1902(a)(10), and
expansions.
§1903(m) of the Act.

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Appendix CAppendix B

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-2)
ITE
DESCRIPTION
CFR/PL CITATION
M
Blind and/or disabled individuals made §1115(a)(1), (a)(2) &
1 eligible under the authority of a §1115
(b)(1) of the Act,
waiver due to poverty-level-related
§1902(a)(10), and
eligibility
§1903(m) of the Act.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-4)
ITE
DESCRIPTION
CFR/PL CITATION
M
Children made eligible under the
§1115(a)(1), (a)(2) &
1
authority of a §1115 waiver due to
(b)(1) of the Act,
poverty-level-related eligibility
§1902(a)(10), and
expansions.
§1903(m) of the Act.

MAS/BOE - SECTION 1115 DEMONSTRATION MEDICAID EXPANSION
MSIS Coding (MAS-5, BOE-5)

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Appendix CAppendix B

ITE
M
1

DESCRIPTION

CFR/PL CITATION

Caretaker relatives, pregnant women §1115(a)(1) and (a)(2)
and/or adults without dependent
of the Act,
children made eligible under the
§1902(a)(10),
authority of at §1115 waiver due to
§1903(m).
poverty-level-related eligibility
expansions.

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Appendix DC

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Appendix D

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Appendix DAppendix D

Appendix D: Types of Service (TOS) Reference
Definitions of Types of Service
The following definitions are adaptations of those given in theType of Service values are predominantly defined
in the Code of Federal Regulations (CFR). These definitions, although abbreviated, are intendedClarification is of
the definitions are provided herebelow to facilitate aid in the classification of medical care and services for T-MSIS
reporting purposes. They do not modify any requirements of the Social Security Act or supersede in any way the
definitions included in the Code of Federal Regulations (CFR).
Effective FY 1999, services provided under Family Planning, EPSDT, Rural Health Clinics, FQHC’s, and Home-andCommunity-Based Waiver programs will be coded according to the types of services listed below. Specific
programs with which these services are associated will be identified using the program type coding as defined in
Attachment 5.
1. Unduplicated Total.--Report the unduplicated total of recipients by maintenance assistance status (MAS) and
by basis of eligibility (BOE). A recipient receiving more than one type of service is reported only once in the
unduplicated total.

Institutional Inpatient Facilityies Services
2.1. Inpatient Hospital Services (TOS Code=001)(See 42 CFR 440.10; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR
§ 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--) include services referenced in the following
regulatory contexts:These are services that are:


Ordinarily furnished in a hospital for the care and treatment of inpatients;



Furnished under the direction of a physician or dentist (except in the case of nurse-midwife services per
42 CFR 440.165); and



Furnished in an institution that:
-

Is maintained primarily for the care and treatment of patients with disorders other than mental health
conditions;

-

Is licensed or formally approved as a hospital by an officially designated authority for State standard
setting;

-

Meets the requirements for participation in Medicare (except in the case of medical supervision of
nurse-midwife services per 42 CFR 440.165); and

-

Has in effect a utilization review plan applicable to all Medicaid patients that meets the requirements
in 42 CFR 482.30 unless a waiver has been granted by the Secretary of Health and Human Services.

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Appendix DAppendix D
Inpatient hospital services do not include nursing facility services furnished by a hospital with swing-bed
approval. However, include services provided in a psychiatric wing of a general hospital if the psychiatric wing
is not administratively separated from the general hospital.
Mental Health Facility Services (See 42 CFR 440.140, 440.160, and 435.1009).-Term
Description
Inpatient hospital services, other than services in an 42 CFR § 440.10
institution for mental diseases
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage.
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: Inpatient hospital services do not include nursing facility services furnished by a hospital with swing-bed
approval. However, include services provided in a psychiatric wing of a general hospital if the psychiatric wing is
not administratively separated from the general hospital.
3.2. Mental Health Facility Services (See 42 CFR 440.140, 440.160, and 435.1009).--An institution for mental
health conditions is a hospital, nursing facility, or other institution that is primarily engaged in providing
diagnosis, treatment or care of individuals with mental health conditions, including medical care, nursing
care, and related services. Report totals for services defined under 3a and 3b.
a. 3a.
Inpatient Psychiatric Facility Services for Individuals Age 21 and Under (TOS Code=048)(See 42
CFR 440.160; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR
§ 457.450). --) include services referenced in the following regulatory contexts:. These are services that:


Are provided under the direction of a physician;



Are provided in a psychiatric facility or inpatient program accredited by the Joint Commission on the
Accreditation of Hospitals; and,



Meet the requirements set forth in 42 CFR Part 441, Subpart D (inpatient psychiatric services for
individuals age 21 and under in psychiatric facilities or programs).

Term
Inpatient psychiatric services for individuals under
age 21
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent cover
coverage.
Existing comprehensive State-based coverage
Secretary-approved coverage
December 2020v4.0.0

Description
42 CFR § 440.160
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450
63

Appendix DAppendix D
b. 3b. Other Mental Health Facility Services (Individuals Age 65 or Older) (TOS Code= 044 and
045)(See 42 CFR 440.140).--) include services referenced in the following regulatory context: These
are services provided under the direction of a physician for the care and treatment of recipients in
an institution for mental health conditions that meets the requirements specified in 42 CFR 440.140.
Term
Inpatient hospital services, nursing facility
services, and intermediate care facility services for
individuals ageaged 65 or older in institutions for
mental diseases

Description
42 CFR 440.140

4.3. Nursing Facilities (NF) Services (TOS Code=009 and 047)(See 42 CFR 440.40 and 440.155).--) include services
referenced in the following regulatory contexts:These are services provided in an institution (or a distinct
part of an institution) which: 1




Is primarily engaged in providing to residents:
-

Skilled nursing care and related services for residents who require medical or nursing care;

-

Rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or

-

On a regular basis, health-related care and services to individuals who, because of their mental or
physical condition, require care and services (above the level of room and board) which can be made
available to them only through institutional facilities, and is not primarily for the care and treatment
of mental health conditions; and;

Meet the requirements for a nursing facility described in subsections 1919(b), (c), and (d) of the Act
regarding:
-

Requirements relating to provision of services;

-

Requirements relating to residents’ rights; and

-

Requirements relating to administration and other matters.

NOTE: ICF Services - All Other.--This is combined with nursing facility services.
Term
Nursing facility services for individuals ageaged 21 or
older (other than services in an institution for mental
disease), EPSDT, and family planning services and
supplies

1

Description
42 CFR § 440.40

ICF Services - All Other.--This is combined with nursing facility services.

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Appendix DAppendix D
Term
Description
Nursing facility services, other than in institutions for 42 CFR § 440.155
mental diseases
NOTE: ICF Services for individuals without intellectual disabilities-. --This is combined with nursing facility
services.
5.4. ICF Services for the Individuals with Intellectually Disabilitiesled (TOS Code=046) (See 42 CFR 440.150).--42
CFR 440.150)include services referenced in the following regulatory context:.--These are services provided in
an institution for individuals with intellectual disabilities persons or persons with related conditions if the:


Primary purpose of the institution is to provide health or rehabilitative services to such individuals;



Institution meets the requirements in 42 CFR 442, Subpart C (certification of ICF/IID); and



The individuals with intellectual disabilities recipients for whom payment is requested are receiving active
treatment as defined in 42 CFR 483.440(a).
Term
Description
Intermediate care facility (ICF/IID) services
42 CFR 440.150

Institutional Outpatient Facility Services
5. Outpatient Hospital Services (TOS Codes=002) include services referenced in the following regulatory
contexts:
Term
Description
Outpatient hospital services and rural health clinic
42 CFR § 440.20
services
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450

Practitioner Services
6. Physicians' Services (TOS Code=012) (See 42 CFR 440.50; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR §
457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450) include services referenced in the following
regulatory contexts:.--Whether furnished in a physician's office, a recipient's home, a hospital, a NF, or
elsewhere, these are services provided:


Within the scope of practice of medicine or osteopathy as defined by State law; and

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Appendix DAppendix D


By, or under, the personal supervision of an individual licensed under State law to practice medicine or
osteopathy, or dental medicine or dental surgery if State law allows such services to be provided by either
a physician or dentist.

Term
Description
Physicians' services and medical and surgical services 42 CFR § 440.50
of a dentist.Outpatient hospital services and rural
health clinic services
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: These services may be provided in a physician’s office, a recipient’s home, a hospital, a nursing facility, or
elsewhere.
Term
Dental services
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent coverage
Existing comprehensive State-based coverage
Secretary-approved coverage

Description
42 CFR § 440.100
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

7. Dental Services (TOS Code=029) include services referenced in the following regulatory contexts:
Term
Description
Dental services
42 CFR § 440.100
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450

NOTE: Include services related to providing and fitting dentures as dental services. Dentures mean artificial
structures made by, or under the direction of, a dentist to replace a full or partial set of teeth.
Dental services do not include services provided as part of inpatient hospital, outpatient hospital, non-dental
clinic, or laboratory services and billed by the hospital, non-dental clinic, or laboratory or services which meet
the requirements of 42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or
physician under State law).
8. Other Licensed Practitioners' Services (TOS Code=015) include services referenced in the following
regulatory contexts:
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Term
Medical or other remedial care provided by licensed
NOTE: The
practitioners
category “Other
Definition of child health assistance
Licensed
Benchmark health benefits coverage
Practitioners'
Benchmark-equivalent health benefits coverage
Services” is
Actuarial report for benchmark-equivalent coverage
different than the
Existing comprehensive State-based coverage
“Other Care”
Secretary-approved coverage
category. Examples of other practitioners (if covered under State law) are:

Description
42 CFR § 440.60
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

 Chiropractors;
 Podiatrists;
 Psychologists; and
 Optometrists.
Other Licensed Practitioners' Services include hearing aids and eyeglasses only if they are billed directly by the
professional practitioner. If billed by a physician, they are reported as Physicians' Services. Otherwise, report
them under Other Care.
Other Licensed Practitioners' Services do not include prosthetic devices billed by physicians, laboratory or Xray services provided by other practitioners, or services of other practitioners that are included in inpatient
or outpatient hospital bills. These services are counted under the related type of service as appropriate.
Devices billed by providers not included under the listed types of service are counted under Other Care.
Report Other Licensed Practitioners' Services that are billed by a hospital as inpatient or outpatient services,
as appropriate.
Speech therapists, audiologists, opticians, physical therapists, and occupational therapists are not included
within Other Licensed Practitioners' Services.
Chiropractors' services include only services that are provided by a chiropractor (who is licensed by the State)
and consist of treatment by means of manual manipulation of the spine that the chiropractor is legally
authorized by the State to perform.
9. Clinic Services (TOS Code=028) include services referenced in the following regulatory contexts:
Term
Description
Clinic services
42 CFR § 440.90
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: For reporting purposes, consider a group of physicians who share, only for mutual convenience, space,
services of support staff, etc., as physicians, rather than a clinic, even though they practice under the name of
the clinic.
Report dental clinic services as dental services.
Report any services not included above under other care.
Clinic staff may include practitioners with different specialties.
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Appendix DAppendix D

10. Laboratory and X-Ray Services (TOS Code=005, 006, 007, and 008) include services referenced in the
following regulatory contexts:
Term
Description
Other laboratory and X-ray services
42 CFR § 440.30
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
7. NOTE: X-ray services provided by dentists are reported under dental services.Outpatient Hospital Services (TOS
Codes=002) (See 42 CFR 440.20; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431;
457.440; 42 CFR § 457.450).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative services
that are furnished:


To outpatients;



Except in the case of nurse-midwife services (see 42 CFR 440.165), under the direction of a physician or
dentist; and



By an institution that:
-

Is licensed or formally approved as a hospital by an officially designated authority for State standard
setting; and

-

Except in the case of medical supervision of nurse midwife services (see 42 CFR 440.165), meets the
requirements for participation in Medicare as a hospital.

Term
Description
Outpatient hospital services and rural health clinic
services
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent coverage
Existing comprehensive State-based coverage
Secretary-approved coverage
8. Prescribed Drugs (TOS Code=033) (See 42 CFR 440.120; 42 CFR § 457.402; 42 CFR § 457.410; 42 CFR § 457.420;
42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--These are simple or compound substances or
mixtures of substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance
that are:

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Appendix DAppendix D


Prescribed by a physician or other licensed practitioner within the scope of professional practice as defined
and limited by Federal and State law;



Dispensed by licensed pharmacists and licensed authorized practitioners in accordance with the State Medical
Practice Act; and



Dispensed by the licensed pharmacist or practitioner on a written prescription that is recorded and maintained
in the pharmacist's or practitioner’s records.

Term
Description
Prescribed drugs, dentures, prosthetic devices, and
eyeglasses
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent coverage
Existing comprehensive State-based coverage
Secretary-approved coverage
Health benefits coverage options
42 CFR § 457.410
9. Dental Services (TOS Code=029) (See 42 CFR 440.100; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42
CFR § 457.431; 457.440; 42 CFR § 457.450).--These are diagnostic, preventive, or corrective procedures provided
by or under the supervision of a dentist in the practice of his or her profession, including treatment of:2


The teeth and associated structures of the oral cavity; and



Disease, injury, or an impairment that may affect the oral or general health of the recipient.

A dentist is an individual licensed to practice dentistry or dental surgery. Dental services include dental screening
and dental clinic services.
NOTE: Include services related to providing and fitting dentures as dental services. Dentures mean artificial
structures made by, or under the direction of, a dentist to replace a full or partial set of teeth.
Dental services do not include services provided as part of inpatient hospital, outpatient hospital, non-dental
clinic, or laboratory services and billed by the hospital, non-dental clinic, or laboratory or services which meet the
requirements of 42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or
physician under State law).

2

Include services related to providing and fitting dentures as dental services. Dentures mean artificial structures made
by, or under the direction of, a dentist to replace a full or partial set of teeth.
Dental services do not include services provided as part of inpatient hospital, outpatient hospital, non-dental clinic, or
laboratory services and billed by the hospital, non-dental clinic, or laboratory or services which meet the requirements
of 42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or physician under State law).
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Appendix DAppendix D

Other Services

Other Licensed Practitioners' Services (TOS Code=015)(See 42
CFR 440.60; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430;
42 CFR § 457.431; 457.440; 42 CFR § 457.450).--) These are medical
or remedial care or services, other than physician services or services
of a dentist, provided by licensed practitioners within the scope of
practice as defined under State law. The category “Other Licensed
Practitioners' Services” is different than the “Other Care” category.
Examples of other practitioners (if covered under State law) are:
10.



Chiropractors;



Podiatrists;



Psychologists; and



Optometrists.

Other Licensed Practitioners' Services include hearing aids and
eyeglasses only if they are billed directly by the professional
practitioner. If billed by a physician, they are reported as Physicians'
Services. Otherwise, report them under Other Care.
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Appendix DAppendix D

Other Licensed Practitioners' Services do not include prosthetic
devices billed by physicians, laboratory or X-ray services provided by
other practitioners, or services of other practitioners that are
included in inpatient or outpatient hospital bills. These services are
counted under the related type of service as appropriate. Devices
billed by providers not included under the listed types of service are
counted under Other Care.

Report Other Licensed Practitioners' Services that are billed by a
hospital as inpatient or outpatient services, as appropriate.

Speech therapists, audiologists, opticians, physical therapists, and
occupational therapists are not included within Other Licensed
Practitioners' Services.

Chiropractors' services include only services that are provided by a
chiropractor (who is licensed by the State) and consist of treatment
by means of manual manipulation of the spine that the chiropractor
is legally authorized by the State to perform.

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Appendix DAppendix D

Clinic Services (TOS Code=028(See 42 CRF 440.90; 42 CFR §
457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431;
457.440; 42 CFR § 457.450).--) Clinic services include preventive,
diagnostic, therapeutic, rehabilitative, or palliative items or services
that are provided:3
11.



To outpatients;

By a facility that is not part of a hospital but is organized and
operated to provide medical care to outpatients including services
furnished outside the clinic by clinic personnel to individuals without
a fixed home or mailing address. For reporting purposes, consider a
group of physicians who share, only for mutual convenience, space,
services of support staff, etc., as physicians, rather than a clinic, even
though they practice under the name of the clinic; and
Except in the case of nurse-midwife services (see 42 CFR
440.165), are furnished by, or under, the direction of a physician.


NOTE: Place dental clinic services under dental services. Report
any services not included above under other care. A clinic staff may
include practitioners with different specialties.

Place dental clinic services under dental services. Report any services not included above under other care. A clinic staff
may include practitioners with different specialties.
3

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Appendix DAppendix D

Laboratory and X-Ray Services (TOS Code=005, 006, 007, and
008) (See 42 CFR 440.30; 42 CFR § 457.402; 42 CFR § 457.420; 42
CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).-These are professional or technical laboratory and radiological
services that are:
12.

Ordered and provided by or under the direction of a physician
or other licensed practitioner of the healing arts within the scope of
his or her practice as defined by State law or ordered and billed by a
physician but provided by referral laboratory


Provided by a laboratory that meets the requirements for
participation in Medicare.


X-ray services provided by dentists are reported under dental
services.


Prescribed Drugs (TOS Code=033) include services referenced in the following regulatory contexts:
Term
Prescribed drugs, dentures, prosthetic devices, and 42 CFR § 440.120
eyeglasses
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Appendix DAppendix D
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
Health benefits coverage options
13. Sterilizations (TOS Code=084) (See 42 CFR 441, Subpart F).-- include services referenced in the following
statutory contexts:These are medical procedures, treatment or operations for the purpose of rendering an
individual permanently incapable of reproducing.
Term
Description
Sterilizations
42 CFR § 441, Subpart F
14. Home Health Services (TOS Code=016,017, 018, 019, 020, and 021) (See 42 CFR 440.70; 42 CFR § 457.402; 42
CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--These are services
provided at the patient's place of residence, in compliance with a physician's written plan of care that is
reviewed every 62 days. The following items and services are mandatory.


Nursing services, as defined in the State Nurse Practice Act that is provided on a part-time or intermittent
basis by a home health agency (a public or private agency or organization, or part of any agency or
organization that meets the requirements for participation in Medicare). If there is no agency in the area,
a registered nurse who:
-

Is licensed to practice in the State;

-

Receives written orders from the patient's physician;

-

Documents the care and services provided; and

-

Has had orientation to acceptable clinical and administrative record keeping from a health
department nurse;



Home health aide services provided by a home health agency; and



Medical supplies, equipment, and appliances suitable for use in the home.

The following therapy services are optional: physical therapy, occupational therapy, or speech pathology and
audiology services provided by a home health agency or by a facility licensed by the State to provide these
medical rehabilitation services. (See 42 CFR 441.15.)
Place of residence is normally interpreted to mean the patient's home and does not apply to hospitals or NFs.
Services received in a NF that are different from those normally provided as part of the institution's care may
qualify as home health services. For example, a registered nurse may provide short-term care for a recipient
in a NF during an acute illness to avoid the recipient's transfer to another NF.
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Appendix DAppendix D
Term
Other laboratory and X-ray services
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent coverage
Existing comprehensive State-based coverage
Secretary-approved coverage

Description

Personal Care and Home Health Services
11. Home Health Services (TOS Code=016,017, 018, 019, 020, and 021) include services referenced in the
following regulatory contexts:
Term
Description
Other laboratory and X-ray services
42 CFR § 440.70
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent coverage
42 CFR § 457.431
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450

15.12. Personal Support Services.--Report total unduplicated recipients and payments for services defined in
15a through 15i.
a. 15a. Personal Care Services (TOS Code=051)(See 42 CFR 440.167).--These are services furnished to an
individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for
individuals with intellectual disabilities, or institution for mental health conditions that are: include
services referenced in the following regulatory contexts:


Authorized for the individual by a physician in accordance with a plan of treatment or (at the option of
the State) otherwise authorized for the individual in accordance with a service plan approved by the State;
and



Provided by an individual who is qualified to provide such services and who is not a member of the
individual’s family.
Term

Personal care services

Description
42 CFR § 440.167

b. 15b. Targeted Case Management Services (TOS Code=053)(See 42 CFR § 440.169; 42 CFR § 457.402; 42
CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--) include services
referenced in the following regulatory contexts:These are services that are furnished to individuals
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Appendix DAppendix D
eligible under the plan to gain access to needed medical, social, educational, and other services. The
agency may make available case management services to:


Specific geographic areas within a State, without regard to statewide requirement in 42 CFR 431.50; and



Specific groups of individuals eligible for Medicaid, without regard to the comparability requirements in
42 CFR 440.240.

The agency must permit individuals to freely choose any qualified Medicaid provider except when obtaining
case management services in accordance with 42 CFR 431.51.
Term
Case management servicesOther laboratory and
X-ray services
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage

Description
42 CFR § 440.169
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

c. 15c. Rehabilitative Services (TOS Code=043)(See 42 CFR 440.130).--)--These include any medical or
remedial services recommended by a physician or other licensed practitioner of the healing arts within
the scope of his/her practice under State law for maximum reduction of physical or mental health
condition and restoration of a recipient to his/her best possible functional level. include services
referenced in the following regulatory context:
Term
Diagnostic, screening, preventive, and
rehabilitative services

Description
42 CFR 440.130

d. 15d. Physical Therapy, Occupational Therapy, and Services For Individuals Withwith Speech, Hearing,
and Language Disorders (TOS Codes=030, 031, and 032)(See 42 CFR 440.110; 42 CFR § 457.402; 42 CFR
§ 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--). These are services
prescribed by a physician or other licensed practitioner within the scope of his or her practice under
State law and provided to a recipient by, or under the direction of, a qualified physical therapist,
occupational therapist, speech pathologist, or audiologist. It includes any necessary supplies and
equipment. include services referenced in the following regulatory contexts:
Term
Physical therapy, occupational therapy, and
services for individuals with speech, hearing, and
language disordersOther laboratory and X-ray
services
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Description
42 CFR § 440.110

76

Appendix DAppendix D
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage

42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

e. 15e. Hospice Services (TOS Code=087) include services referenced in the following regulatory contexts:
(See 42 CFR 418.202; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440;
42 CFR § 457.450).--Whetherwhether received in a hospice facility or elsewhere, these are services that
are:
 Furnished to a terminally ill individual, as defined in 42 CFR 418.3;


Furnished by a hospice, as defined in 42 CFR 418.3, that meets the requirements for participation in
Medicare specified in 42 CFR 418, Subpart C or by others under an arrangement made by a hospice
program that meets those requirements and is a participating Medicaid provider; and



Furnished under a written plan that is established and periodically reviewed by:
-

The attending physician;

-

The medical director or physician designee of the program, as described in 42 CFR 418.54; and

-

The interdisciplinary group described in 42 CFR 418.68.

Term
Other laboratory and X-ray servicesHospice care
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage
f.

Description
SSA §1905(o) 42 CFR § 418.202
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

15f. Nurse Midwife (TOS Code=025) (See 42 CFR 440.165; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR §
457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450) include services referenced in the following
regulatory contexts:.--These are services that are concerned with management and the care of mothers
and newborns throughout the maternity cycle and are furnished within the scope of practice authorized
by State law or regulation.

Term
Description
Nurse-midwife serviceOther laboratory and X-ray 42 CFR § 440.165
services
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Appendix DAppendix D
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage

42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

Nurse Practitioner (TOS Code=026) include services referenced in the following regulatory contexts:
g.
15g. Nurse Practitioner (TOS Code=026) (See 42 CFR 440.166; 42 CFR § 457.402; 42 CFR § 457.420; 42
CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--). These are services furnished by a
registered
a.
professional nurse who meets State’s advanced educational and clinical practice requirements,
if any, beyond the 2 to 4 years of basic nursing education required of all registered nurses.
Term
Nurse practitioner services
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage

Description
42 CFR § 440.166
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

h. 15h. Private Duty Nursing (TOS Code=022) (See 42 CFR 440.80; 42 CFR § 457.402; 42 CFR § 457.420; 42
CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--) include services referenced in the
following regulatory contexts:. When covered in the State plan, these are services of registered nurses
or licensed practical nurses provided under direction of a physician to recipients in their own homes,
hospitals or nursing facilities (as specified by the State).
Term
Private duty nursing services
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
Secretary-approved coverage
i.

Description
42 CFR § 440.80
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
42 CFR § 457.450

15i. Religious Non-Medical Health Care Institutions (TOS Code=058) (See 42 CFR 440.170).--) include
services referenced in the following regulatory context:. These are non-medical health care services

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Appendix DAppendix D
equivalent to a hospital or extended care level of care provided in facilities that meet the requirements
of Section 1861(ss)(1) of the Act.
Term
Any other medical care or remedial care
recognized under State law and specified by the
Secretary

Description
See 42 CFR § 440.170

Other CareServices
13. Other CareServices
a. Prescribed Drugs (TOS Code=033) include services referenced in the following regulatory contexts:
Term
Description
Prescribed drugs, dentures, prosthetic devices,
42 CFR § 440.120
and eyeglasses
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent 42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
Health benefits coverage options
42 CFR § 457.410
b. Sterilizations (TOS Code=084) include services referenced in the following statutory contexts:
Term
Description
Sterilizations
42 CFR § 441, Subpart F
16. (See 42 CFR 440.120(b), (c), and (d), and 440.170(a)).----Report total unduplicated recipients and
payments for services in sections 16a, 16b, and 16c. Such services do not meet the definition of,
and are not classified under, any of the previously described categories.
c. 16a. Transportation (TOS Code=056) (See 42 CFR 440.170; 42 CFR § 457.402; 42 CFR § 457.420; 42
CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--) include services referenced in the
following regulatory contexts:--Report totals for services provided under this title to include
transportation and other related travel services determined necessary by you to secure medical
examinations and treatment for a recipient. 4
Term
Description
Any other medical care or remedial care
42 CFR 440.170
recognized under State law and specified by the
Secretary
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Transportation, as defined above, is furnished only by a provider to whom a direct vendor payment can appropriately be
made. If other arrangements are made to assure transportation under 42 CFR 431.53, FFP is available as an administrative
cost.
4

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Appendix DAppendix D
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
NOTE: Transportation, as defined above, is furnished only by a provider to whom a direct vendor
payment can appropriately be made. If other arrangements are made to assure transportation under
42 CFR 431.53, FFP is available as an administrative cost.

Term
NOTE:
Any other medical care or remedial care
42 CFR 440.170
Transportation,
recognized under State law and specified by the
as defined above, is Secretary
furnished only by a
Definition of child health assistance
42 CFR § 457.402
provider to whom a
Benchmark health benefits coverage
42 CFR § 457.420
direct
vendor
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
payment
can
Actuarial report for benchmark-equivalent 42 CFR § 457.431
appropriately
be
coverage
made.
If other
Existing comprehensive State-based coverage
42 CFR § 457.440
arrangements
are
42 CFR § 457.450
made
to
assure Secretary-approved coverage
transportation under 42 CFR 431.53, FFP is available as an administrative cost.

Description

d. 16b. Other Pregnancy-related Procedures (TOS Code=086) (See 42 CFR 441, Subpart E; 42 CFR §
457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431; 457.440; 42 CFR § 457.450).--). In
accordance with the terms of the DHHS Appropriations Bill and 42 CFR 441, Subpart E, FFP is
available for other pregnancy-related procedures: include services referenced in the following
regulatory contexts:


When a physician has certified in writing to the Medicaid agency that, on the basis of his or her
professional judgment, the life of the mother would be endangered if the fetus were carried to term; or



When the other pregnancy-related procedure is performed to terminate a pregnancy resulting from an
act of rape or incest. FFP is not available for the other pregnancy-related procedure under any other
circumstances.

Term
Abortions
Definition of child health assistance
Benchmark health benefits coverage
Benchmark-equivalent health benefits coverage
Actuarial report for benchmark-equivalent
coverage
Existing comprehensive State-based coverage
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Description
42 CFR Subpart E
42 CFR § 457.402
42 CFR § 457.420
42 CFR § 457.430
42 CFR § 457.431
42 CFR § 457.440
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Appendix DAppendix D
Secretary-approved coverage

42 CFR § 457.450

e. 16c. OtherOther Services – Continued (TOS Code= 035, 036, 037, 062, 063, 064, 065, 066, 067, 068,
069, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083).--). These services do not meet the
definitions of any of the previously described service categories. These include, but are not limited
to services referenced in the following regulatory contexts:They may include, but are not limited to:

Prosthetic devices (see 42 CFR 440.120; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR §
457.431; 457.440; 42 CFR § 457.450)Prosthetic devices, which are replacement, corrective, or supportive devices
prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as defined
by State law to:
-

Artificially replace a missing portion of the body;

-

Prevent or correct physical deformity or malfunctions; or

-

Support a weak or deformed portion of the body.



Eyeglasses (see 42 CFR 440.120; 42 CFR § 457.402; 42 CFR § 457.420; 42 CFR § 457.430; 42 CFR § 457.431;
457.440; 42 CFR § 457.450). Eyeglasses mean lenses, including frames, and other aids to vision prescribed
by a physician skilled in diseases of the eye or an optician. It includes optician fees for services.



Home and Community-Based Waiver services (See §1915(c) of the Act and 42 CFR 440.180) that cannot
be associated with other TYPE-OF-SERVICE codes (e.g., community homes for the disabled and adult day
care.)

Term
Description
Prescribed drugs, dentures, prosthetic devices,
42 CFR § 440.120
and eyeglasses
Definition of child health assistance
42 CFR § 457.402
Benchmark health benefits coverage
42 CFR § 457.420
Benchmark-equivalent health benefits coverage
42 CFR § 457.430
Actuarial report for benchmark-equivalent
42 CFR § 457.431
coverage
Existing comprehensive State-based coverage
42 CFR § 457.440
Secretary-approved coverage
42 CFR § 457.450
17. Capitated Care (See 42 CFR Part 434).----This includes enrollees and capitated payments for the plan types
defined in 17a and b below. Report unduplicated enrolled eligibleseligible and payments for 17a and b.
Term
CONTRACTS

Description
42 CFR Part 434

17a. Health Maintenance Organization (HMO) and Health Insuring Organization (HIO) (TOS Code=119).-These include plans contracted to provide capitated comprehensive services. An HMO is a public or private
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Appendix DAppendix D
organization that contracts on a prepaid capitated risk basis to provide a comprehensive set of services and
is federally qualified or State-plan defined. An HIO is an entity that provides for or arranges for the provision
of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.
17b. Prepaid Health Plans (PHP) (TOS Code=122).--These include plans that are contracted to provide less
than comprehensive services. Under a non-risk or risk arrangement, the State may contract with (but not
limited to these entities) a physician, physician group, or clinic for a limited range of services under capitation.
A PHP is an entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis
or the entity provides comprehensive services on a non-risk basis.5
NOTE: Include dental, mental health, and other plans covering limited services under PHP.
18. Primary Care Case Management (PCCM) (TOS Code=120) (See §1915(b)(1) of the Act).--)--The State contracts
directly with primary care providers who agree to be responsible for the provision and/or coordination of
medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary
care physician a monthly case management fee. Report these recipients and associated PCCM fees in this
section.6
NOTE: Where the fee includes services beyond case management, report the enrollees and fees under
prepaid health plans (17b).
Term
Primary Care Case Management

Description
See §1915(b)(1) of the Act

19.14. COVID-19 Testing (See §1902(a)(10)(G) of the act). --This includes in vitro diagnostic products for the
detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, and any visit for COVID–19
testing-related services for which payment may be made under the State plan.
a. 19a. COVID-19 Testing (TOS Code= 136) should be reported for any COVID-19 diagnostic product
that is administered during any portion of the emergency period, beginning March 18, 2020, to an
uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testingrelated services.
a. 19b. COVID-19 Testing-Related Services (TOS Code= 137) should be reported for any COVID–19
testing-related services provided to an uninsured individual who receives limited Medicaid coverage
for COVID-19 testing and testing-related services for which payment may be made under the State
plan.

5

Include dental, mental health, and other plans covering limited services under PHP.
Where the fee includes services beyond case management, report the enrollees and fees under prepaid health plans
(17b).
6

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Appendix DAppendix D
20.
21.
22.
23.

Per member per month (PMPM) payments for health home services (TOS 138)
Per member per month (PMPM) payments for Medicare Part A premiums (TOS 139)
Per member per month (PMPM) payments for Medicare Part B premiums (TOS 140)
Per member per month (PMPM) payments for Medicare Advantage Dual Special Needs Plans (D-SNP) –
Medicare Part C (TOS 141)
24. Per member per month (PMPM) payments for Medicare Part D premiums (TOS 142)
25. Per member per month (PMPM) payments for other payments (TOS 143)
26. Payments to individuals for personal assistance services under 1915(j) (TOS 144)
16. Medication Assisted Treatment (MAT) services and drugs for evidenced-based treatment of Opioid Use
Disorder (OUD) (TOS Code=145) include services referenced in the following regulatory context:( of the
Social Security Act) Effective October 1, 2020, state Medicaid programs are required to provide coverage of
Medication Assisted Treatment (MAT) services and drugs under a new mandatory benefit. The SUPPORT Act
of 2018 (P.L. 115-271) amended the Social Security Act (the Act) to add this new mandatory benefit. The
purpose of the new mandatory MAT benefit found at section 1905(a)(29) of the Act is to increase access to
evidenced-based treatment for Opioid Use Disorder (OUD) for all Medicaid beneficiaries and to allow
patients to seek the best course of treatment and particular medications that may not have been previously
covered. CMS interprets sections 1905(a)(29) and 1905(ee) of the Act to require that, as of October 1, 2020,
states must include as part of the new MAT mandatory benefit all forms of drugs and biologicals that the
Food and Drug Administration (FDA) has approved or licensed for MAT to treat OUD. More specifically,
under the new mandatory MAT benefit, states are required to cover such FDA approved or licensed drugs
and biologicals used for indications for MAT to treat OUD. States currently cover many of these MAT drugs
and biologicals (for all medically-accepted indications) under the optional benefit for prescribed drugs
described at section 1905(a)(12) of the Act
15.
Term
Description
Medication-assisted treatment
SSA §1905(a)(29)

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Appendix D
.

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Appendix E

Appendix E: Program Type Reference
Definitions of Program Type Reference
The following definitions describe special Medicaid/CHIP programs that are coded independently of type of
service for T-MSIS purposes. These programs tend to cover bands of services that cut across many types of service.

Program Type 1-3
Program Type 01.
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) (See 42 CFR § 440.40(b)).-This includes either general health screening services and vision, dental, and hearing services
furnished to Medicaid eligibles under age 21 to fulfill the requirements of the EPSDT program or
services rendered based on referrals from EPSDT visits. The Act specifies two sets of EPSDT
screenings:


Periodic screenings, which are provided at distinct intervals determined by the State, and which must
include the following services:
-

A comprehensive health and developmental history assessment (including assessment
of both physical and mental health development);

-

A comprehensive unclothed physical exam;

-

Appropriate immunizations according to the Advisory Committee on Immunization
Practices schedule;

- Laboratory tests (including blood lead level assessment); and
- Health education (including anticipatory guidance); and


Interperiodic screenings, which are provided when medically necessary to determine the existence of
suspected physical or mental illness or conditions.

Program Type 02.
Family Planning (See 42 CFR § 440.40(c)).-- Only items and procedures clearly provided
or performed for family planning purposes and matched at the 90 percent FFP rate should be
included as Family Planning. Services covered under this program include, but are not limited to:


Counseling and patient education and treatment furnished by medical professionals in accordance
with State law;



Laboratory and X-ray services;

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Appendix E


Medically approved methods, procedures, pharmaceutical supplies, and devices to prevent
conception;



Natural family planning methods; and



Diagnosis and treatment for infertility.

Program Type 03.
Rural Health Clinics (RHC) (See 42 CFR § 440.20(b)).--These include services (as allowed by
State law) furnished by a rural health clinic which has been certified in accordance with the conditions of 42 CFR
Part 491 (certification of certain health facilities). Services performed in RHCs include, but are not limited to:
-



Services furnished by a physician within the scope of his or her profession as defined by
State law. The physician performs these services in or away from the clinic and has an
agreement with the clinic providing that he or she will be paid for these services;

Services furnished by a physician assistant, nurse practitioner, nurse midwife, or other specialized nurse
practitioner (as defined in 42 CFR 405.2401 and 491.2) if the services are furnished in accordance with the
requirements specified in 42 CFR 405.2412(a);
o

Services and supplies provided in conjunction with professional services furnished by a physician,
physician assistant, nurse practitioner, nurse midwife, or specialized nurse practitioner. (See 42 CFR
405.2413 and 405.2415 for the criteria determining whether services and supplies are included here.);
or

o

Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and
biologicals) if:

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-

The clinic is located in an area in which the Secretary has determined that there is a
shortage of home health agencies (see 42 CFR 405.2417);

-

The services are furnished by a registered nurse or licensed practical or vocational nurse
employed, or otherwise compensated for the services, by the clinic;

-

The services are furnished under a written plan of treatment that is either established
and reviewed at least every 60 days by a supervising physician of the clinic, or that is
established by a physician, physician's assistant, nurse practitioner, nurse midwife, or
specialized nurse practitioner and reviewed and approved at least every 60 days by a
supervising physician of the clinic; and

-

The services are furnished to a homebound patient. For purposes of visiting nurse
services, a homebound recipient means one who is permanently or temporarily confined
to a place of residence because of a medical or health condition and leaves the place of
residence infrequently. For this purpose, a place of residence does not include a hospital
or nursing facility.

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Appendix E

Program Type 4-5
Program Type 04.
Federally Qualified Health Center (FQHC) (See SSA § 1905(a)(2) of the Act).--FQHCs are
facilities or programs more commonly known as community health centers, migrant health
centers, and health care for the homeless programs. A facility or program qualifies as a FQHC
providing services covered under Medicaid if:
-

They receive grants under §§329, 330, or 340 of the Public Health Service Act (PHS);

-

The Health Resources and Services Administration, PHS, certifies the center as meeting FQHC
requirements; or

-

The Secretary determines that the center qualifies through waiver of the requirements.

Services performed in FHQCs are defined the same as the services provided by rural health
clinics. They may include physician services, services provided by physician assistants, nurse
practitioners, clinical psychologists, clinical social workers, and services and supplies incident to
such services as are otherwise covered if furnished by a physician or as incident to a physician's
services. In certain cases, services to a homebound Medicaid patient may be provided. Any
other ambulatory service included in the State's Medicaid plan is considered covered by a FQHC
program if the center offers it.
Program Type 05.

Indian Health Services (See SSA §1911 of the Act) (See 42 CFR § 431.110).—

Indian Health Services (See §1911 of the Act) (See 42 CFR 431.110).--These are services provided
by a program of the Indian Health Services (IHS), tribe or tribal organization under the Indian
Self-Determination and Education Assistance Act, and an urban Indian organization under title V
of the Indian Health Care Improvement Act. A State plan must provide that an IHS, tribal or
urban facility, meeting State plan requirements for Medicaid participants, must be accepted as
a Medicaid provider on the same basis as any other qualified provider.

Program Type 6-10
Program Type 06.
Home and Community-Based Services for Disabled and Elderly (See §1929 of the Act) and
for Individuals Age 65 and Older (MSIS) (See 42 CFR 441, Subpart H).--This program is for
§1915(d) recipients of home and community-based services for individuals age 65 or older. This
is an option within the Medicaid program to provide home and community-based care to
functionally disabled individuals age 65 or older who are otherwise eligible for Medicaid or for
non-disabled elderly individuals.
Program Type 07.
Home and Community Based Waivers (See SSA § 1915(c) of the Act and 42 CFR §
440.180).--This program includes services furnished under a waiver approved under the
provisions in 42 CFR Part 441, Subpart G (home and community-based services; waiver
requirements).

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Appendix E
Program Type 08.
Money Follows Patient the Person (MFP) service package (established by Section 6071 of
Deficit Reduction Act of 2005 [Public Law 109-171] and extended by Section 2403 off the Patient
Protection and Affordable Care Act of 2010 [Public Law 111-148]). helps States rebalance their
long-term care systems through the development of transition programs that move people with
Medicaid from institutional-based long-term care to community-based long-term care. To
qualify for MFP, Medicaid recipients need to have been in institutional care for at least 90 days,
exclusive of Medicare-paid rehabilitation days. Upon the initial transition to community-based
long-term care, MFP participants are eligible for MFP benefits for up to 365 days. At the
conclusion of MFP eligibility, the person continues as a typical Medicaid beneficiary. While
eligible for MFP benefits, the restricted benefits flag in the eligibility file should be set to value
08 whenever the beneficiary has a single day of MFP eligibility during the month.
Any service financed with MFP grant funds is considered an MFP service. MFP services are homeand community-based services (HCBS) financed with MFP grant funds. They can be 1915(c) waiver
services or HCBS state plan services. The program has three classes of HCBS, including qualified
HCBS (HCBS that the person would have been eligible for regardless of participation in MFP),
demonstration HCBS (HCBS that are above and beyond what they would have qualified for as a
regular Medicaid beneficiary), and supplemental services (which are typically one-time services
someone needs to make the transition to community-based long-term care). States received
enhanced matching funds for the qualified and demonstration services, and their regular mating
rate for the supplemental services. Examples of MFP-financed services include, but are not limited
to:
-

1915(c) waiver services
Personal care assistance services provided through the state plan
Behavioral health services, including psychosocial rehabilitation

Program Type 10.
Balancing Incentive Payments (BIP). The Balancing Incentive Program authorizes grants
to States to increase access to non-institutional long-term services and supports (LTSS) as of
October 1, 2011.
The Balancing Incentive Program will help States transform their long-term care systems by:
• Lowering costs through improved systems performance & efficiency
• Creating tools to help consumers with care planning & assessment
• Improving quality measurement & oversight
The Balancing Incentive Program also provides new ways to serve more people in home and
community-based settings, in keeping with the integration mandate of the Americans with
Disabilities Act (ADA), as required by the Olmstead decision. The Balancing Incentive Program
was created by the Affordable Care Act of 2010 (Section 10202).
Program Type 11-13

ram Type 11.
Community First Choice (See SSA § 1915(k)). The “Community First Choice Option” lets States provide
home and community-based attendant services to Medicaid enrollees with disabilities under their State Plan.
This option became available on October 1, 2011 and provides a 6 % increase in Federal matching payments to
States for expenditures related to this option.
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Appendix E
Program Type 12.
Psychiatric Rehab Facility for Children. Under the authority of section 2707 of the Patient
Protection and Affordable Care Act of 2010 (Affordable Care Act), the Centers for Medicare &
Medicaid Services (CMS) is funding the Medicaid Emergency Psychiatric Demonstration, which
will be conducted by participating States. This is a 3-year Demonstration that permits
participating States to provide payment under the State Medicaid plan to certain nongovernment psychiatric hospitals for inpatient emergency psychiatric care to Medicaid recipients
aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and are
determined to be dangerous to themselves or others.
Program Type 13.
Home and Community-Based Services (HCBS) State Plan Option (See SSA § 1915(i)). States
can offer a variety of services under a State Plan Home and Community-Based Services (HCBS)
benefit. People must meet State-defined criteria based on need and typically get a combination
of acute-care medical services (like dental services, skilled nursing services) and long-term
services (like respite, case management, supported employment and environmental
modifications).
1915(i) State plan HCBS: State Options
• Target the HCBS benefit to one or more specific populations
• Establish separate additional needs-based criteria for individual HCBS
• Establish a new Medicaid eligibility group for people who get State plan HCBS
• Define the HCBS included in the benefit, including State- defined and CMS-approved
“other services” applicable to the population
Option to allow any or all HCBS to be self-directed

Program Type 14
Program Type 14

(a)–(m)

Program Type 14.
State Plan CHIP (See 42 CRF § 457). ‘This program is for Title XXI recipients (children age 0
through 18, children receiving prenatal care through the conception to birth option, pregnant
women), “Child health assistance” services (as allowed by State law and defined at § 457.402)
means payment for part or all of the cost of health benefits coverage provided to targeted lowincome children for the following services:
(a) Inpatient hospital services.
(b) Outpatient hospital services.
(c) Physician services.
(d) Surgical services.
(e) Clinic services (including health center services) and other ambulatory health care
services.
(f) Prescription drugs and biologicals and the administration of these drugs and
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Appendix E
biologicals, only if these drugs and biologicals are not furnished for the purpose of
causing, or assisting in causing, the death, suicide, euthanasia, or mercy killing of a
person.
(g) Over-the-counter medications.
(h) Laboratory and radiological services.
(i) Prenatal care and pre-pregnancy family planning services and supplies.
(j) Inpatient mental health services, other than services described in paragraph (r) of this
section but including services furnished in a state-operated mental health hospital and
including residential or other 24-hour therapeutically planned structured services.
(k) Outpatient mental health services, other than services described in paragraph (s) of
this section but including services furnished in a State-operated mental health hospital
and including community-based services.
(l) Durable medical equipment and other medically-related or remedial devices (such as
prosthetic devices, implants, eyeglasses, hearing aids, dental devices and adaptive
devices).
(m) Disposable medical supplies.
Program Type 14

(n)–(bb)
(n) Home and community-based health care services and related supportive services
(such as home health nursing services, personal care, assistance with activities of daily
living, chore services, day care services, respite care services, training for family
members and minor modification to the home.)
(o) Nursing care services (such as nurse practitioner services, nurse midwife services,
advanced practice nurse services, private duty nursing, pediatric nurse services and
respiratory care services) in a home, school, or other setting.
(p) Other pregnancy-related procedure only if necessary to save the life of the mother
or if the pregnancy is the result of rape or incest.
(q) Dental services.
(r) Inpatient substance abuse treatment services and residential substance abuse
treatment services.
(s) Outpatient substance abuse treatment services.
(t) Case management services.
(u) Care coordination services.

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Appendix E

(v) Physical therapy, occupational therapy, and services for individuals with speech,
hearing and language disorders.
(w) Hospice care.
(x) Any other medical, diagnostic, screening, preventive, restorative, remedial,
therapeutic, or rehabilitative services (whether in a facility, home, school, or other
setting) if recognized by State law and only if the service is—
(1) Prescribed by or furnished by a physician or other licensed or registered
practitioner within the scope of practice as defined by State law;
(2) Performed under the general supervision or at the direction of a physician;
or
(3) Furnished by a health care facility that is operated by a State or local
government or is licensed under State law and operating within the scope of the
license.
(y) Premiums for private health care insurance coverage.
(z) Medical transportation.
(aa) Enabling services (such as transportation, translation, and outreach services) only if
designed to increase the accessibility of primary and preventive health care services for
eligible low-income individuals.
(bb) Any other health care services or items specified by the Secretary and not excluded
under this subchapter.

Program Type 15-16
Program Type 15.
Psychiatric Residential Treatment Facilities Demonstration Grant Program. The
Community Alternatives to Psychiatric Residential Treatment Facilities (PRTF) Demonstration
Grant Program was authorized by Section 6063 of the Deficit Reduction Act of 2005 to provide
up to $218 million to up to 10 states to develop 5-year demonstration programs that provide
home and community-based services to children as alternatives to PRTF's. Nine states
implemented demonstration grants. These projects were designed to test the costeffectiveness of providing services in a child’s home or community rather than in a PRTF and
whether the services improve or maintain the child’s functioning.
Program Type 16.
SSA § 1915(j) (Self-directed personal assistance services/personal care under State Plan
or 1915(c) waiver). Self-directed personal assistance services (PAS) are personal care and
related services provided under the Medicaid State plan and/or section 1915(c) waivers the
State already has in place.
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Appendix E
•
•

Participation in self-directed PAS is voluntary
Participants set their own provider qualifications and train their PAS providers
Participants determine how much they pay for a service, support or item

Program Type 17
Program Type 17.
COVID-19 Testing Services Section 6004(a)(3) of the Families First Coronavirus Response
Act (FFCRA) added Section 1902(a)(10)(A)(ii)(XXIII) to the Social Security Act (the Act). During
any portion of the public health emergency period beginning March 18, 2020, this provision
permits states to temporarily cover uninsured individuals through an optional Medicaid
eligibility group for the limited purpose of COVID-19 testing. Such medical assistance, as limited
by clause XVIII in the text following Section 1902(a)(10)(G) of the Act, includes: in vitro
diagnostic products for the detection of SARS–CoV–2 or the diagnosis of the virus that causes
COVID–19, and any visit for COVID–19 testing-related services for which payment may be made
under the State plan. For the purposes of this eligibility group, please reference the COVID-19
FAQs on implementation of Section 6008 of the Families First Coronavirus Response Act and
Coronavirus Aid, Relief, and Economic Security (CARES) Act for the definition of an uninsured
individual.[4] States can claim 100 percent FMAP for services provided to an individual enrolled
in the COVID-19 testing group. The 100 percent match is only available for the testing and
testing-related services provided to beneficiaries enrolled in the new COVID-19 testing group
(and for related administrative expenditures).

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Appendix E

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Appendix F

Appendix F: Eligibility Group Table
MEDICAID MANDATORY COVERAGE
Code

Eligibility Group

Short Description

Citation

01

Parents and Other
Caretaker Relatives

Parents and other
caretaker relatives of
dependent children with
household income at or
below a standard
established by the state.

42 CFR
435.110;
1902(a)(10)(A)
(i)(I); 1931(b)
and (d)

Family/Adult

Mandatory
Coverage

02

Transitional
Medical Assistance

Families with Medicaid
eligibility extended for up
to 12 months because of
earnings.

408(a)(11)(A);
1902(a)(52);
1902(e)(1)(B);
1925;
1931(c)(2)

Family/Adult

Mandatory
Coverage

03

Extended Medicaid
due to Earnings

Families with Medicaid
eligibility extended for 4
months because of
increased earnings.

42 CFR
435.112;
408(a)(11)(A);
1902 (e)(1)(A);
1931
(c)(2)1902
(e)(1)(A);
1931 (c)(2)

Family/Adult

Mandatory
Coverage

04

Extended Medicaid
due to Spousal
Support Collections

Families with Medicaid
eligibility extended for 4
months as the result of
the collection of spousal
support.

42 CFR
435.115;
408(a)(11)(B);
1931 (c)(1)

Family/Adult

Mandatory
Coverage

05

Pregnant Women

Women who are
pregnant or post-partum,
with household income
at or below a standard
established by the state.

42 CFR
435.116;
1902(a)(10)(A)
(i)(III) and (IV);
1902(a)(10)(A)
(ii)(I), (IV) and
(IX);
1931(b) and
(d);

Family/Adult

Mandatory
Coverage

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Type

Category

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Appendix F
Code

Eligibility Group

Short Description

06

Deemed Newborns

Children born to women
covered under Medicaid
or a separate CHIP for
the date of the child's
birth, who are deemed
eligible for Medicaid until
the child turns age 1

42 CFR
435.117;
1902(e)(4)
and 2112€

Family/Adult

Mandatory
Coverage

07

Infants and
Children under Age
19

Infants and children
under age 19 with
household income at or
below standards
established by the state
based on age group.

42 CFR
435.118
1902(a)(10)(A)
(i)(III), (IV),
(VI) and (VII);
1902(a)(10)(A)
(ii)(IV) and
(IX); 1931(b)
and (d)

Family/Adult

Mandatory
Coverage

08

Children with Title
IV-E Adoption
Assistance, Foster
Care or
Guardianship Care

Individuals for whom an
adoption assistance
agreement is in effect or
foster care or kinship
guardianship assistance
maintenance payments
are made under Title IV-E
of the Act.

42 CFR
435.145;
473(b)(3);
1902(a)(10)(A)
(i)(I)

Family/Adult

Mandatory
Coverage

09

Former Foster Care
Children

Individuals under the age
of 26, not otherwise
mandatorily eligible, who
were in foster care and
on Medicaid either when
they turned age 18 or
aged out of foster care.

42 CFR
435.150;
1902(a)(10)(A)
(i)(IX)

Family/Adult

Mandatory
Coverage

11

Individuals
Receiving SSI

Individuals who are aged,
blind or disabled who
receive SSI.

42 CFR
435.120;
1902(a)(10)(A)
(i)(II)(aa)

ABD

Mandatory
Coverage

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Citation

Type

Category

96

Appendix F
Code

Eligibility Group

12

Aged, Blind and
Disabled Individuals
in 209(b) States

In 209(b) states, aged,
blind and disabled
individuals who meet
more restrictive criteria
than used in SSI.

42 CFR
435.121;
1902(f)

ABD

Mandatory
Coverage

13

Individuals
Receiving
Mandatory State
Supplements

Individuals receiving
mandatory State
Supplements to SSI
benefits.

42 CFR
435.130

ABD

Mandatory
Coverage

14

Individuals Who
Are Essential
Spouses

Individuals who were
eligible as essential
spouses in 1973 and who
continue be essential to
the well-being of a
recipient of cash
assistance.

42 CFR
435.131;
1905(a)

ABD

Mandatory
Coverage

15

Institutionalized
Individuals
Continuously
Eligible Since 1973

Institutionalized
individuals who were
eligible for Medicaid in
1973 as inpatients of
Title XIX medical
institutions or
intermediate care
facilities, and who
continue to meet the
1973 requirements.

42 CFR
435.132

ABD

Mandatory
Coverage

16

Blind or Disabled
Individuals Eligible
in 1973

Blind or disabled
individuals who were
eligible for Medicaid in
1973 who meet all
current requirements for
Medicaid except for the
blindness or disability
criteria.

42 CFR
435.133

ABD

Mandatory
Coverage

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Short Description

Citation

Type

Category

97

Appendix F
Code

Eligibility Group

Short Description

Citation

Type

Category

17

Individuals Who
Lost Eligibility for
SSI/SSP Due to an
Increase in OASDI
Benefits in 1972

Individuals who would be 42 CFR
eligible for SSI/SSP except 435.134
for the increase in OASDI
benefits in 1972, who
were entitled to and
receiving cash assistance
in August, 1972.

ABD

Mandatory
Coverage

18

Individuals Who
Would be Eligible
for SSI/SSP but for
OASDI COLA
increases since
April, 1977

Individuals who are
receiving OASDI and
became ineligible for
SSI/SSP after April, 1977,
who would continue to
be eligible if the cost of
living increases in OASDI
since their last month of
eligibility for
SSI/SSP/OASDI were
deducted from income.

42 CFR
435.135;

ABD

Mandatory
Coverage

19

Disabled Widows
and Widowers
Ineligible for SSI
due to Increase in
OASDI

Disabled widows and
widowers who would be
eligible for SSI /SSP,
except for the increase in
OASDI benefits due to
the elimination of the
reduction factor in P.L.
98-21, who therefore are
deemed to be SSI or SSP
recipients.

42 CFR
435.137;
1634(b)

ABD

Mandatory
Coverage

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Appendix F
Code

Eligibility Group

Short Description

20

Disabled Widows
and Widowers
Ineligible for SSI
due to Early Receipt
of Social Security

Disabled widows and
widowers who would be
eligible for SSI/SSP,
except for the early
receipt of OASDI
benefits, who are not
entitled to Medicare Part
A, who therefore are
deemed to be SSI
recipients.

42 CFR
435.138;
1634(d)

ABD

Mandatory
Coverage

21

Working Disabled
under 1619(b)

Blind or disabled
individuals who
participated in Medicaid
as SSI cash recipients or
who were considered to
be receiving SSI, who
would still qualify for SSI
except for earnings.

1619(b);
1902(a)(10)(A)
(i)(II)(bb);
1905(q)

ABD

Mandatory
Coverage

22

Disabled Adult
Children

Individuals who lose
eligibility for SSI at age 18
or older due to receipt of
or increase in Title II
OASDI child benefits.

1634(c)

ABD

Mandatory
Coverage

23

Qualified Medicare
Beneficiaries

Individuals with income
equal to or less than
100% of the FPL who are
entitled to Medicare Part
A, who qualify for
Medicare cost-sharing.

1902(a)(10)(E)
(i);

ABD

Mandatory
Coverage

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Citation

Type

Category

1905(p)

99

Appendix F
Code

Eligibility Group

Short Description

Citation

Type

Category

24

Qualified Disabled
and Working
Individuals

Working, disabled
individuals with income
equal to or less than
200% of the FPL, who are
entitled to Medicare Part
A under section 1818A,
who qualify for payment
of Medicare Part A
premiums.

1902(a)(10)(E)
(ii);
1905(p)(3)(A)(
i); 1905(s)

ABD

Mandatory
Coverage

25

Specified Low
Income Medicare
Beneficiaries

Individuals with income
between 100% and 120%
of the FPL who are
entitled to Medicare Part
A, who qualify for
payment of Medicare
Part B premiums.

1902(a)(10)(E)
(iii);
1905(p)(3)(A)(
ii)

ABD

Mandatory
Coverage

26

Qualifying
Individuals

Individuals with income
between 120% and 135%
of the FPL who are
entitled to Medicare Part
A, who qualify for
payment of Medicare
Part B premiums.

1902(a)(10)(E)
(iv);
1905(p)(3)(A)(
ii)

ABD

Mandatory
Coverage

MEDICAID MANDATORYOPTIONS FOR COVERAGE
Code
Code
27

Eligibility Group

Optional Coverage
of Parents and
Other Caretaker
Relatives

December 2020v4.0.0

Short Description

Citation

Individuals qualifying as
parents or caretaker
relatives who are not
mandatorily eligible and
who have income at or
below a standard
established by the State.

42 CFR
435.220;
1902(a)(10)(A)
(ii)(I)

Type

Family/Adult

Category

Options for
Coverage

100

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

28

Reasonable
Classifications of
Individuals under
Age 21

Individuals under age 21
who are not mandatorily
eligible and who have
income at or below a
standard established by
the State.

42 CFR
435.222;
1902(a)(10)(A)
(ii)(I) and (IV)

Family/Adult

Options for
Coverage

29

Children with NonIV-E Adoption
Assistance

Children with special
needs for whom there is
a non-IV-E adoption
assistance agreement in
effect with a state, who
either were eligible for
Medicaid or had income
at or below a standard
established by the state.

42 CFR
435.227;
1902(a)(10)(A)
(ii)(VIII);

Family/Adult

Options for
Coverage

30

Independent Foster
Care Adolescents

Individuals under an age
specified by the State,
less than age 21, who
were in State-sponsored
foster care on their 18th
birthday and who meet
the income standard
established by the State.

42 CFR
435.226;
1902(a)(10)(A)
(ii)(XVII)

Family/Adult

Options for
Coverage

31

Optional Targeted
Low Income
Children

Uninsured children who
meet the definition of
optional targeted low
income children at 42
CFR 435.4, who have
household income at or
below a standard
established by the State.

42 CFR
435.229 and
435.4;
1902(a)(10)(A)
(ii)(XIV);
1905(u)(2)(B)

Family/Adult

Options for
Coverage

December 2020v4.0.0

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Appendix F
Code
Code

Eligibility Group

Short Description

Citation

32

Individuals Electing
COBRA
Continuation
Coverage

Individuals choosing to
continue COBRA benefits
with income equal to or
less than 100% of the
FPL.

1902(a)(10)(F)
; 1902(u)(1)

Family/Adult

Options for
Coverage

33

Individuals above
133% FPL under
Age 65

Individuals under 65, not
otherwise mandatorily or
optionally eligible, with
income above 133% FPL
and at or below a
standard established by
the State.

CFR 435.218;
1902(hh);
1902(a)(10)(A)
(ii)(XX)

Family/Adult

Options for
Coverage

34

Certain Individuals
Needing Treatment
for Breast or
Cervical Cancer

Individuals under the age
of 65 who have been
screened for breast or
cervical cancer and need
treatment.

42 CFR
435.213;
1902(a)(10)(A)
(ii)(XVIII);
1902(aa)

Family/Adult

Options for
Coverage

35

Individuals Eligible
for Family Planning
Services

Individuals who are not
pregnant, with income
equal to or below the
highest standard for
pregnant women, as
specified by the State,
limited to family planning
and related services.

42 CFR
435.214;
1902(a)(10)(A)
(ii)(XXI)

Family/Adult

Options for
Coverage

36

Individuals with
Tuberculosis

Individuals infected with
tuberculosis whose
income does not exceed
established standards,
limited to tuberculosisrelated services.

42 CFR
435.215;
1902(a)(10)(A)
(ii)(XII);
1902(z)

Family/Adult

Options for
Coverage

December 2020v4.0.0

Type

Category

102

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

37

Aged, Blind or
Disabled Individuals
Eligible for but Not
Receiving Cash
Assistance

Individuals who meet the
requirements of SSI or
Optional State
Supplement, but who do
not receive cash.

42 CFR
435.210 &
230;
1902(a)(10)(A)
(ii)(I);

ABD

Options for
Coverage

38

Individuals Eligible
for Cash Assistance
except for
Institutionalization

Individuals who meet the
requirements of AFDC,
SSI or Optional State
Supplement, and would
be eligible if they were
not living in a medical
institution.

42 CFR
435.211;
1902(a)(10)(A)
(ii)(IV);

ABD

Options for
Coverage

39

Individuals
Receiving Home
and Community
Based Services
under Institutional
Rules

Individuals who would be
eligible for Medicaid
under the State Plan if in
a medical institution,
who would live in an
institution if they did not
receive home and
community based
services.

42 CFR
435.217;
1902(a)(10)(A)
(ii)(VI)

ABD

Options for
Coverage

40

Optional State
Supplement
Recipients - 1634
States, and SSI
Criteria States with
1616 Agreements

Individuals in 1634 States
and in SSI Criteria States
with agreements under
1616, who receive a state
supplementary payment
(but not SSI).

42 CFR
435.232;
1902(a)(10)(A)
(ii)(IV)

ABD

Options for
Coverage

41

Optional State
Supplement
Recipients - 209(b)
States, and SSI
Criteria States
without 1616
Agreements

Individuals in 209(b)
States and in SSI Criteria
States without
agreements under 1616,
who receive a state
supplementary payment
(but not SSI).

42 CFR
435.234;
1902(a)(10)(A)
(ii)(XI)

ABD

Options for
Coverage

December 2020v4.0.0

Type

Category

103

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

42

Institutionalized
Individuals Eligible
under a Special
Income Level

Individuals who are in
institutions for at least 30
consecutive days who are
eligible under a special
income level.

42 CFR
435.236;
1902(a)(10)(A)
(ii)(V)

ABD

Options for
Coverage

43

Individuals
participating in a
PACE Program
under Institutional
Rules

Individuals who would be
eligible for Medicaid
under the State Plan if in
a medical institution,
who would require
institutionalization if they
did not participate in the
PACE program.

1934

ABD

Options for
Coverage

44

Individuals
Receiving Hospice
Care

Individuals who would be
eligible for Medicaid
under the State Plan if
they were in a medical
institution, who are
terminally ill, and who
will receive hospice care.

1902(a)(10)(A)
(ii)(VII);
1905(o)

ABD

Options for
Coverage

45

Qualified Disabled
Children under Age
19

Certain children under 19
living at home, who are
disabled and would be
eligible if they were living
in a medical institution.

1902(e)(3)

ABD

Options for
Coverage

46

Poverty Level Aged
or Disabled

Individuals who are aged
or disabled with income
equal to or less than a
percentage of the FPL,
established by the state
(no higher than 100%).

1902(a)(10)(A)
(ii)(X);
1902(m)(1)

ABD

Options for
Coverage

December 2020v4.0.0

104

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

47

Work Incentives
Eligibility Group

Individuals with a
disability with income
below 250% of the FPL,
who would qualify for SSI
except for earned
income.

1902(a)(10)(A)
(ii)(XIII)

ABD

Options for
Coverage

48

Ticket to Work
Basic Group

Individuals with earned
income between ages 16
and 64 with a disability,
with income and
resources equal to or
below a standard
specified by the State.

1902(a)(10)(A)
(ii)(XV)

ABD

Options for
Coverage

49

Ticket to Work
Medical
Improvements
Group

Individuals with earned
income between ages 16
and 64 who are no longer
disabled but still have a
medical impairment, with
income and resources
equal to or below a
standard specified by the
State.

1902(a)(10)(A)
(ii)(XVI)

ABD

Options for
Coverage

50

Family Opportunity
Act Children with
Disabilities

Children under 19 who
are disabled, with income
equal to or less than a
standard specified by the
State (no higher than
300% of the FPL).

1902(a)(10)(A)
(ii)(XIX);
1902(cc)(1)

ABD

Options for
Coverage

December 2020v4.0.0

105

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

51

Individuals Eligible
for Home and
Community-Based
Services

Individuals with income
equal to or below 150%
of the FPL, who qualify
for home and community
based services without a
determination that they
would otherwise live in
an institution.

1902(a)(10)(A)
(ii)(XXII);
1915(i)

ABD

Options for
Coverage

52

Individuals Eligible
for Home and
Community-Based
Services - Special
Income Level

Individuals with income
equal to or below 300%
of the SSI federal benefit
rate, who meet the
eligibility requirements
for a waiver approved for
the State under 1915(c),
(d) or (e), or 1115.

1902(a)(10)(A)
(ii)(XXII);
1915(i)

ABD

Options for
Coverage

Adult Group Individuals at or
below 133% FPL
Age 19 through 64 newly eligible for all
states

Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.

42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)

Family/Adult

Mandatory
Coverage

*727

7

ACA Medicaid expansion for childless adults (represented in T-MSIS by ELIGIBILITY-GROUP valid values "72" through "75")
are still technically characterized as mandatory eligibility groups by Subsection 1902(a)(10)(A) of the Social Security Act
(SSA) despite the U.S. Supreme Court ruling (National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012))
which ruled that states could not be required to offer such coverage. Therefore, some states may not report any of the
Medicaid expansion groups to T-MSIS if these groups are not applicable to a particular state.
December 2020v4.0.0

106

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

*738

Adult Group Individuals at or
below 133% FPL
Age 19 through 64not newly eligible
for non 1905z(3)
states

Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.

42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)
1905z(3)

Family/Adult

Mandatory
Coverage

*741

Adult Group Individuals at or
below 133% FPL
Age 19 through 64
– not newly eligible
parent/ caretakerrelative(s) in
1905z(3) states

Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.

42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)

Family/Adult

Mandatory
Coverage

1905z(3)

8

ACA Medicaid expansion for childless adults (represented in T-MSIS by ELIGIBILITY-GROUP valid values "72" through "75")
are still technically characterized as mandatory eligibility groups by Subsection 1902(a)(10)(A) of the Social Security Act
(SSA) despite the U.S. Supreme Court ruling (National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012))
which ruled that states could not be required to offer such coverage. Therefore, some states may not report any of the
Medicaid expansion groups to T-MSIS if these groups are not applicable to a particular state.
December 2020v4.0.0

107

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

*751

Adult Group Individuals at or
below 133% FPL
Age 19 through 64not newly eligible
non-parent/
caretakerrelative(s) in
1905z(3) states

Non-pregnant individuals
aged 19 through 64, not
otherwise mandatorily
eligible, with income at
or below 133% FPL.

42 CFR
435.119;
1902(a)(10)(A)
(i)(VIII)

Uninsured
Individual eligible
for COVID-19
testing

Uninsured individuals
who are eligible for
medical assistance for
COVID-19 diagnostic
products and any visit
described as a COVID–19
testing-related service
for which payment may
be made under the State
plan during any portion
of the public health
emergency period,
beginning March 18,
2020.

1902(a)(10)
(A)(ii)(XXIII)

76

Type

Category

Family/Adult

Mandatory
Coverage

Family/Adult

Optional

1905z(3)

MEDICAID OPTIONS FOR COVERAGEMEDICALLY NEEDY
Code
Code
53

Eligibility Group

Medically Needy
Pregnant Women

December 2020v4.0.0

Short Description

Women who are
pregnant, who would
qualify as categorically
needy, except for
income.

Citation

42 CFR
435.301(b)(1)(
i) and (iv);
1902(a)(10)(C)
(ii)(II)

Type

Family/Adult

Category

Medically
Needy

108

Appendix F
Code
Code

Eligibility Group

54

Medically Needy
Children under Age
18

Children under 18 who
would qualify as
categorically needy,
except for income.

42 CFR
435.301(b)(1)(
ii);
1902(a)(10)(C)
(ii)(II)

Family/Adult

Medically
Needy

55

Medically Needy
Children Age 18
through 20

Children over 18 and
under an age established
by the State (less than
age 21), who would
qualify as categorically
needy, except for
income.

42 CFR
435.308;
1902(a)(10)(C)
(ii)(II)

Family/Adult

Medically
Needy

56

Medically Needy
Parents and Other
Caretakers

Parents and other
caretaker relatives of
dependent children,
eligible as categorically
needy except for income.

42 CFR
435.310

Family/Adult

Medically
Needy

59

Medically Needy
Aged, Blind or
Disabled

Individuals who are age
65 or older, blind or
disabled, who are not
eligible as categorically
needy, who meet income
and resource standards
specified by the State, or
who meet the income
standard using medical
and remedial care
expenses to offset excess
income.

42 CFR
435.320,
435.322,
435.324, and
435.330;
1902(a)(10)(C)

ABD

Medically
Needy

December 2020v4.0.0

Short Description

Citation

Type

Category

109

Appendix F
Code
Code

Eligibility Group

Short Description

60

Medically Needy
Blind or Disabled
Individuals Eligible
in 1973

Blind or disabled
individuals who were
eligible for Medicaid as
Medically Needy in 1973
who meet all current
requirements for
Medicaid except for the
blindness or disability
criteria.

Citation

42 CFR
435.340

Type

ABD

Category

Medically
Needy

MEDICAID MEDICALLY NEEDY
CHIP COVERAGE
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

61

Targeted LowIncome Children

Uninsured children under
age 19 who do not have
access to public
employee coverage and
whose household income
is within standards
established by the state.

42 CFR
457.310;
2102(b)(1)(B)(
v)

Children

Optional

62

Deemed Newborn

Children born to targeted
low-income pregnant
women who are deemed
eligible for CHIP or
Medicaid for one year.

2112(e)

Children

Optional

63

Children Ineligible
for Medicaid Due
to Loss of Income
Disregards

Children determined to
be ineligible for Medicaid
as a result of the
elimination of income
disregards under the
MAGI income
methodology.

42 CFR
457.340(d)
Section
2101(f) of the
ACA

Children

Mandatory

CHIP ADDITIONAL OPTIONS FOR COVERAGE
December 2020v4.0.0

110

Appendix F

Code
Code

Eligibility Group

Short Description

Citation

Type

Category

64

Coverage from
Conception to
Birth

Uninsured children from
conception to birth who
do not have access to
public employee
coverage and whose
household income is
within standards
established by the state.

42 CFR
457.310
2102(b)(1)(B)(
v)

Children

Option for
Coverage

65

Children with
Access to Public
Employee
Coverage

Uninsured children under
age 19 having access to
public employee
coverage and whose
household income is
within standards
established by the state.

2110(b)(2)(B)
and (b)(6)

Children

Option for
Coverage

66

Children Eligible
for Dental Only
Supplemental
Coverage

Children who are
otherwise eligible for
CHIP but for the fact that
they are enrolled in a
group health plan or
health insurance offered
through an employer.
Coverage is limited to
dental services.

2110(b)(5)

Children

Option for
Coverage

67

Targeted LowIncome Pregnant
Women

Uninsured pregnant
women who do not have
access to public
employee coverage and
whose household income
is within standards
established by the state.

2112

Pregnant
Women

Option for
Coverage

December 2020v4.0.0

111

Appendix F
Code
Code
68

Eligibility Group

Pregnant Women
with Access to
Public Employee
Coverage

Short Description

Citation

Uninsured pregnant
women having access to
public employee
coverage and whose
household income is
within standards
established by the state.

2110(b)(2)(B)
and (b)(6)

Type

Pregnant
Women

Category

Option for
Coverage

CHIP ADDITIONAL OPTIONS FOR COVERAGE

1115 EXPANSION ELIGIBILITY GROUPS
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

69

Individuals with
Mental Health
Conditions
(expansion group)

Individuals with mental
health conditions who do
not qualify for Medicaid
due to the severity or
duration of their
disability or due to other
eligibility factors; and/or
those who are otherwise
eligible but require
benefits or services that
are not comparable to
those provided to other
Medicaid beneficiaries.

1115
expansion

N/A

N/A

December 2020v4.0.0

112

Appendix F
Code
Code

Eligibility Group

Short Description

Citation

Type

Category

70

Family Planning
Participants
(expansion group)

Individuals of child
bearing age who require
family planning services
and supplies and for
which the state does not
choose to, or cannot
provide, optional
eligibility coverage under
the Individuals Eligible
for Family Planning
Services eligibility group
(1902(a)(10)(A)(ii)(XXI)).

1115
expansion

N/A

N/A

71

Other expansion
group

Individuals who do not
qualify for Medicaid or
CHIP under a mandatory
eligibility or coverage
group and for whom the
state chooses to provide
eligibility and/or benefits
in a manner not
permitted by title XIX or
XXI of the Social Security
Act.

1115
expansion

N/A

N/A

Table 43-1115 EXPANSION ELIGIBILITY GROUPS

December 2020v4.0.0

113

Appendix GD

Appendix G: ISO 639 Language Codes Reference
ISO 639-2 Code

Language

ISO 639-2 Code

Language

abk

Abkhazian

kut

Kutenai

ace

Achinese

lad

Ladino

ach

Acoli

lah

Lahnda

ada

Adangme

lam

Lamba

ady

Adyghe; Adygei

day

Land Dayak languages

aar

Afar

lao

Lao

afh

Afrihili

lat

Latin

afr

Afrikaans

lav

Latvian

afa

Afro-Asiatic languages

lez

Lezghian

ain

Ainu

lim

Limburgan; Limburger; Limburgish

aka

Akan

lin

Lingala

akk

Akkadian

lit

Lithuanian

alb

Albanian

jbo

Lojban

alb

Albanian

nds

Low German; Low Saxon; German,
Low; Saxon, Low

ale

Aleut

dsb

Lower Sorbian

alg

Algonquian languages

loz

Lozi

tut

Altaic languages

lub

Luba-Katanga

amh

Amharic

lua

Luba-Lulua

anp

Angika

lui

Luiseno

apa

Apache languages

smj

Lule Sami

ara

Arabic

lun

Lunda

Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

arg

Aragonese

luo

Luo (Kenya and Tanzania)

arp

Arapaho

lus

Lushai

arw

Arawak

ltz

Luxembourgish; Letzeburgesch

arm

Armenian

mac

Macedonian

rup

Aromanian; Arumanian;
Macedo-Romanian

mad

Madurese

art

Artificial languages

mag

Magahi

asm

Assamese

mai

Maithili

ast

Asturian; Bable; Leonese;
Asturleonese

mak

Makasar

ath

Athapascan languages

mlg

Malagasy

aus

Australian languages

may

Malay

map

Austronesian languages

mal

Malayalam

ava

Avaric

mlt

Maltese

ave

Avestan

mnc

Manchu

awa

Awadhi

mdr

Mandar

aym

Aymara

man

Mandingo

aze

Azerbaijani

mni

Manipuri

ban

Balinese

mno

Manobo languages

bat

Baltic languages

bal

glv

Manx

Baluchi

mao

Maori

bam

Bambara

arn

Mapudungun; Mapuche

bai

Bamileke languages

mar

Marathi

bad

Banda languages

chm

Mari

December 2020v4.0.0

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Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

bnt

Bantu languages

mah

Marshallese

bas

Basa

mwr

Marwari

bak

Bashkir

mas

Masai

baq

Basque

myn

Mayan languages

btk

Batak languages

men

Mende

bej

Beja; Bedawiyet

mic

Mi'kmaq; Micmac

bel

Belarusian

min

Minangkabau

bem

Bemba

mwl

Mirandese

ben

Bengali

moh

Mohawk

ber

Berber languages

mdf

Moksha

bho

Bhojpuri

lol

Mongo

bih

Bihari languages

mon

Mongolian

bik

Bikol

mkh

Mon-Khmer languages

bin

Bini; Edo

mos

Mossi

bis

Bislama

mul

Multiple languages

byn

Blin; Bilin

mun

Munda languages

zbl

Blissymbols; Blissymbolics; Bliss

nah

Nahuatl languages

nob

Bokmål, Norwegian; Norwegian
Bokmål

nau

Nauru

bos

Bosnian

nav

Navajo; Navaho

bra

Braj

nde

Ndebele, North; North Ndebele

bre

Breton

nbl

Ndebele, South; South Ndebele

bug

Buginese

ndo

Ndonga

bul

Bulgarian

nap

Neapolitan

December 2020v4.0.0

116

Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

bua

Buriat

new

Nepal Bhasa; Newari

bur

Burmese

nep

Nepali

cad

Caddo

nia

Nias

cat

Catalan; Valencian

nic

Niger-Kordofanian languages

cau

Caucasian languages

ssa

Nilo-Saharan languages

ceb

Cebuano

niu

Niuean

cel

Celtic languages

nqo

N'Ko

cai

Central American Indian
languages

nog

Nogai

khm

Central Khmer

non

Norse, Old

chg

Chagatai

nai

North American Indian languages

cmc

Chamic languages

frr

Northern Frisian

cha

Chamorro

sme

Northern Sami

che

Chechen

nor

Norwegian

chr

Cherokee

nno

Norwegian Nynorsk; Nynorsk,
Norwegian

chy

Cheyenne

nub

Nubian languages

chb

Chibcha

nym

Nyamwezi

nya

Chichewa; Chewa; Nyanja

nyn

Nyankole

chi

Chinese

nyo

Nyoro

chn

Chinook jargon

nzi

Nzima

chp

Chipewyan; Dene Suline

oci

Occitan (post 1500)

cho

Choctaw

arc

Official Aramaic (700-300 BCE);
Imperial Aramaic (700-300 BCE)

December 2020v4.0.0

117

Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

chu

Church Slavic; Old Slavonic;
Church Slavonic; Old Bulgarian;
Old Church Slavonic

oji

Ojibwa

chk

Chuukese

ori

Oriya

chv

Chuvash

orm

Oromo

nwc

Classical Newari; Old Newari;
Classical Nepal Bhasa

osa

Osage

syc

Classical Syriac

oss

Ossetian; Ossetic

cop

Coptic

oto

Otomian languages

cor

Cornish

pal

Pahlavi

cos

Corsican

pau

Palauan

cre

Cree

pli

Pali

mus

Creek

pam

Pampanga; Kapampangan

crp

Creoles and pidgins

pag

Pangasinan

cpe

Creoles and pidgins, English
based

pan

Panjabi; Punjabi

cpf

Creoles and pidgins, Frenchbased

pap

Papiamento

cpp

Creoles and pidgins, Portuguesebased

paa

Papuan languages

crh

Crimean Tatar; Crimean Turkish

nso

Pedi; Sepedi; Northern Sotho

hrv

Croatian

per

Persian

cus

Cushitic languages

peo

Persian, Old (ca.600-400 B.C.)

cze

Czech

phi

Philippine languages

dak

Dakota

phn

Phoenician

dan

Danish

pon

Pohnpeian

December 2020v4.0.0

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Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

dar

Dargwa

pol

Polish

del

Delaware

por

Portuguese

din

Dinka

pra

Prakrit languages

div

Divehi; Dhivehi; Maldivian

pro

Provençal, Old (to 1500);Occitan, Old
(to 1500)

doi

Dogri

pus

Pushto; Pashto

dgr

Dogrib

que

Quechua

dra

Dravidian languages

raj

Rajasthani

dua

Duala

rap

Rapanui

dum

Dutch, Middle (ca.1050-1350)

rar

Rarotongan; Cook Islands Maori

dut

Dutch; Flemish

roa

Romance languages

dyu

Dyula

rum

Romanian; Moldavian; Moldovan

dzo

Dzongkha

roh

Romansh

frs

Eastern Frisian

rom

Romany

efi

Efik

run

Rundi

egy

Egyptian (Ancient)

rus

Russian

eka

Ekajuk

sal

Salishan languages

elx

Elamite

sam

Samaritan Aramaic

eng

English

smi

Sami languages

enm

English, Middle (1100-1500)

smo

Samoan

ang

English, Old (ca.450-1100)

sad

Sandawe

myv

Erzya

sag

Sango

epo

Esperanto

san

Sanskrit

December 2020v4.0.0

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Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

est

Estonian

sat

Santali

ewe

Ewe

srd

Sardinian

ewo

Ewondo

sas

Sasak

fan

Fang

sco

Scots

fat

Fanti

sel

Selkup

fao

Faroese

sem

Semitic languages

fij

Fijian

srp

Serbian

fil

Filipino; Pilipino

srr

Serer

fin

Finnish

shn

Shan

fiu

Finno-Ugrian languages

sna

Shona

fon

Fon

fre

French

scn

Sicilian

frm

French, Middle (ca.1400-1600)

sid

Sidamo

fro

French, Old (842-ca.1400)

sgn

Sign Languages

fur

Friulian

bla

Siksika

ful

Fulah

snd

Sindhi

gaa

Ga

sin

Sinhala; Sinhalese

gla

Gaelic; Scottish Gaelic

sit

Sino-Tibetan languages

car

Galibi Carib

sio

Siouan languages

glg

Galician

sms

Skolt Sami

lug

Ganda

den

Slave (Athapascan)

gay

Gayo

sla

Slavic languages

gba

Gbaya

slo

Slovak

December 2020v4.0.0

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Sichuan Yi; Nuosu

120

Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

gez

Geez

slv

Slovenian

geo

Georgian

sog

Sogdian

ger

German

som

Somali

gmh

German, Middle High (ca.10501500)

son

Songhai languages

goh

German, Old High (ca.750-1050)

snk

Soninke

gem

Germanic languages

wen

Sorbian languages

Gilbertese

sot

Sotho, Southern

gon

Gondi

sai

South American Indian languages

gor

Gorontalo

alt

Southern Altai

got

Gothic

sma

Southern Sami

grb

Grebo

spa

Spanish; Castilian

grc

Greek, Ancient (to 1453)

srn

Sranan Tongo

gre

Greek, Modern (1453-)

suk

Sukuma

grn

Guarani

sux

Sumerian

guj

Gujarati

sun

Sundanese

gwi

Gwich'in

sus

Susu

hai

Haida

swa

Swahili

hat

Haitian; Haitian Creole

ssw

Swati

hau

Hausa

swe

Swedish

haw

Hawaiian

gsw

Swiss German; Alemannic; Alsatian

heb

Hebrew

syr

Syriac

her

Herero

tgl

Tagalog

gil

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Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

hil

Hiligaynon

tah

Tahitian

him

Himachali languages; Western
Pahari languages

tai

Tai languages

hin

Hindi

tgk

Tajik

hmo

Hiri Motu

tmh

Tamashek

Hittite

tam

Tamil

hmn

Hmong; Mong

tat

Tatar

hun

Hungarian

tel

Telugu

hup

Hupa

ter

Tereno

iba

Iban

tet

Tetum

ice

Icelandic

tha

Thai

ido

Ido

tib

Tibetan

ibo

Igbo

tig

Tigre

ijo

Ijo languages

tir

Tigrinya

ilo

Iloko

hit

tem

Timne

smn

Inari Sami

tiv

Tiv

inc

Indic languages

tli

Tlingit

ine

Indo-European languages

tpi

Tok Pisin

ind

Indonesian

tkl

Tokelau

inh

Ingush

tog

Tonga (Nyasa)

ina

Interlingua (International
Auxiliary Language Association)

ton

Tonga (Tonga Islands)

ile

Interlingue; Occidental

tsi

Tsimshian

iku

Inuktitut

tso

Tsonga

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Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

ipk

Inupiaq

tsn

Tswana

ira

Iranian languages

tum

Tumbuka

gle

Irish

tup

Tupi languages

mga

Irish, Middle (900-1200)

tur

Turkish

sga

Irish, Old (to 900)

ota

Turkish, Ottoman (1500-1928)

iro

Iroquoian languages

tuk

Turkmen

ita

Italian

tvl

Tuvalu

jpn

Japanese

tyv

Tuvinian

jav

Javanese

twi

Twi

jrb

Judeo-Arabic

udm

Udmurt

jpr

Judeo-Persian

uga

Ugaritic

kbd

Kabardian

uig

Uighur; Uyghur

kab

Kabyle

ukr

Ukrainian

kac

Kachin; Jingpho

umb

Umbundu

kal

Kalaallisut; Greenlandic

mis

Uncoded languages

xal

Kalmyk; Oirat

und

Undetermined

kam

Kamba

hsb

Upper Sorbian

kan

Kannada

urd

Urdu

kau

Kanuri

uzb

Uzbek

krc

Karachay-Balkar

vai

Vai

kaa

Kara-Kalpak

ven

Venda

krl

Karelian

vie

Vietnamese

kar

Karen languages

vol

Volapük

December 2020v4.0.0

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Appendix G
ISO 639-2 Code

Language

ISO 639-2 Code

Language

kas

Kashmiri

vot

Votic

csb

Kashubian

wak

Wakashan languages

kaw

Kawi

wln

Walloon

kaz

Kazakh

war

Waray

kha

Khasi

was

Washo

khi

Khoisan languages

wel

Welsh

kho

Khotanese; Sakan

fry

Western Frisian

kik

Kikuyu; Gikuyu

wal

Wolaitta; Wolaytta

kmb

Kimbundu

wol

Wolof

kin

Kinyarwanda

xho

Xhosa

kir

Kirghiz; Kyrgyz

sah

Yakut

tlh

Klingon; tlhIngan-Hol

yao

Yao

kom

Komi

yap

Yapese

kon

Kongo

yid

Yiddish

kok

Konkani

yor

Yoruba

kor

Korean

ypk

Yupik languages

kos

Kosraean

znd

Zande languages

kpe

Kpelle

zap

Zapotec

kro

Kru languages

zza

Zaza; Dimili; Dimli; Kirdki; Kirmanjki;
Zazaki

kua

Kuanyama; Kwanyama

zen

Zenaga

kum

Kumyk

zha

Zhuang; Chuang

kur

Kurdish

zul

Zulu

kru

Kurukh

zun

Zuni

December 2020v4.0.0

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Appendix G
*This Section Intentionally Left Blank*

December 2020v4.0.0

125

Appendix H

Appendix H: Benefit Types
Mandatory Benefits for Categorically Needy (Mandatory and Options for Coverage) Individuals and Optional
Benefits for Medically Needy Individuals
Code
Value

Type of
Care

Long
Term
Care*

Mandatory

Institutional

No

1905(a)(1),
440.10,
440.189(g)

Mandatory

Ambulatory

No

1905(a)(2)(A),
440.20(a)

Benefit

Short Description

Category

001

Inpatient
Hospital
Services

Services furnished in a hospital or
institution (licensed or formally
approved as a hospital), for the
care and treatment of inpatients
with disorders other than mental
health disease.

002

Outpatient
Hospital
Services

Preventive, diagnostic, therapeutic,
rehabilitative, or palliative services
furnished to outpatients by a
hospital or institution (licensed or
formally approved as a hospital).

December 2020v4.0.0

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and 42 CFR)

126

Appendix H

Code
Value

Type of
Care

Long
Term
Care*

Citations (Act
and 42 CFR)

Mandatory

Ambulatory

No

1905(a)(2)(B),
440.20(b) and
(c), 1910(a)

Mandatory

Ambulatory

No

1905(a)(2)(C)

Benefit

Short Description

Category

003

Rural Health
Clinics

Services and supplies provided by a
physician within the scope of
his/her practice, a physician
assistant (if not prohibited by state
law), nurse practitioner (if not
prohibited by state law) nurse
midwife, or other specialized nurse
practitioners, intermittent visiting
nurse care and related medical
supplies (other than drugs and
biologicals), and other ambulatory
services when furnished in a
certified rural health clinic or away
from the clinic if an agreement
between the physician and clinic
for payment of services by the
clinic exists.

004

Federally
Qualified
Health
Centers

Services and related supplies
provided by a physician within the
scope of his/her practice, physician
assistants, nurse practitioners,
nurse midwives, clinical
psychologists, clinical social
workers, and other ambulatory
services when furnished in a
federally qualified health center.

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Appendix H

Code
Value

Type of
Care

Long
Term
Care*

Mandatory

Ambulatory

No

1905(a)(3),
440.30

Services (other than services in an
institution for mental health
conditions), furnished to
individuals age 21 and older, which
are needed on a daily basis and
required to be provided in an
inpatient basis provided by a
Medicaid-approved facility and
ordered by and provided under the
direction of a physician.

Mandatory

Institutional

Yes

1905(a)(4)(A),
440.40(a)

Screening and diagnostic services
to determine physical or mental
health condition; health care
treatment and other measures to
correct or ameliorate any chronic
conditions discovered in recipients
under age 21.

Mandatory

Both

No

1905(a)(4)(B),
1902(a)(43),
1905(r)

Benefit

Short Description

Category

005

Other
Laboratory
and X-Ray
Services

Technical and radiological services
ordered and provided by or under
direction of a physician or other
licensed practitioner in an office or
similar facility other than a clinic or
hospital outpatient department
and furnished by an approved
laboratory.

006

Nursing
Facility
Services for
Individuals
Age 21 and
Older

007

Early and
Periodic
Screening,
Diagnostic
and
Treatment
Services

December 2020v4.0.0

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and 42 CFR)

128

Appendix H

Code
Value

Type of
Care

Long
Term
Care*

Citations (Act
and 42 CFR)

Mandatory

Ambulatory

No

1905(a)(4)(C),
441 Subpart F

Counseling and pharmacotherapy
services for cessation of tobacco
use by pregnant women.

Mandatory

Ambulatory

No

1905(a)(4)(D)

Physician
Services

Services furnished by a statelicensed physician within his or her
scope of practice of medicine or
osteopathy.

Mandatory

Ambulatory

No

1905(a)(5)(A),
440.50(a)

011

Medical and
Surgical
Services
Furnished by
a Dentist

Medical and surgical services
furnished by a doctor of dental
medicine or dental surgery, or if
permitted by state law, by a
physician.

Mandatory

Ambulatory

No

1905(a)(5)(B),
440.50(b)

012

Nurse
Midwife
Services

Services furnished by a licensed
nurse midwife within the scope of
practice authorized by State law or
regulation; Inpatient or outpatient
hospital services or clinic services
furnished by a licensed nurse
midwife under the supervision of,
or associated with a physician or
other health care provider.

Mandatory

Ambulatory

No

1905(a)(17),
440.165

Benefit

Short Description

Category

008

Family
Planning
Services and
Supplies

Family planning services and
supplies furnished (directly or
under arrangements with others)
to individuals of child-bearing age
(including minors who can be
considered to be sexually active)
who desire such services and
supplies.

009

Cessation of
Tobacco Use
by Pregnant
Women

010

December 2020v4.0.0

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Appendix H

Code
Value

Type of
Care

Long
Term
Care*

Mandatory

Ambulatory

No

1905(a)(21),
440.166

Mandatory

Institutional

No

1905(a)(28)

Ambulatory

Yes

1905(a)(7),
440.70(b)(1),
441.15

Ambulatory

Yes

1905(a)(7),
440.70(b)(2),
441.15

Benefit

Short Description

Category

013

Certified
Pediatric or
Family Nurse
Practitioner
Services

Services furnished by a certified
pediatric nurse practitioner with a
practice limited to providing
primary health care to individuals
under age 21; or a certified family
nurse practitioner with a practice
limited to providing primary health
care to individuals and families.

014

Free Standing
Birth Center
Services

Services furnished to an individual
at a freestanding birth center,
which include prenatal labor and
delivery, or postpartum care and
other ambulatory services related
to the health and safety of the
individual.

015

Home Health
Services Intermittent
and Part-time
Nursing
Services
Provided by a
Home Health
Agency

Nursing service that is provided on
a part-time or intermittent basis by
a home health agency or in the
absence of an agency in the area,
by a registered nurse.

016

Home Health
Services Home Health
Aide Services
Provided by a
Home Health
Agency

Home health aide services
provided by a home health agency.

December 2020v4.0.0

Mandatory

Mandatory

Citations (Act
and 42 CFR)

130

Appendix H

Code
Value

017

Benefit

Short Description

Category

Home Health
Services Medical
Supplies,
Equipment
and
Appliances
Suitable for
Use in the
Home

Services include medical supplies,
equipment and appliances suitable
for use in the home.

Mandatory

Type of
Care

Long
Term
Care*

Citations (Act
and 42 CFR)

Ambulatory

Yes

1905(a)(7),
440.70(b)(3),
441.15

MandatoryOptional Benefits for Categorically Needy (Mandatory and Options for Coverage) Individuals and Optional
Benefits for and Medically Needy Individuals
Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

018

Medical Care
and Any Type
of Remedial
Care
Recognized
Under State
Law Podiatrist
Services

Medical or remedial care or
services provided by licensed
podiatrists within the scope of
practice as defined under state
law.

Optional

Ambulatory

No

1905(a)(6),
440.60

019

Medical Care
and Any Type
of Remedial
Care
Recognized
Under State
Law Optometrist
Services

Medical or remedial care or
services provided by licensed
optometrists within the scope of
practice as defined under state
law

Optional

Ambulatory

No

1905(a)(6),
440.60

December 2020v4.0.0

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and 42 CFR)

131

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

020

Medical Care
and Any Type
of Remedial
Care
Recognized
Under State
Law Chiropractors'
Services

Services provided by licensed
chiropractors consisting of
treatment by means of manual
manipulation of the spine within
the scope authorized by the state
to perform.

Optional

Ambulatory

No

1905(a)(6),
440.60

021

Medical Care
and Any Type
of Remedial
Care
Recognized
Under State
Law - Other
Licensed
Practitioner
Services

Medical or any other remedial
care or services provided by a
licensed practitioner within the
scope of his/her practice as
defined by state law.

Optional

Ambulatory

No

1905(a)(6),
440.60

022

Home Health
Services Physical
Therapy,
Occupational
Therapy,
Speech
Pathology,
Audiology
Provided by a
Home Health
Agency

Physical therapy, occupational
therapy, or speech pathology and
audiology services provided by a
home health agency or by a
facility licensed by the state to
provide medical rehabilitation
services.

Optional

Ambulatory

Yes

1905(a)(7),
440.70(b)(4),
441.15

023

Private Duty
Nursing
Services

Nursing services, provided by RNs
or LPNs, in a home, hospital, or
skilled nursing facility, to
recipients who require more
individual and continuous care
than is available from a visiting
nurse, or routinely provided by
hospital or skilled nursing facility
staff.

Optional

Ambulatory

Yes

1905(a)(8),
440.80

December 2020v4.0.0

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and 42 CFR)

132

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

024

Clinic Services

Preventive, diagnostic,
therapeutic, rehabilitative or
palliative services furnished by a
facility that is not part of a
hospital, but is organized and
operated to provide medical care;
services provided at the clinic or
outside the clinic under the
direction of a physician or dentist.

Optional

Ambulatory

No

1905(a)(9),
440.90

025

Dental
Services

Diagnostic, preventive, or
corrective procedures provided
by or under the supervision of a
licensed dentist; treatment of the
teeth and associated structures of
the oral cavity; treatment of
disease, injury, or impairment
that my affect general health of
recipient.

Optional

Ambulatory

No

1905(a)(10),
440.100

026

Physical
Therapy and
Related
ServicesPhysical
Therapy

Services prescribed by a physician
or other licensed practitioner of
the healing arts, and provided to
a recipient by or under the
direction of a qualified physical
therapist; includes supplies and
equipment.

Optional

Ambulatory

Yes

1905(a)(11),
440.110(a)

027

Physical
Therapy and
Related
ServicesOccupational
Therapy

Services provided by a qualified
occupational therapist, which
have been prescribed by a
physician or practitioner of the
healing arts; includes supplies and
equipment.

Optional

Ambulatory

Yes

1905(a)(11),
440.110(b)

December 2020v4.0.0

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and 42 CFR)

133

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

028

Physical
Therapy and
Related
Services Services for
Individuals
with Speech,
Hearing and
Language
Disorders

Diagnostic, screening, preventive
or corrective services for
individuals with speech, hearing
and language disorders; provided
by or under the direction of a
certified speech pathologist or
audiologist or other licensed
practitioner of the healing arts;
includes supplies and equipment.

Optional

Ambulatory

Yes

1905(a)(11),
440.110(c )

029

Prescribed
Drugs,
Dentures, and
Prosthetic
Devices; and
Eyeglasses Prescribed
Drugs

Single or compound substances or
mixture of substances prescribed
by a physician or licensed
practitioner, and dispensed by a
licensed pharmacist or authorized
practitioner, for the cure,
mitigation, or prevention of
disease or maintenance of health.

Optional

Ambulatory

No

1905(a)(12),
440.120(a)

030

Prescribed
Drugs,
Dentures, and
Prosthetic
Devices; and
Eyeglasses Dentures

Artificial structures made by or
under the direction of a dentist to
replace a full or partial set of
teeth.

Optional

Ambulatory

No

1905(a)(12),
440.120(b)

031

Prescribed
Drugs,
Dentures, and
Prosthetic
Devices; and
Eyeglasses Prosthetic
Devices

Replacement, corrective or
supportive devices prescribed by
a physician or licensed
practitioner, to artificially replace
a missing portion of the body,
prevent or correct physical
deformity or malfunction, or to
support a weak or deformed
portion of the body.

Optional

Ambulatory

No

1905(a)(12),
440.120(c )

December 2020v4.0.0

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and 42 CFR)

134

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

032

Prescribed
Drugs,
Dentures, and
Prosthetic
Devices; and
Eyeglasses Eyeglasses

Lenses, including frames and
other aids to vision, prescribed by
a physician skilled in eye disease,
or an optometrist.

Optional

Ambulatory

No

1905(a)(12),
440.120(d)

033

Other
Diagnostic,
Screening,
Preventive,
and
Rehabilitative
Services Diagnostic
Services

Medical procedures or supplies
recommended by a physician or
licensed practitioner to enable
him/her to identify the existence,
nature or extent of illness, injury
or other health deviation in a
recipient.

Optional

Ambulatory

No

1905(a)(13),
440.130(a)

034

Other
Diagnostic,
Screening,
Preventive,
and
Rehabilitative
Services Screening
Services

Use of standardized tests given to
a designated population, to
detect the existence of one or
more particular diseases or health
deviations or to identify for more
definitive studies individuals
suspected of having certain
diseases.

Optional

Ambulatory

No

1905(a)(13),
440.130(b)

035

Other
Diagnostic,
Screening,
Preventive,
and
Rehabilitative
Services Preventive
Services

Services provided by a physician
or other licensed practitioner to
prevent disease, disability or
other health conditions or their
progression, to prolong life and to
promote physical and mental
health efficiency.

Optional

Ambulatory

No

1905(a)(13),
440.130(c )

December 2020v4.0.0

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and 42 CFR)

135

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

036

Other
Diagnostic,
Screening,
Preventive,
and
Rehabilitative
Services Rehabilitative
Services

Medical or remedial services
recommended by a physician or
other licensed practitioner for
maximum reduction of physical or
mental health condition, and
restoration of a recipient to
his/her best possible functional
level.

Optional

Ambulatory

Yes

1905(a)(13),
440.130(d)

037

Services for
Individuals Age
65 and Over in
IMDs Inpatient
Hospital
Services

Services for the care and
treatment of recipients, age 65
and older, in an institution for
mental health conditions,
provided under the direction of a
physician.

Optional

Institutional

Yes

1905(a)(14),
440.140(a)

038

Services for
Individuals Age
65 and Over in
IMDs - Nursing
Facility
Services

Nursing services needed on a
daily basis and required to be
provided on an inpatient basis to
individuals age 65 and older in an
institution for mental health
conditions.

Optional

Institutional

Yes

1905(a)(14),
440.140(b)

039

Intermediate
Care Facility
Services for
Individuals
with
Intellectual
Disabilities
(ICF-IID)

Items and health rehabilitative
services provided to persons with
intellectual disabilities or related
conditions, receiving active
treatment in a licensed ICF/IID.

Optional

Institutional

Yes

1905(a)(15),
440.150

040

Inpatient
Psychiatric
Services for
Individuals
Under 21

Inpatient psychiatric services
provided to individuals under age
21, under the direction of a
physician, furnished in an
approved and accredited
psychiatric hospital or facility.

Optional

Institutional

Yes

1905(a)(16),
440.160

December 2020v4.0.0

Citations (Act
and 42 CFR)

136

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

041

Hospice Care
Services

Items and services provided to a
terminally ill individual, which
includes nursing care, physical or
occupational therapy, medical
social services, homemaker
services, medical supplies and
appliances, physician services,
short-term inpatient care and
counseling.

Optional

Both

Yes

1905(a)(18)

042

Case
Management
and TBRelated
Services - Case
Management
and Targeted
Case
Management
Services

Services to assist eligible
individuals who reside in a
community setting or are
transitioning to a community
setting, in gaining access to
medical, social, educational, and
other services. As specified in a
state’s plan, may be offered to
individuals within targeted
groups.

Optional

Ambulatory

Yes

1905(a)(19),
440.169,
1915(g)

December 2020v4.0.0

Citations (Act
and 42 CFR)

137

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

043

Case
Management
Services and
TB-Related
Services Special TB
Related
Services

Services for the treatment of
infection with tuberculosis
consisting of prescribed drugs,
physicians’ services, laboratory
and x-ray services (including
services to confirm the presence
of infection), clinic services and
federally-qualified health center
services, case management
services, and services (other than
room and board) designed to
encourage completion of
regimens of prescribed drugs by
outpatients, including services to
observe directly the intake of
prescribed drugs.

Optional

Ambulatory

No

1905(a)(19)

044

Respiratory
Care Services

Services provided in home, under
the direction of a physician, by a
respiratory therapist or other
health care professional trained in
respiratory therapy, to an
individual who is medically
dependent on a ventilator for life
support for 6 hours or more per
day, has been dependent on the
ventilator for at least 30
consecutive days as an inpatient
in a hospital, NF or ICF/IID, has
adequate social support, and
wishes to be cared for at home.

Optional

Ambulatory

No

1905(a)(20),
1902(e)(9)(A)(C ), 440.185

December 2020v4.0.0

Citations (Act
and 42 CFR)

138

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

045

Personal Care
Services

Services, furnished to an
individual who is not an inpatient
or resident of a hospital, nursing
facility, or intermediate facility for
individuals with intellectual and
or developmental disabilities, or
institution for mental health
conditions, that are authorized by
a physician in accordance with a
plan of treatment, and provided
by an individual qualified to
provide such services, who is not
a legally responsible relative.

Optional

Ambulatory

Yes

1905(a)(24),
440.167

046

Primary Care
Case
Management
Services
(Integrated
Care Model)

Case management related
services which include location,
coordination, and monitoring of
primary health care services and
provider under a contract
between the State and either a
PCCM who is a physician, or at
the State’s option, a physician
assistant, nurse practitioner,
certified nurse midwife, physician
group practice, or an entity that
employs or arranges with
physicians to furnish services.

Optional

Ambulatory

No

1905(a)(25),
440.168

047

Special SickleCell AnemiaRelated
Services

Primary and secondary medical
strategies and treatment and
services for individuals who have
Sickle Cell Disease.

Optional

Ambulatory

No

1905(a)(27)

December 2020v4.0.0

Citations (Act
and 42 CFR)

139

Appendix H

Code
Value

Type of
Care

Long
Term
Care*

Optional, but
states are
required to
assure that
transportation
is available to
and from
Medicaid
services, either
as a State Plan
benefit, an
administrative
activity or
under a waiver

Ambulatory

No

1905(a)(29),
440.170(a)

Optional

Institutional

Yes

1905(a)(29),
440.170(b) and
(c )

Benefit

Short Description

Category

048

Any other
medical care
and any other
type of
remedial care
recognized
under State
law, specified
by the
Secretary Transportation

Expenses for transportation and
other related travel expenses
determined to be necessary by
the agency to secure medical
examinations and treatment for a
beneficiary.

049

Any other
medical care
and any other
type of
remedial care
recognized
under State
law, specified
by the
Secretary Services
provided in
religious nonmedical health
care facilities

Non-medical services and items,
furnished in an institution that is
defined in the Internal Revenue
Code and is exempt from taxes, to
patients who choose to rely solely
upon a religious method of
healing and for whom the
acceptance of medical health
services would be inconsistent
with their religious beliefs.

December 2020v4.0.0

Citations (Act
and 42 CFR)

140

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

050

Any other
medical care
and any other
type of
remedial care
recognized
under State
law, specified
by the
Secretary Nursing facility
services for
individuals
under age 21

Services (other than services in an
Institution for mental health
conditions), furnished to
individuals under the age of 21,
which are needed on a daily basis
and required to be provided in an
inpatient basis provided by a
Medicaid-approved facility and
ordered by and provided under
the direction of a physician.

Optional

Institutional

Yes

1905(a)(29),
440.170(d)

051

Any other
medical care
and any other
type of
remedial care
recognized
under State
law, specified
by the
Secretary Emergency
hospital
services

Services that are necessary to
prevent death or serious
impairment of health of a
recipient, and that the threat to
life or health necessitates that use
of the most accessible hospital
available that is equipped to
furnish the services, with no
regard to conditions of
participation under Medicare or
definitions of inpatient or
outpatient hospital services.

Optional

Ambulatory

No

1905(a)(29),
440.170(e)

052

Any other
medical care
and any other
type of
remedial care
recognized
under State
law, specified
by the
Secretary Critical Access
Hospitals

Services that are furnished by a
Medicare participating Critical
Access Hospital (CAH) provider
and are of a type that would be
paid for by Medicare when
provided to a Medicare recipient,
other than nursing facility services
by a CAH with a swing-bed
approval.

Optional

Institutional

No

1905(a)(29),
440.170(g)

December 2020v4.0.0

Citations (Act
and 42 CFR)

141

Appendix H

Code
Value

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

Citations (Act
and 42 CFR)

053

Extended
Services for
Pregnant
Women Additional
Services for
Any Other
Medical
Conditions
That May
Complicate
Pregnancy

Extended services for pregnant
women - Additional Services for
any other medical conditions that
may complicate pregnancy,
except Pregnancy-related and
postpartum services for a 60-day
period after the pregnancy ends
and any remaining days in the
month in which the 60th day falls.
(These services will fall into valid
value # 71.)

Optional

Ambulatory

No

1902(a)(10)(en
d)(V)

054

Community
First Choice

Home and community-based
attendant services and supports
to assist eligible beneficiaries in
accomplishing activities of daily
living (ADLs), instrumental
activities of daily living (IADLs),
and health-related tasks through
hands-on assistance, supervision
or cueing.

Optional

Ambulatory

No

1915(k)

December 2020v4.0.0

142

Appendix H

Code
Value

055

Benefit

Short Description

Category

Type of
Care

Long
Term
Care*

Health Homes

Comprehensive and timely highquality services that are provided
by a designated provider, a team
of health care professionals
operating with such a provider, or
a health team. Services include
care management, care
coordination and promotion,
comprehensive transitional care,
patient and family support,
referral to community and social
support services, and use of
information technology to link
services.

Optional

Ambulatory

No

Citations (Act
and 42 CFR)

1945

Optional Benefits for Categorically Needy (Mandatory and Options for Coverage) and Medically Needy Individuals

Special Benefit Provisions

December 2020v4.0.0

143

Appendix H

Code
Value

Type of Care

Long
Term
Care*

N/A

N/A

No

1902(a)(10)(end)(VII),
440.210(a)(2),
440.250(p)

N/A

N/A

No

1920, 1902(a)(47)

Benefit

Short Description

Category

056

Limited PregnancyRelated Services for
Pregnant Women
with Income Above
the Applicable
Income Limit

Potentially limited
services for pregnant
women with income
above a certain limit to
pregnancy-related
services that are
necessary for the
health of the pregnant
woman and fetus, or
have become
necessary as a result
of the woman having
been pregnant,
including, but not
limited to prenatal
care, delivery,
postpartum care, and
family planning
services.

057

Ambulatory
prenatal care for
pregnant women
furnished during a
presumptive
eligibility period

Ambulatory prenatal
care services provided
to an eligible pregnant
woman during the PE
period, which begins
on the date a pregnant
woman is determined
presumptively eligible
by a Medicaid
qualified provider
based on preliminary
information, and ends
on the day on which a
full determination of
eligibility is made or at
the end of the month
following the month in
which the PE
determination was
made if the woman
fails to file an
application for full
benefits.

December 2020v4.0.0

Citations (Act and 42
CFR)

144

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

058

Benefits for
Families Receiving
Transitional
Medical Assistance

Benefits provided to
families who would
have lost eligibility
because of hours of, or
income from
employment of the
caretaker relative.
Benefits may be
limited or provided
through alternative
methods during the
second six months of
the 12 month period
of extended benefits.

N/A

N/A

N/A

1925, 1902(a)(52)

059

Standards for
Coverage of
Transplant Services

Standards which
provide that similarly
situated individuals
are treated alike and
any restriction, on the
facilities or
practitioners which
may provide such
procedures, is
consistent with
accessibility to high
quality care.

N/A

N/A

N/A

1903(i)(1), 441.35

060

School-Based
Services Payment
Methodologies

Provision of benefits in
a school-based setting
or arranged by a
school to a child with a
disability even if such
services are included
in the child's
individualized
education program
(IEP), and to an infant
or toddler with a
disability even if such
services are included
in the child's
individualized family
service plan (IFSP).

N/A

N/A

N/A

1903(c )

December 2020v4.0.0

Citations (Act and 42
CFR)

145

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

Citations (Act and 42
CFR)

061

Indian Health
Services and Tribal
Health Facilities

Allows for
reimbursement of
state plan covered
services when
provided by a facility
of the Indian Health
Service, including a
hospital, nursing
facility or any other
type of facility which
provides covered
services under the
state plan.

N/A

N/A

N/A

1911, 431.110(b)

062

Methods and
Standards to Assure
High Quality Care

The plan must include
a description of
methods and
standards used to
assure that services
are of high quality and
that the care and
services are available
under the plan at least
to the extent that such
care and services are
available to the
general populations in
the geographic area.

N/A

N/A

N/A

1902(a)(30)(A), 440.260

Type of Care

Long
Term
Care*

Citations (Act and 42
CFR)

N/A

N/A

1902(a)(10(E ), 1905(p),
1905(s), 1933, 431.625

Coordination of Medicaid with Medicare and Other Insurance
Special Benefit Provisions

Code
Value

063

Benefit

Short Description

Category

Medicare Premium
Payments

Provisions related to
payment of Medicare
A, B and C premiums
for qualifying Medicaid
beneficiaries.

N/A

December 2020v4.0.0

146

Appendix H

Code
Value

Type of Care

Long
Term
Care*

Citations (Act and 42
CFR)

N/A

N/A

N/A

1902(a)(10(E ), 1902(n),
1905(p)(3) and (4)

N/A

N/A

N/A

1906, 1906A,
1902(a)(10)(F),
1902(u)(1)

Type of Care

Long
Term
Care*

N/A

N/A

Benefit

Short Description

Category

064

Medicare
Coinsurance and
Deductibles

Provisions for
Medicaid payment of
Medicare coinsurance
and deductibles for
individuals dually
eligible for Medicare
and Medicaid.

065

Other Medical
Insurance Premium
Payments

Payment of insurance
premiums, if costeffective, for eligible
individuals; payment
of COBRA premiums;
and requirement of
enrollment in an
employer-sponsored
insurance with
payment of premiums,
if cost-effective.

Coordination of Medicaid with Medicare and Other Insurance
Special Benefit Programs
Code
Value

066

Benefit

Short Description

Category

Programs for
Distribution of
Pediatric Vaccines

The establishment of a
pediatric vaccine
distribution program,
which provides eligible
children with qualified
pediatric vaccines.

Mandatory

Citations (Act and 42
CFR)

1928

Home and Community-Based Services
Special Benefit Programs

December 2020v4.0.0

147

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

Citations (Act and 42
CFR)

067

Laboratory and xray services

068

Home Health
Services - Home
health aide services
provided by a home
health agency

N/A

N/A

N/A

N/A

N/A

069

Private duty nursing
services

N/A

N/A

N/A

N/A

N/A

070

Physical Therapy
and Related
Services - Audiology
services

N/A

N/A

N/A

N/A

N/A

071

Extended services
for pregnant
women - Additional
Pregnancy-related
and postpartum
services for a 60day period after the
pregnancy ends and
any remaining days
in the month in
which the 60th day
falls.

N/A

N/A

N/A

N/A

N/A

072

Home and
Community Care
for Functionally
Disabled Elderly
individuals as
defined and
described in the
State Plan

N/A

N/A

N/A

N/A

N/A

December 2020v4.0.0

148

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

073

Emergency services
for certain legalized
aliens and
undocumented
aliens

An emergency medical
condition is a medical
condition (including
emergency labor and
delivery) manifesting
itself by acute
symptoms of sufficient
severity (including
severe pain) such that
the absence of
immediate medical
attention could
reasonably be
expected to result in
placing the patient’s
health in serious
jeopardy, serious
impairment to bodily
functions, or serious
dysfunction of any
bodily organ or part.

N/A

N/A

N/A

N/A

074

Licensed or
Otherwise StateApproved FreeStanding Birthing
Center and other
ambulatory services
that are offered by
a freestanding birth
center

N/A

N/A

N/A

N/A

N/A

075

Homemaker

N/A

N/A

N/A

N/A

N/A

076

Home Health Aide

N/A

N/A

N/A

N/A

N/A

077

Adult Day Health
services

N/A

N/A

N/A

N/A

N/A

078

Habilitation

N/A

N/A

N/A

N/A

N/A

079

Habilitation:
Residential
Habilitation

N/A

N/A

N/A

N/A

N/A

December 2020v4.0.0

Citations (Act and 42
CFR)

149

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

080

Habilitation:
Supported
Employment

N/A

N/A

N/A

N/A

N/A

081

Habilitation:
Education (non
IDEA available)

N/A

N/A

N/A

N/A

N/A

082

Habilitation: Day
Habilitation

N/A

N/A

N/A

N/A

N/A

083

Habilitation: PreVocational

N/A

N/A

N/A

N/A

N/A

084

Habilitation: Other
Habilitative Services

N/A

N/A

N/A

N/A

N/A

085

Respite

N/A

N/A

N/A

N/A

N/A

086

Day Treatment
(mental health
service)

N/A

N/A

N/A

N/A

N/A

087

Psychosocial
rehabilitation

N/A

N/A

N/A

N/A

N/A

088

Environmental
Modifications
(Home Accessibility
Adaptations)

N/A

N/A

N/A

N/A

N/A

089

Vehicle
Modifications

N/A

N/A

N/A

N/A

N/A

090

Non-Medical
Transportation

N/A

N/A

N/A

N/A

N/A

091

Special Medical
Equipment (minor
assistive Devices)

N/A

N/A

N/A

N/A

N/A

092

Home Delivered
meals

N/A

N/A

N/A

N/A

N/A

December 2020v4.0.0

Citations (Act and 42
CFR)

150

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

Citations (Act and 42
CFR)

093

Assistive
Technology (i.e.,
communication
devices)

N/A

N/A

N/A

N/A

N/A

094

Personal
Emergency
Response (PERS)

N/A

N/A

N/A

N/A

N/A

095

Nursing Services

N/A

N/A

N/A

N/A

N/A

096

Community
Transition Services

N/A

N/A

N/A

N/A

N/A

097

Adult Foster Care

N/A

N/A

N/A

N/A

N/A

098

Day Supports (nonhabilitative)

N/A

N/A

N/A

N/A

N/A

099

Supported
Employment

N/A

N/A

N/A

N/A

N/A

100

Supported Living
Arrangements

N/A

N/A

N/A

N/A

N/A

101

Supports for
Consumer Direction
(Supports
Facilitation)

N/A

N/A

N/A

N/A

N/A

102

Participant Directed
Goods and Services

N/A

N/A

N/A

N/A

N/A

103

Senior Companion
(Adult Companion
Services)

N/A

N/A

N/A

N/A

N/A

104

Assisted Living

N/A

N/A

N/A

N/A

N/A

Home and Community-Based Services

Other

December 2020v4.0.0

151

Appendix H

Code
Value

Benefit

Short Description

Category

Type of Care

Long
Term
Care*

105

Program for Allinclusive Care for
the Elderly (PACE)
Services

N/A

N/A

N/A

N/A

N/A

106

Self-directed
Personal Assistance
Services under
1915(j)

N/A

N/A

N/A

N/A

N/A

107

COVID - 19 Testing

In vitro diagnostic
products (as defined in
section 809.3(a) of
title 21, Code of
Federal Regulations)
administered during
any portion of the
emergency period
defined in paragraph
(1)(B) of section
1135(g) beginning on
or after the date of the
enactment of this
subparagraph for the
detection of SARS–
CoV–2 or the diagnosis
of the virus that
causes COVID–19, and
the administration of
such in vitro diagnostic
products

Optional

Family/Adult

N/A

Section 1902(a)(10)(G)

108

COVID - 19 Testingrelated services

COVID–19 testingrelated services

Optional

Family/Adult

N/A

Section 1902(a)(10)(G)

December 2020v4.0.0

Citations (Act and 42
CFR)

152

Appendix I

December 2020v4.0.0

153

Appendix I

Other

Appendix I: MBES CBES Category of Service Line Definitions for the
64.9 Base Form
Line

Line - Form Display

Line - Definition

1A

Inpatient Hospital - Reg.
Payments

1A. - Inpatient Hospital Services. -- Regular Payments.--Other than services
in an institution for mental health conditions. (See 42 CFR 440.10). These
are services that:

-

-

Are ordinarily furnished in a hospital for the care and treatment of
inpatients;
Are furnished under the direction of a physician or dentist (except
in the case of nurse-midwife services under 42 CFR 440.165); and
Are furnished in an institution that:
Is maintained primarily for the care and treatment of patients
with disorders other than mental health conditions;

Is licensed and formally approved as a hospital by an
officially designated authority for State standard setting;
Meets the requirements for participation in Medicare
(except in the case of medical supervision of nurse-midwife
services under 42 CFR 440.165); and,
Has, in effect, a utilization review plan (that meets the
requirements under 42 CFR 482.30 applicable to all
Medicaid patients, unless a waiver has been granted by
DHHS.

NOTE: Inpatient hospital services do not include NF services furnished by a
hospital with swing-bed approval. However, include services provided in a
psychiatric wing of a general hospital if the psychiatric wing is not
administratively separated from the general hospital.

December 2020v4.0.0

154

Appendix I

Line

Line - Form Display

Line - Definition

1B

Inpatient Hospital - DSH

1B. - Inpatient Hospital Services -- DSH Adjustment Payment. - Other than
services in an institution for mental health conditions. DSH payments are
for the express purpose of assisting hospitals that serve a disproportionate
share of low-income patients with special needs and are made in
accordance with section 1923 of the Act.
Report the total payments that were determined to be disproportionate
share payments to the hospital by entering the amounts on the pop-up
feeder form which in turn will pre-fill the Form CMS-64.9D as well as the
appropriate lines on the Forms CMS-64.9, CMS-64.9P, CMS-64.21, CMS64.21P, CMS-6421U or CMS-64.21UPs.

1C

Inpatient Hospital - Sup.
Payments

1C. - Inpatient Hospital Services. - Supplemental Payments.--Other than
services in an institution for mental health conditions. (Refer to the
definition on Line 1A above). These are payments made in addition to the
standard fee schedule or other standard payment for those services.
These payments are separate and apart from regular payments and are
based on their own payment methodology. Payments may be made to all
providers or targeted to specific groups or classes of providers. Groups
may be defined by ownership type (state, county or private) and/or by the
other characteristics, e.g., caseload, services or costs. The combined
standard payment and supplemental payment cannot exceed the upper
payment limit described in 42 CFR 447.272. Address supplemental
payments for inpatient hospitals associated with (1) state government
operated facilities, (2) non-state government operated facilities, and (3)
privately operated facilities by entering payments on the pop-up feeder
form.

1D

Inpatient Hospital - GME
Payments

1D. - Inpatient Hospital Services.—Graduate Medical Education (GME)
Payments.-- GME payments include supplemental payments for direct
medical education (DME) (i.e. costs of training physicians such as resident
and teaching physician salaries/benefits, overhead and other costs directly
related to the program) and indirect medical education (IME) costs
hospitals incur for operating teaching programs. Report all supplemental
payments for DME and IME that are provided for in the State plan.

December 2020v4.0.0

155

Appendix I

Line

Line - Form Display

Line - Definition

2A

Mental Health Facility Services Reg. Payments

2A. Mental Health Facility Services - Report Institution for Mental Disease
(IMD) (or mental health conditions) services for individuals age 65 or older
and/or under age 21 (See 42 CFR 440.140 and 440.160.).
Report Other Mental Services which are not provided in an inpatient
setting in the Other Appropriate Service categories, e.g., Physician Services,
Clinic Services.
1. Mental Health Hospital Services for the Aged. Refers to those
inpatient hospital services provided under the direction of a physician
for the care and treatment of recipients in an institution for mental
health conditions that meets the Conditions of Participation under 42
CFR Part 482. Institution for mental health conditions means an
institution that is primarily engaged in providing diagnosis, treatment,
or care of individuals with mental health conditions, including medical
care, nursing care, and related services. (See 42 CFR 440.140(a)(2).)
2. NF Services for the Aged. Means those NF services (as defined at 42
CFR 440.40) and those ICF services (as defined at 42 CFR 483, Subpart
B) provided in an institution for mental health conditions to recipients
determined to be in need of such services. (See 42 CFR 440.140.)
3. Inpatient Psychiatric Facility Services for Individuals Age 21 and
Under. (See 42 CFR 441.151) --Means those services that:



2B

Mental Health Facility - DSH

Are provided under the direction of a physician;
Are provided in a facility or program accredited by the
Joint Commission on the Accreditation of Health Care
Organizations; and
 Meet the requirements set forth at Subpart D of Part 441
(Inpatient Psychiatric Services for Individuals Age 21 and under in
Psychiatric Facilities or Programs).
2B. Mental Health Facility Services -- DSH Adjustment Payments. - (See 42
CFR 440.140 and 440.160). DSH payments are for the express purpose of
assisting hospitals that serve a disproportionate share of low-income
patients with special needs and are made in accordance with section 1923
of the Act.
Report the total payments that were determined to be disproportionate
share payments to the hospital by entering the amounts on the pop-up
feeder form which in turn will pre-fill the Form CMS-64.9D as well as the
appropriate lines on the Forms CMS-64.9, CMS-64.9P, CMS-64.21, CMS64.21P, CMS-6421U or CMS-64.21UPs.

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Line

Line - Form Display

2C

Certified Community
Behavior Health Clinic
Payments

Line - Definition

2C - Certified Community Behavior Health Clinic Payments
On April 1, 2014, the Protecting Access to Medicare Act of 2014
(Public Law 113-93) was enacted. The law included “Demonstration
Programs to Improve Community Mental Health Services” at Section
223 of the Act. This eight-state demonstration will be made
operational January 1, 2017 through July 1, 2017 and will serve
adults with serious mental illness, children with serious emotional
disturbance, and those with long term and serious substance use
disorders, as well as others with mental illness and substance use
disorders. The eight states selected for the demonstration (see
state listing below) must pay certified clinics using a prospective
payment system (PPS) that applies to fee for service (FFS) payment
and payment made through managed care. Demonstration
expenditures are eligible for enhanced federal matching funds.
States must stop reporting demonstration expenditures eligible for
enhanced FMAP at the end of their programs. In accordance with
Section 1132 of the Social Security Act and the implementing
regulations at 45 CFR, Part 95, Subpart A states can make claim
adjustments within two years after the calendar quarter in which
the state agency made the original expenditure for their
demonstrations. When states end their programs, they will cease
reporting demonstration expenditures on the new CMS-64/64.21
lines. A demonstration state may choose to continue services in
another form through the state plan or through their managed care
programs but these expenditures would be reported using the
established 1905a reporting categories and existing FMAPs, not
enhanced FMAP.

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Appendix I

Line

Line - Form Display

Line - Definition

3A

Nursing Facility Services - Reg.
Payments

3A. - Nursing Facility Services.--Regular Payments. -- (Other than services in
an institution for mental health conditions). (See 42 CFR 483.5 and
440.155).
These are services provided by an institution (or a distinct part of an
institution) which:








3B

Nursing Facility Services - Sup.
Payments

Is primarily engaged in providing to residents:
Skilled nursing care and related services for residents
who require medical or nursing care;
Rehabilitation services for the rehabilitation of injured,
disabled or sick persons; or
On a regular basis, health-related care and services to
individuals who because of their mental or physical
condition require care and services (above the level of
room and board) which can be made available to them
only through institutional facilities, and is not primarily
for the care and treatment of mental health conditions;
and,
Meet the requirements for a nursing facility described in
subsections 1919 (b), (c) and (d) of the Act regarding:

 Requirements relating to Provision of Services,
 Requirements relating to Residences Rights, and,
 Requirements relating to Administration and Other Matters.
3B. - Nursing Facility Services - Supplemental Payments. -- (Other than
services in an institution for mental health conditions). (Refer to the
definition on Line 3A above). These are payments made in addition to the
standard fee schedule or other standard payment for those services.
These payments are separate and apart from regular payments and are
based on their own payment methodology. Payments may be made to all
providers or targeted to specific groups or classes of providers. Groups
may be defined by ownership type (state, county or private) and/or by the
other characteristics, e.g., caseload, services or costs. The combined
standard payment and supplemental payment cannot exceed the upper
payment limit described in 42 CFR 447.272.
Address supplemental payments for nursing facility services associated
with
(1) state government operated facilities,
(2) non-state government operated facilities, and
(3) Privately operated facilities by entering payments on the pop-up
feeder form.

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Appendix I

Line

Line - Form Display

4A

Intermediate Care Facility
Services – Individuals with
Intellectual Disabilities: Public
Providers

Line - Definition
4A Intermediate Care Facility Services - Public Providers – Individuals with
Intellectual Disabilities (ICF/IID) (See 42 CFR 440.150).
These include services provided in an institution for individuals with
intellectual disabilities or persons with related conditions if:





The primary purpose of the institution is to provide
health or rehabilitative services to such individuals;
The institution meets the standards in 42 CFR 442,
Subpart C (Intermediate Care Facility Requirements; All
Facilities); and,
Individuals with intellectual disabilities recipient for
whom payment is requested is receiving active
treatment as defined in 42 CFR 435.1009.

NOTE: Line 4 is divided into sections for public providers (Line 4.A.) and
private providers (Line 4.B.). Public providers are owned or operated by a
State, county, city or other local governmental agency or instrumentality.
Increasing adjustments related to private providers are considered current
expenditures for the quarter in which the expenditure was made and are
matched at the FMAP rate for that quarter. Increasing adjustments related
to public providers are considered adjustments to prior period claims and
are matched using the FMAP rate in effect at the earlier of the time the
expenditure was paid or recorded by any State agency. (See 45 CFR Part 95
and §2560.)

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Line

Line - Form Display

4B

Intermediate Care Facility
Services - Individuals with
Intellectual Disabilities: Private
Providers

Line - Definition
4B --Intermediate Care Facility Services - Private Providers - Individuals
with Intellectual Disabilities (ICF/IID). (See 42 CFR 440.150).
These include services provided in an institution for individuals with
intellectual disabilities or persons with related conditions if:






4C

Intermediate Care Facility
Services – Individuals with
Intellectual Disabilities:
Supplemental Payments

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The primary purpose of the institution is to provide
health or rehabilitative services to such individuals;
The institution meets the standards in 42 CFR 442,
Subpart C (Intermediate Care Facility Requirements; All
Facilities); and
Individuals with intellectual disabilities recipient for
whom payment is requested is receiving active
treatment as defined in 42 CFR 435.1009.
NOTE: Line 4 is divided into sections for public providers
(Line 4.A.) and private providers (Line 4.B.). Public
providers are owned or operated by a State, county, city
or other local governmental agency or instrumentality.
Increasing adjustments related to private providers are
considered current expenditures for the quarter in
which the expenditure was made and are matched at
the FMAP rate for that quarter. Increasing adjustments
related to public providers are considered adjustments
to prior period claims and are matched using the FMAP
rate in effect at the earlier of the time the expenditure
was paid or recorded by any State agency. (See 45 CFR
Part 95 and §2560.)

Line 4C. Intermediate Care Facility Services (ICF/IID) - Supplemental
Payments (Refer to the definition on Line 4A above). These are payments
made in addition to the standard fee schedule or other standard payment
for those services. These payments are separate and apart from regular
payments and are based on their own payment methodology. Payments
may be made to all providers or targeted to specific groups or classes of
providers. Groups may be defined by ownership type (state, county or
private) and/or by the other characteristics, e.g., caseload, services or
costs. The combined standard payment and supplemental payment cannot
exceed the upper payment limit described in 42 CFR 447.272. Address
supplemental payments for ICF/IID services associated with (1) state
government operated facilities, (2) non-state government operated
facilities, and (3) privately operated facilities by entering payments on the
pop-up feeder form.

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Appendix I

Line

Line - Form Display

Line - Definition

5A

Physician & Surgical Services Reg. Payments

5A. - Physician and Surgical Services.--Regular Payments. -- (See 42 CFR
440.50.).--Whether furnished in the office, the recipient's home, a hospital,
a NF, or elsewhere, physicians' services are services provided:





5B

Physician & Surgical Services Sup. Payments

Within the scope of practice of medicine or osteopathy
as defined by State law; and
By, or under, the personal supervision of an individual
licensed under State law to practice medicine or
osteopathy.
NOTE: Exclude all services provided and billed for by a
hospital, clinic, or laboratory. Include any services
provided and billed by a physician under physician
services with the exception of lab and X-ray services.
Include such services provided and billed for by a
physician under the lab and X-ray services category. In a
primary care case management system under a
Freedom of Choice waiver, you sometimes use a
physician as the case manager. In these situations, the
physician is allowed to charge a flat fee for each person.
Although this fee is not truly a physician service, report
the expenditures for the fee on this line.

5B. - Physician and Surgical Services.--Supplemental Payments.-- (refer to
definition for Line 5A above) Payments for physician and other practitioner
services as defined in Line 5A that are made in addition to the standard fee
schedule payment for those services. When combined with regular
payments, these supplemental payments are equal to or less than the
Federal upper payment limit. Address supplemental payments for
physicians and practitioners associated with
(1) governmental hospitals or university teaching hospitals,
(2) private hospitals, and

5C

Physician & Surgical Services Evaluation and Management

5D

Physician & Surgical Services Vaccine codes

December 2020v4.0.0

(3) other supplemental payments by entering payment
information on the pop-up feeder sheet.
5C. Physician & Surgical Services - Evaluation and Management -- ACA
Section 1202 - Services in the category designated Evaluation and
Management in the Healthcare Common Procedure Coding System. 100%
Federal Share Matching.
5D. Physician & Surgical Services - Vaccine codes -- ACA Section 1202 Services related to immunization administration for vaccines and toxoids
for which CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or
90474 (as subsequently modified) apply under such system. 100% Federal
Share Matching Rate

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Appendix I

Line

Line - Form Display

6A

Outpatient Hospital Services Reg. Payments

Line - Definition
6A. - Outpatient Hospital Services.--Regular Payments. -- (See 42 CFR
440.20.).--These are preventive, diagnostic, therapeutic, rehabilitative, or
palliative services that:

-

6B

Outpatient Hospital Services Sup. Payments

7

Prescribed Drugs

Are furnished to outpatients;
Except in the case of nurse-midwife services (see 42 CFR
440.165), are furnished by, or under the direction of, a physician
or dentist; and
 Are furnished by an institution that:
Is licensed or formally approved as a hospital by an officially
designated authority for State standard setting; and
 Except in the case of medical supervision of nurse-midwife
services, meets the requirements for participation in Medicare.
(See 42 CFR 440.165.)
6B. - Outpatient Hospital Services.--Supplemental Payments.-- (refer to
definition for Line 6A above) Payments for outpatient hospital services as
defined in line 6A that are made in addition to the base fee schedule or
other standard payment for those services. These payments are separate
and apart from regular payments and are based on their own payment
methodology. The combined standard payment and supplemental
payment cannot exceed the Federal upper payment limit. Address
outpatient hospital services supplemental payments associated with (1)
state owned or operated hospitals, (2) non state government owned or
operated hospitals and (3) private hospitals by entering payment
information on the pop-up feeder sheet.
7 - Prescribed Drugs. (See 42 CFR 440.120(a).).--These are simple or
compound substances or mixtures of substances prescribed for the cure,
mitigation, or prevention of disease, or for health maintenance that are:






December 2020v4.0.0

Prescribed by a physician or other licensed practitioner of the
healing arts within the scope of a professional practice as defined
and limited by Federal and State law;
Dispensed by licensed pharmacists and licensed authorized
practitioners in accordance with the State Medical Practice Act;
and
Dispensed by the licensed pharmacist or practitioner on a written
prescription that is recorded and maintained in the pharmacist's
or practitioner's record.

162

Appendix I

Line

Line - Form Display

Line - Definition

7A1

Drug Rebate Offset - National

7A.1. Drug Rebate Offset.--This is a refund from the manufacturer to the
State Medical Assistance plan for single source drugs, innovator multiple
source drugs, and non-innovator multiple source drugs that are dispensed
to Medicaid recipients. Rebates are to take place quarterly. Report these
offsets as (1) National Agreement or (2) State Sidebar Agreement. National
Agreement refers to rebates manufacturers pay your State pursuant to the
manufacturers' agreements with CMS under OBRA 1990 provisions. State
Sidebar Agreements refer to rebates manufacturers pay under an
agreement directly with your State. These may have been entered into
before January 1, 1991, the effective date of the OBRA rebate program. Or
they may represent agreements your State entered into with a given
manufacturer on or after January 1, 1991, under which the manufacturer
pays at least as great a rebate as it would under the National Agreement.
All States receive rebates under the National Agreements. A few States
receive most of their rebates under the National Agreement, but some
States receive other rebates under their State Sidebar Agreement with
specific manufacturers. All manufacturer rebates received under CMS's
National Agreement are reported on Line 7.A.1, National Agreement. All
rebates received under State Sidebar Agreements are reported on Line
7.A.2, State Sidebar Agreement.
NOTE: Vaccines are not subject to the rebate agreements.

7A2

Drug Rebate Offset - State
Sidebar Agreement

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7A2. Drug Rebate Offset.--This is the rebate collected under a separate
State agreement Sidebar Agreement. These are rebates received that do
not fall under 7A1 (National Drug Rebate).

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Appendix I

Line

Line - Form Display

Line - Definition

7A3

MCO - National Agreement

7A.3. National Agreement 7A3. Managed Care Organizations (MCO) –
National Agreement: The Affordable Care Act requires manufacturers that
participate in the Medicaid Drug Rebate Program to pay rebates for drugs
dispensed to individuals enrolled with a Medicaid MCO if the MCO is
responsible for coverage of such drugs, effective March 23, 2010. This is a
refund from the manufacturer to the State Medical Assistance plan for
single source drugs, innovator multiple source drugs, and non-innovator
multiple source drugs that are dispensed to Medicaid recipients who are
enrolled in a Medicaid MCO. Rebates are to take place quarterly. Report
these offsets as MCO National Agreement. National Agreement refers to
rebates manufacturers pay your State pursuant to the manufacturers
agreements with CMS under OBRA 1990 provisions. All States receive
rebates under the National Agreement. For rebates for Medicaid MCO
drugs, there will be no rebates under their State Sidebar Agreement with
specific manufacturers. All MCO manufacturer rebates received under CMS
National Agreement are reported on Line 7.A.3, National Agreement
NOTE: Vaccines are not subject to the National agreement.

7A4

MCO - State Sidebar Agreement

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7A.4. MCO State Sidebar Agreement. This is the rebate collected under a
separate State agreement Sidebar Agreement. These are rebates received
that do not fall under 7A3 (National Drug Rebate).

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Appendix I

Line

Line - Form Display

7A5

Increased ACA OFFSET - Fee for
Service - 100%

Line - Definition
Brand name drugs that are blood clotting factors and drugs approved by
the FDA exclusively for pediatric indications are subject to a minimum
rebate percentage of 17.1 percent of AMP:







If the difference between AMP and BP is greater than
15.1 percent of AMP, but less than 23.1 percent of AMP,
then we plan to offset the difference between 23.1
percent of AMP and AMP minus BP.
If the difference between AMP and BP is less than or
equal to 15.1 percent of AMP, then we plan to offset
the full 2 percent of AMP (the difference between 17.1
percent of AMP and 15.1 percent of AMP).
If the difference between AMP and BP is greater than
15.1 percent of AMP, but less than 17.1 percent of AMP,
then we plan to offset the difference between 17.1
percent of AMP and AMP minus BP.
If the difference between AMP and BP is greater than or
equal to 17.1 percent of AMP, then we do not plan to
take any offset amount.

For a drug that is a line extension of a brand name drug that is an oral solid
dosage form, we plan to apply the same offset calculation as described
above to the basic rebate. Further, we plan to offset only the difference in
the additional rebate of the reformulated drug based on the calculation
methodology of the additional rebate for the drug preceding the
requirements of the Affordable Care Act and the calculation of the
additional rebate for the reformulated drug, if greater, in accordance with
the Affordable Care Act. If there is no difference in the additional rebate
amount in accordance with the Affordable Care Act, then we do not plan to
take any offset amount.
For a noninnovator multiple source drug, we plan to offset an amount
equal to two percent of the AMP (the difference between 13 percent of
AMP and 11 percent of AMP).

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7A6

Increased ACA OFFSET - MCO 100%

7A.6. Increased ACA OFFSET - MCO - 100% 7A6. Increased ACA OFFSET –
MCO: Similar to the increased ACA offset for fee-for-service, for covered
outpatient drugs that are dispensed to Medicaid MCO enrollees, the
Affordable Care Act also required that amounts “attributable” to the
increased rebates be remitted to the Federal Government. Below is a
description of how the offset is calculated: Brand name drugs other than
blood clotting factors and drugs approved by the Food and Drug
Administration (FDA) exclusively for pediatric indications are subject to a
minimum rebate percentage of 23.1 percent of AMP:







If the difference between AMP and BP is less than or
equal to 15.1 percent of AMP, then we plan to offset
the full 8 percent of AMP (the difference between 23.1
percent of AMP and 15.1 percent of AMP).
If the difference between AMP and BP is greater than
15.1 percent of AMP, but less than 23.1 percent of AMP,
then we plan to offset the difference between 23.1
percent of AMP and AMP minus BP.
If the difference between AMP and BP is greater than or
equal to 23.1 percent of AMP, then we do not plan to
take any offset amount.

Brand name drugs that are blood clotting factors and drugs approved by
the FDA exclusively for pediatric indications are subject to a minimum
rebate percentage of 17.1 percent of AMP:







If the difference between AMP and BP is less than or
equal to 15.1 percent of AMP, then we plan to offset
the full 2 percent of AMP (the difference between 17.1
percent of AMP and 15.1 percent of AMP).
If the difference between AMP and BP is greater than
15.1 percent of AMP, but less than 17.1 percent of AMP,
then we plan to offset the difference between 17.1
percent of AMP and AMP minus BP.
If the difference between AMP and BP is greater than or
equal to 17.1 percent of AMP, then we do not plan to
take any offset amount.

For a drug that is a line extension of a brand name drug that is an oral solid
dosage form, we plan to apply the same offset calculation as described
above to the basic rebate. Further, we plan to offset only the difference in
the additional rebate of the reformulated drug based on the calculation
methodology of the additional rebate for the drug preceding the
requirements of the Affordable Care Act and the calculation of the
additional rebate for the reformulated drug, if greater, in accordance with
the Affordable Care Act. If there is no difference in the additional rebate

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Appendix I

Line

Line - Form Display

Line - Definition
amount in accordance with the Affordable Care Act, then we do not plan to
take any offset amount.
For a noninnovator multiple source drug, we plan to offset an amount
equal to two percent of the AMP (the difference between 13 percent of
AMP and 11 percent of AMP).

8

Dental Services

8. Dental Services (See 42 CFR 440.100.).--These are services that are
diagnostic, preventive, or corrective procedures provided by, or under the
supervision of, a dentist in the practice of his/her profession including
treatment of:



The teeth and associated structures of the oral cavity; and,
Disease, injury, or impairment that may affect the oral or general
health of the recipient.
Report all EPSDT dental services on this line.
Dentist means an individual licensed to practice dentistry or dental
surgery.
NOTE: Exclude all such services provided as part of inpatient hospital,
outpatient hospital, nondental, clinic or laboratory services and billed for
by the hospital, nondental clinic, or laboratory.
9A

Other Practitioners Services Reg. Payments

9A. - Other Practitioners Services - Regular Payments (see CFR 440.60).
Any medical or remedial care or services, other than physicians' services,
provided by licensed practitioners with the scope of practice defined under
State law. Chiropractors' services may be included here as long as the
services that (1) are provided by a chiropractor who is licensed by the State
and meets standards issued by the Secretary under section 405.232(b), and
(2) consists of treatment by means of manual manipulation of the spine
that the chiropractor is legally authorized by the State to perform.

9B

Other Practitioners Services Sup. Payments

9B. - Other Practitioners Services - Supplemental Payments. Payments for
other practitioner services as defined in Line 9A that are made in addition
to the standard fee schedule payment for those services. When combined
with regular payments, these supplemental payments are equal to or less
than the Federal upper payment limit. Address supplemental payments for
other practitioners associated with (1) governmental hospitals or university
medical schools, and (2) private hospitals or university medical schools,
and (3) other supplemental payments by entering payment information on
the pop-up feeder sheet.

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Line

Line - Form Display

10

Clinic Services

Line - Definition
10. Clinic Services (See 42 CFR 440.90.).--These are preventive, diagnostic,
therapeutic, rehabilitative, or palliative items or services that:
Are provided to outpatients;


Are provided by a facility that is not part of a hospital but is
organized and operated to provide medical care to outpatients.
For reporting purposes, consider a group of physicians who share,
only for mutual convenience, space, services of supporting staff,
etc., as physicians, rather than a clinic, even though they practice
under the name of a clinic; and
 Except in the case of nurse-midwife services (see 42 CFR
440.165), are furnished by, or under, the direction of a physician.
NOTE: Place dental clinics under Dental Services. Report any services not
included above under Other Care Services. A clinic staff may include
practitioners with different specialties.
11

Laboratory/Radiological

11. Laboratory And Radiological Services (See 42 CFR 440.30.).--These are
professional, technical laboratory and radiological services:


Ordered and provided by, or under, the direction of a physician or
other licensed practitioner of the healing arts within the scope of
a practice as defined by State law or ordered and billed by a
physician but provided by an independent laboratory;



Provided in an office or similar facility other than a
hospital inpatient or outpatient department or clinic;
and
 Provided by a laboratory that meets the requirements
for participation in Medicare.

NOTE: Report X-rays by dentists under Dental
Services, Line 8.

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Line

Line - Form Display

Line - Definition

12

Home Health Services

12, Home Health Services (See 42 CFR 440.70.).--These are services
provided at the patient's place of residence in compliance with a
physician's written plan of care that is renewed every 60 days and includes
the following items and services:



Nursing service as defined in the State Nurse Practice
Act that is provided on a part-time or intermittent basis
by a home health agency (HHA) (a public or private
agency or organization, or part of an agency or
organization that meets the requirements for
participation in Medicare). If there is no agency in the
area, a registered nurse who:






13

December 2020v4.0.0

Sterilizations

Is licensed to practice in the State;
Receives written orders from the patient's physician;
Documents the case and services provided; and
Has had orientation to acceptable clinical and administrative
record keeping from a health department nurse.
Home health aide services provided by an HHA;
 Medical supplies, equipment, and appliances suitable for use in
the home; and
 Physical therapy, occupational therapy, or speech pathology and
audiology services provided by an HHA or by a facility licensed by
the State to provide medical rehabilitation services. (See 42 CFR
441.15 - Home Health Services.)
Place of residence is normally interpreted to mean the patient's home,
and does not apply to hospitals or NFs. Services received in a NF that are
different from those normally provided as part of the institution's care may
qualify as Home Health Services. For example, a registered nurse may
provide short-term care for a recipient in a NF during an acute illness to
avoid the recipient's transfer to another NF.
13. Sterilizations (See 42 CFR 441, Subpart F.).--These are medical
procedures, treatments, or operations for the primary purpose of
rendering an individual permanently incapable of reproducing.

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Appendix I

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Line - Definition

14

Other Pregnancy-related
ProceduresAbortions

14. Other Pregnancy-related Procedures (See 42 CFR 441, Subpart E.).--FFP
is available when a physician has certified, in writing, to the Medicaid
agency, that on the basis of professional judgment the woman suffers from
a physical disorder, physical injury, or physical illness, including a lifeendangering physical condition caused by or arising from the pregnancy
itself, that would, as certified by a physician, place the woman in danger of
death unless a termination is performed. The certification must contain
the name and address of the patient.
The revision to the Hyde Amendment, P.L. 103-112, Health and Human
Services Appropriations Bill, made FFP available for expenditures for other
pregnancy-related procedures when the pregnancy is a result of an act of
rape or incest. This reimbursement is effective for dates of service October
1, 1993 and thereafter.

Provide a breakout of the number of other pregnancyrelated procedures and associated expenditures in the
following cases:
 ProceduresAbortions performed to save the life of the
mother,
 ProceduresAbortions performed in the case of
pregnancies resulting from incest, and
 ProceduresAbortions performed in the case of
pregnancies resulting from rape.
NOTE 1: Report all other pregnancy-related procedures on this line
regardless of the type of provider. For prior period adjustments, only
include any entry in number of procedures if, for increasing claims, it is a
new pregnancy-related procedure that has not been previously reported,
or, for decreasing claims, you want to remove a procedure previously
claimed. Make no entry in number of procedures if all you are changing is
the dollar amount claimed.
NOTE 2: The "morning after pill" (ECP) is not considered a termination as it
is a contraceptive to prevent pregnancy. However, the drug Mifepristone
(RU486) should be counted as another pregnancy-related procedure as
long as all Hyde amendment and other federal requirements are met.

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Line

Line - Form Display

Line - Definition

15

EPSDT Screening

15. EPSDT Screening Services - Physical and mental assessment given to
Medicaid eligibles under age 21 to carry out the screening provisions of the
EPSDT program. However, the agency must provide at least the following
services through consultation with health experts, determine the specific
health evaluation procedures to be used, and the mechanisms needed to
carry out the screening program.









A comprehensive health and developmental history
(including assessment of both physical and mental
health development);
A comprehensive unclothed physical exam;
Appropriate immunizations according to the Advisory
Committee on Immunization Practices
Laboratory tests (including blood lead level assessment
according to age/risk factors);
Health education (including anticipatory guidance); and
Dental Services - Referral to a dentist in accordance with
the States’ periodicity schedule.
Vision Services

The above services may be provided by any qualified Medicaid provider.
NOTE: Do not include data for dental, hearing, or vision services here.
Report dental examinations and preventative dental services on Line 8,
Dental Services. Report hearing services, including hearing aids, on Line
32, Services for Speech, Hearing and Language. Report vision services
rendered by professionals (e.g. – examinations, etc.) on Line 9, Other
Practitioners' Services. Note that the cost of eyeglasses and other aids to
vision is to be reported on Line 33, Prosthetic Devices, Dentures, and
Eyeglasses. Report other necessary health care according to the
appropriate category.

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16

Rural Health

16. Rural Health Clinic (RHC) Services (See 42 CFR 440.20(b).).--If a State
permits the delivery of primary care by a nurse practitioner (NP) or
physician's assistant (PA), rural health clinic (RHC) means the following
services furnished by a RHC that has been certified in accordance with the
conditions of 42 CFR Part 491 (Certification of Certain Health Facilities):














December 2020v4.0.0

Services furnished by a physician within a professional
scope under State law, whether the physician performs
these services in or away from the clinic and the
physician has an agreement with the clinic to be paid by
it for such services.
Services furnished by a PA, NP, nurse midwife or other
specialized NP (as defined in 42 CFR 405.2401 and
491.2) if they are furnished in accordance with the
requirements specified in 42 CFR 405.2414(a).
Services and supplies that are furnished as incident to
professional services furnished by a physician, PA, NP,
nurse midwife, or specialized NP. (See 42 CFR 405.2413
and 405.2415 for the criteria determining whether
services and supplies are included.)
Part-time or intermittent visiting nurse care and related
medical supplies (other than drugs and biological) if:
The clinic is located in an area in which the Secretary
has determined that there is a shortage of HHAs (see 42
CFR 405.2417);
The services are furnished by an RN or licensed PN or a
licensed vocational nurse employed by, or otherwise
compensated for the services by, the clinic;
The services are furnished under a written plan of
treatment that is established and reviewed at least
every 60 days by a supervising physician of the clinic or
that is established by a physician, PA, NP, nurse
midwife, or specialized NP and reviewed and approved
at least every 60 days by a supervising physician of the
clinic; and
The services are furnished to a homebound recipient.
For purposes of visiting nurse services, a homebound
recipient means one who is permanently or temporarily
confined to a place of residence because of a medical or
health condition, and leaves the place of residence
infrequently. For this purpose, place of residence does
not include a hospital or an NF.Rural Health Clinic (RHC)
Services (See 42 CFR 440.20(b).).--If a State permits the
delivery of primary care by a nurse practitioner (NP) or
physician's assistant (PA), rural health clinic (RHC)
means the following services furnished by a RHC that
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Line

Line - Form Display

16

Rural Health

Line - Definition














17A

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Medicare - Part A

has been certified in accordance with the conditions of
42 CFR Part 491 (Certification of Certain Health
Facilities):
Services furnished by a physician within a professional
scope under State law, whether the physician performs
these services in or away from the clinic and the
physician has an agreement with the clinic to be paid by
it for such services.
Services furnished by a PA, NP, nurse midwife or other
specialized NP (as defined in 42 CFR 405.2401 and
491.2) if they are furnished in accordance with the
requirements specified in 42 CFR 405.2414(a).
Services and supplies that are furnished as incident to
professional services furnished by a physician, PA, NP,
nurse midwife, or specialized NP. (See 42 CFR 405.2413
and 405.2415 for the criteria determining whether
services and supplies are included.)
Part-time or intermittent visiting nurse care and related
medical supplies (other than drugs and biological) if:
The clinic is located in an area in which the Secretary
has determined that there is a shortage of HHAs (see 42
CFR 405.2417);
The services are furnished by an RN or licensed PN or a
licensed vocational nurse employed by, or otherwise
compensated for the services by, the clinic;
The services are furnished under a written plan of
treatment that is established and reviewed at least
every 60 days by a supervising physician of the clinic or
that is established by a physician, PA, NP, nurse
midwife, or specialized NP and reviewed and approved
at least every 60 days by a supervising physician of the
clinic; and
The services are furnished to a homebound recipient.
For purposes of visiting nurse services, a homebound
recipient means one who is permanently or temporarily
confined to a place of residence because of a medical or
health condition, and leaves the place of residence
infrequently. For this purpose, place of residence does
not include a hospital or an NF.

17A. Part A Premiums--(See §301 P.L. 100-360 and §1902 (a)(10) (E)(ii) of
the Act) -- Include Part A premiums paid for Qualified Disabled and
Working Individuals (QWDIs) under §1902(a)(10)(E)(ii) of the Act.

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Line

Line - Form Display

Line - Definition

17B

Medicare - Part B

17B. Part B Premiums--(See §1902(a). Part B Premiums - Include premiums
paid through Medicare buy-in under 1843 for Qualified Medicare
Beneficiaries (QMBs) under 1902(a)(10)(E)(i),Specified Low-Income
Medicare Beneficiaries (SLMBs) under 1902(a)(10)(E)(iii),and other
Medicare/Medicaid dual eligibles covered in 1902(a)(10) of the Act. Do
not include part B premiums for line 17C (Qualifying Individuals). This
amount is shown on the bottom of each monthly bill sent to you on the
summary accounting statement Form CMS-1604.

17C1

120% - 134% Of Poverty

Line 17C.1. - 120% - 134% of Poverty - Include premiums paid for Medicare
Part B under §1902(a)(10)(E)(iv)(I).

17D

Coinsurance

17D. Coinsurance and Deductibles-- Include Medicare deductibles and
coinsurance required to be paid for QMBs under §1905 (p)(3). (Do not
include any Medicare deductibles and coinsurance for other
Medicare/Medicaid dual eligibles. Report expenditures for Medicaid
services also covered by Medicare under the appropriate Medicaid service
category.) Coinsurance is a joint assumption of risk by the insured and the
insurer, whereby each shares on a specific basis, the applicable medical
expenses of the insured. The insured's share of coinsurance may be paid
on his/her behalf. For example, under part B of Medicare, the beneficiary's
coinsurance responsibility is a percent of reasonable and customary
expenses greater than the stipulated deductible. A deductible is that
portion of applicable medical expenses which must be borne by the
insured (or be paid on his/her behalf) before insurance benefits for the
calendar year begin.
EXCEPTION: REPORT ALL OTHER PREGNANCY-RELATED PROCEDURES ON
LINE 14.

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Line

Line - Form Display

Line - Definition

18A

Medicaid - MCO

18A. Managed Care Organizations (MCOs) -- (See §1903(m)(1)(A) of the Act
revised by BBA §4701(b)). - Include capitated payments made to a
Medicaid Managed Care Organization which is defined as follows:
A Medicaid Managed Care Organization (MCO) means a health
maintenance organization, an eligible organization with a contract
under §1876 or a Medicare+ Choice organization with a contract under
part C of title XVIII, a provider sponsored organization, which meets
the requirements of §1902(w)and (i)

makes services it provides to individuals eligible for
benefits under this title accessible to such
individuals, within the area served by the
organization, to the same extent as such services are
made accessible to individuals (eligible for Medical
Assistance under the State plan) not enrolled with
the organization, and

(ii)

has made adequate provision against the risk of
insolvency, which provision is satisfactory to the
State and which assures that individuals eligible for
benefits under this title are in no case held liable for
debts of the organization in case of the
organization's insolvency.

An organization that is a qualified health maintenance organization (as
defined in §1310(d) of the Public Health Service Act) is deemed to meet the
requirements of clauses (i) and (ii).
18A1

Medicaid MCO - Evaluation and
Management

18A1. Medicaid MCO - Evaluation and Management -- ACA Section 1202 Services in the category designated Evaluation and Management in the
Healthcare Common Procedure Coding System. 100% Federal Share
Matching.

18A2

Medicaid MCO - Vaccine codes

18A2. Medicaid MCO - Vaccine codes -- ACA Section 1202 - Services related
to immunization administration for vaccines and toxoids for which CPT
codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as
subsequently modified) apply under such system. 100% Federal Share
matching rate

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Line

Line - Form Display

Line - Definition

18A3

Medicaid MCO - Community
First Choice

18A3. Medicaid MCO - Community First Choice -- 6% FMAP rate for Total
Computable entered at the FMAP Federal Share rate. ACA Section 2401 The provision established a new Medicaid State Plan option effective
October 1, 2011 to allow States to cover HCBS and supports for individuals
with incomes not exceeding 150 percent of the FPL, or, if greater, who
have been determined to require an institutional level of care. States are
provided an additional 6% increase in the FMAP matching funds for
services and supports provided to such individuals.

18A4

Medicaid MCO - Preventive
Services Grade A OR B, ACIP
Vaccines and their Admin

18A4. Medicaid MCO - Preventive Services Grade A or B, ACIP Vaccines and
their Admin -- 1% FMAP rate for Total Computable entered at the FMAP
Federal Share rate. As a result of ACA 4106 Any clinical preventive services
that are assigned a grade of A or B by the United States Preventive Services
Task Force. States get the 1% additional FMAP upon an approved SPA.
Effective January 1, 2013

18A5

Medicaid MCO - Certified
Community Behavior Health
Clinic Payments

18A5 - Medicaid MCO - Certified Community Behavior Health Clinic
Payments

18B1

Prepaid Ambulatory Health
Plan

A Prepaid Ambulatory Health Plan (PAHP) means an entity that provides
medical services to enrollees under contract with the State agency, and on
the basis of prepaid capitation payments, or other payment arrangements
that do not use State plan payment rates. A PAHP does not provide or
arrange for the provision of any inpatient hospital or institutional services
for its enrollees, and does not have a comprehensive risk contract.
NOTE: Include dental, mental health, transportation and other plans
covering limited services (without inpatient hospital or institutional
services) under PAHP.

18B1a

MCO PAHP - Evaluation and
Management

18B1a. MCO PAHP - Evaluation and Management -- ACA Section 1202 Services in the category designated Evaluation and Management in the
Healthcare Common Procedure Coding System. 100% Federal Share
Matching.

18B1b

MCO PAHP - Vaccine codes

18B1b. MCO PAHP - Vaccine codes -- ACA Section 1202 - Services related to
immunization administration for vaccines and toxoids for which CPT codes
90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as
subsequently modified) apply under such system. 100% Federal Share
matching rate

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Line

Line - Form Display

Line - Definition

18B1c

MCO PAHP - Community First
Choice

18B1c. MCO PAHP - Community First Choice -- 6% FMAP rate for Total
Computable entered at the FMAP Federal Share rate. ACA Section 2401 The provision established a new Medicaid State Plan option effective
October 1, 2011 to allow States to cover HCBS and supports for individuals
with incomes not exceeding 150 percent of the FPL, or, if greater, who
have been determined to require an institutional level of care. States are
provided an additional 6% increase in the FMAP matching funds for
services and supports provided to such individuals.

18B1d

MCO PAHP - Preventive
Services Grade A OR B, ACIP
Vaccines and their Admin

18B1d. MCO PAHP. Preventive Services Grade A OR B, ACIP Vaccines and
their Admin -- 1% FMAP rate for Total Computable entered at the FMAP
Federal Share rate. As a result of ACA 4106 Any clinical preventive services
that are assigned a grade of A or B by the United States Preventive Services
Task Force. States get the 1% additional FMAP upon an approved SPA.
Effective January 1,

18B1e

Medicaid PAHP - Certified
Community Behavior Health
Clinic Payments

18B1e - Medicaid PAHP - Certified Community Behavior Health Clinic
Payments

18B2

Prepaid Inpatient Health Plan

A Prepaid Inpatient Health Plan (PIHP) means an entity that provides
medical services to enrollees under contract with the State agency, and on
the basis of prepaid capitation payments, or other payment arrangements
that do not use State plan payment rates. A PIHP provides, arranges for, or
otherwise has responsibility for the provision of any inpatient hospital or
institutional services for its enrollees. A PIHP does not have a
comprehensive risk contract.
NOTE: Include dental, mental health, transportation and other plans
covering limited services (with inpatient hospital or institutional services)
under PIHP.

18B2a

MCO PIHP - Evaluation and
Management

18B2a. MCO PIHP - Evaluation and Management -- ACA Section 1202 Services in the category designated Evaluation and Management in the
Healthcare Common Procedure Coding System. 100% Federal Share
Matching.

18B2b

MCO PIHP - Vaccine codes

18B2b. MCO PIHP - Vaccine codes -- ACA Section 1202 - Services related to
immunization administration for vaccines and toxoids for which CPT codes
90465, 90466, 90467, 90468, 90471, 90472, 90473, or 90474 (as
subsequently modified) apply under such system. 100% Federal Share
matching rate

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Line

Line - Form Display

Line - Definition

18B2c

MCO PIHP - Community First
Choice

18B2c. MCO PIHP - Community First Choice -- 6% FMAP rate for Total
Computable entered at the FMAP Federal Share rate. ACA Section 2401 The provision establishes a new Medicaid State Plan option effective
October 1, 2011 to allow States to cover HCBS and supports for individuals
with incomes not exceeding 150 percent of the FPL, or, if greater, who
have been determined to require an institutional level of care. States are
provided an additional 6% increase in the FMAP matching funds for
services and supports provided to such individuals.

18B2d

MCO PIHP - Preventive Services
Grade A OR B, ACIP Vaccines
and their Admin

18B2d. MCO PIHP. Preventive Services Grade A OR B, ACIP Vaccines and
their Admin -- 1% FMAP rate for Total Computable entered at the FMAP
Federal Share rate. As a result of ACA 4106 Any clinical preventive services
that are assigned a grade of A or B by the United States Preventive Services
Task Force. States get the 1% additional FMAP upon an approved SPA.
Effective January 1,

18B2e

Medicaid PIHP Certified Community Behavior
Health Clinic Payments

18B2e - Medicaid PIHP - Certified Community Behavior Health Clinic
Payments

18C

Medicaid - Group Health

18C. Group Health Plan Payments-- Include payments for premiums for
cost effective employer group health insurance under §1906 of the Act.

18D

Medicaid - Coinsurance

18D. Coinsurance and Deductibles-- Include payments for coinsurance
and deductibles for cost employer group health insurance under §1906 of
the Act.

18E

Medicaid - Other

18E. Other--Include premiums paid for other insurance for medical or any
other type of remedial care in order to maintain a third party resource
under §1905(a). (Report expenditures here only if you have elected to pay
these premiums in item 3.2(a)(2) on page 29b of your State Plan Preprint.)
EXCEPTION: REPORT ALL OTHER PREGNANCY-RELATED PROCEDURES ON
LINE 14.

19A

Home & Community-Based
Services - Reg. Pay. (Waiv)

19A. Home and Community-Based Services (See 42 CFR 440.180.(a).).-These are services furnished under a 1915(c) waiver approved under the
provisions in 42 CFR 441, Subpart G (Home and Community-Based Services;
Waiver Requirements).
NOTE: Report only approved waiver services as designated in the State's
approved waiver applications which are provided to eligible waiver
recipients.

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Line

Line - Form Display

Line - Definition

19B

Home & Community-Based
Services - St. Plan 1915(i) Only
Pay.

19B. - Other Practitioners Services - State Plan 1915(i) Only Payment. Only
the home and community based services elected and defined in the
approved State plan may be claimed on this line and form. Enter cost data
on the lines in the pop-up feeder sheet that match the services approved in
the State plan.

19C

Home & Community-Based
Services - St. Plan 1915(j) Only
Pay.

19C Home and Community Based Services – State Plan 1915(j) Only
Payment – 42 CFR Part 441 – Self-Directed Personal Assistance Services
Program State Plan Option. These are PAS services provided under the
self-directed service delivery model authorized by 1915(j) including any
approved home and community-based services otherwise available under
a 1915(c) waiver. The MBES will automatically enter in row 19C the totals
from the pop-up 1915(j) Self-Directed Personal Assistance Services Feeder
Form. Expenditures for 1915(c) waiver like services provided under 1915(j)
Self Direction are entered on the line 19C Feeder Form rather than on the
Line 19A Waiver Form which is reserved for approved waiver expenditures.
NOTE: 1915(j) services that are using the self-directed service delivery
model for State Plan Personal Care and related services should be claimed
separately on Line 23B.

19D

Home & Community Based
Services State Plan 1915(k)
Community First Choice

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19D Home and Community Based Services State Plan 1915(k) Community
First Choice ACA Section 2401 - The provision established a new Medicaid
State Plan option effective October 1, 2011 to allow States to cover HCBS
and supports for individuals with incomes not exceeding 150 percent of the
FPL, or, if greater, who have been determined to require an institutional
level of care. States are provided an additional 6% increase in the FMAP
matching funds for services and supports provided to such individuals.

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Line

Line - Form Display

22

All-Inclusive Care Elderly

Line - Definition
22. Programs of All-Inclusive Care for the Elderly (PACE)(See 42 CFR Part
460).--PACE provides pre-paid, capitated, comprehensive health care
services designed to enhance the quality of life and autonomy for frail,
older adults. Required services (See 42 CFR 460.92) The PACE benefit
package for all participants, must include:
(a) All Medicaid-covered services, as specified in the State's approved
Medicaid plan.
NOTE: This is an option within the Medicaid Program to establish
Programs of All-Inclusive Care for the Elderly beginning August 5, 1998.
(See §1905(a)(26) and §1934 of the Act.) Do not report payments for PACE
programs which continue to operate under §1115 authority on this line.
Report payments for PACE programs continuing to operate under §1115
waiver authority on the appropriate waiver forms under the appropriate
categories of services.

23A

Personal Care Services - Reg.
Payments

23A. - Personal Care Services.--Regular Payment.-- (See 42 CFR 440.167).-Unless defined differently by a State agency for purposes of a waiver
granted under Part 441, subpart G of this chapter
Personal care services means services furnished to an individual who is not
an inpatient or resident of a hospital, nursing facility, intermediate care
facility for individuals with intellectual disabilities, or institution for mental
health conditions that are-(1) Authorized for the individual by a physician in accordance with a
plan of treatment or (at the option of the State) otherwise
authorized for the individual in accordance with a service plan
approved by the State;
(2) Provided by an individual who is qualified to provide such services
and who is not a member of the individual's family; and

23B

Personal Care Services - SDS
1915(j)

(3) Furnished in a home, and at the State's option in another location.
23B. - Personal Care Services.--SDS 1915(j). -- (See 42 CFR Part 441). -- SelfDirected Personal Assistance Services (PAS) State Plan Option. These are
PAS provided under the self-directed service delivery model authorized by
1915(j) for State plan personal care and related services.
NOTE: 1915(j) PAS that are using the self-directed service delivery model
for section 1915(c) home and community-based services should be claimed
separately on line 19C.

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Line

Line - Form Display

Line - Definition

24A

Targeted Case Management
Services - Com. Case-Man.

24A. - Targeted Case Management Services (see section 1915(g)(1) of the
Social Security Act) are case management services that are furnished
without regard to the requirements of section 1902(a)(1) and section
1902(a)(10)(B) to specific classes of individuals or to individuals who reside
in specified areas. Case management services means services which will
assist individuals eligible under the plan in gaining access to needed
medical, social, educational, and other services (See section 1915(g)(2) of
the Act).

24B

Case Management - State Wide

24B. - Case Management.--State Wide. -- (See §1915(g)(2) of the Act.).-These are services that assist individuals eligible under the State plan in
gaining access to needed medical, social, educational and other services.
The agency must permit individuals to freely choose any qualified Medicaid
provider when obtaining case management services in accordance with 42
CFR 431.51.

25

Primary Care Case
Management

25. Primary Care Case Management Services (PCCM) (See §1905(a)(25) and
§1905 (t)--These are case-management related services (including locating,
coordinating, and monitoring of health care services) provided by a
primary care case manager under a primary care case management
contract. Currently most PCCM programs pay the primary care case
manager a monthly case management fee. Report service costs and/or
related fees on this line. Report other service costs and/or related fees on
the appropriate type of service line.
NOTE: Where the fee includes services beyond case management, report
the fees under line 18B.

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Line

Line - Form Display

26

Hospice Benefits

Line - Definition
26 - Hospice Benefits (See Section 1905(o)(1)(A) of the Act.).--The care
described in section 1861(dd)(1) furnished by a hospice program (as
defined in section 1861(dd)(2)) to a terminally ill individual who has
voluntarily elected to have payment made for hospice care instead of
having payment made for certain benefits described under 1812(d)(2)(A)
and for which payment may otherwise be made under Title XVIII and
intermediate care facility services under the plan. Hospice care may be
provided to an individual while such individual is a resident of a skilled
nursing facility or intermediate care facility, but the only payment made
under the State plan shall be for the hospice care.
NOTE: These are services that are:







Meets the requirements for participation in Medicare specified in
42 CFR 418, Subpart C or by others under an arrangement made
by a hospice program that meets those requirements; and
Is a participating Medicaid provider;





27

Emergency Services for
Undocumented Aliens

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Covered in 42 CFR 418.202;
Furnished to a terminally ill individual, as defined in 42
CFR 418.3;
Furnished by a hospice, as defined in 42 CFR 418.3, that:

Furnished under a written plan that is established and
periodically reviewed by:
The attending physician;
The medical director of the program, as described in 42
CFR 418.54; or
The interdisciplinary group described in 42 CFR 418.68.

27. Emergency Services Undocumented Aliens Pursuant to the Act
The Medicaid program pays for emergency medical services provided to
certain aliens. Section §1903(v) of the Act sates that "...no payment may
be made to a State under this section for medical assistance furnished to
an alien who is not lawfully admitted... "The only exception is if such care
and services are for
1)

an emergency medical condition,

2)

if such alien otherwise meets the eligibility requirements for
medical assistance under the State Plan, and

3)

such care and services are not related to an organ transplant
procedure.

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Appendix I

Line

Line - Form Display

Line - Definition

28

Federally-Qualified Health
Center

28. Federally-Qualified Health Center (FQHC) (See §1905(a)(2) of the Act.) -These are services performed by facilities or programs more commonly
known as Community Health Centers, Migrant Health Centers, and Health
Care for the Homeless Programs. FQHCs qualify to provide covered services
under Medicaid if:




29

Non-Emergency Medical
Transportation

They receive grants under §§329, 330, or 340 of the
Public Health Service (PHS) Act;
The Health Resources and Services Administration, PHS
certifies the center as meeting FQHC requirements; or
The Secretary determines that the center qualifies
through waiver of the requirements.

29. - Non-Emergency Medical Transportation (see 42CFR431.53; 440.170;
440.170(a); 440.170(a)(4))--A ride, or reimbursement for a ride, provided
so that a Medicaid beneficiary with no other transportation resources can
receive services from a medical provider. (NEMT does not include
transportation provided on an emergency basis, such as trips to the
emergency room for life-threatening situations.
NOTE: Transportation provided via the State is consider an administrative
cost and should be reported on the form CMS-64.10.

30

Physical Therapy

30. - Physical Therapy (See 42CFR440.110(a)(1)).--Services prescribed by a
physician or other licensed practitioner of the healing arts within the scope
of his or her practice under State law and provided to a recipient by or
under the direction of a qualified physical therapist. It includes any
necessary supplies and equipment.
NOTE: Do not include any costs for physical therapy services provided
under the school based environment. Those costs should be reported on
the pop-up feeder form for Line 39 below.
NOTE: Do not include any costs for physical therapy services provided
under the rehabilitative services option. Those costs should be reported
on the pop-up feeder form for Line 40 below.

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Line

Line - Form Display

Line - Definition

31

Occupational Therapy

31. - Occupational Therapy (see 42CFR440.110(b))--Occupational therapy
means services prescribed by a physician or other licensed practitioner of
the healing arts within the scope of his or her practice under State law and
provided to a recipient by or under the direction of a qualified occupational
therapist. It includes any necessary supplies and equipment.
NOTE: Do not include any costs for occupational therapy services provided
under the school based environment. Those costs should be reported on
the pop-up feeder form for Line 39 below.
NOTE: Do not include any costs for occupational therapy services
provided under the rehabilitative services option. Those costs should be
reported on the pop-up feeder form for Line 40 below.

32

Services for Speech, Hearing &
Language

32. - Services for Speech, Hearing and Language--Services for individuals
with speech, hearing, and language disorders (See 42CFR440.110(c)).
Services for individuals with speech, hearing, and language disorders
means diagnostic, screening, preventive, or correction services provided by
or under the direction of a speech pathologist or audiologist, for which a
patient is referred by a physician or other licensed practitioner of the
healing arts within the scope of his or her practice under State law. It
includes any necessary supplies and equipment, including hearing aids.
NOTE: Do not include any costs for speech and language services provided
under the school based environment. Those costs should be reported on
the pop-up feeder form for Line 39 below.
NOTE: Do not include any costs for speech / language therapy services
provided under the rehabilitative services option. Those costs should be
reported on the pop-up feeder form for Line 40 below. It includes any
necessary supplies and equipment.

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Appendix I

Line

Line - Form Display

33

Prosthetic Devices, Dentures,
Eyeglasses

Line - Definition
Line 33 - Prosthetic Devices, Dentures, Eyeglasses (See 42 CFR 440.120)
Prosthetic devises means replacement, corrective, or supportive devices
prescribed by a physician or other licensed practitioner to:
1. Artificially replace a missing portion of the body;
2. Prevent or correct physical deformity or malfunction;
3. Support a weak or deformed portion of the body.
Dentures are artificial structures made by or under the direction of a
dentist to replace a full or partial set of teeth.
Eyeglasses means lenses, including frames, and other aids to vision
prescribed by a physician skilled in diseases of the eye or an optometrist.

34

Diagnostic Screening &
Preventive Services

34. - Diagnostic Screening & Preventive Services (see 42CFR440.130)
(a) "Diagnostic services", except as otherwise provided under this
subpart, includes any medical procedures or supplies
recommended by a physician or other licensed practitioner of the
healing arts within the scope of his or her practice under State
law, to enable him to identify the existence, nature, or extent of
illness, injury, or other health deviation in a recipient.
(b) "Screening services" means the use of standardized tests given
under medical direction in the mass examination of a designated
population to detect the existence of one or more particular
diseases or health deviations or to identify for more definitive
studies individuals suspected of having certain diseases.
(c) "Preventive services" means services provided by a physician or
other licensed practitioner of the healing arts within the scope of
his practice under State law to:
(1) Prevent disease, disability, and other health conditions or
their progression;
(2) Prolong life; and
(3) Promote physical and mental health and efficiency.
NOTE: This does not include Rehabilitative services - those services are
reported on the pop-up feeder sheet for line 40 below.

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Appendix I

Line

Line - Form Display

Line - Definition

34A

Preventive Services Grade A OR
B, ACIP Vaccines and their
Admin

34A. Preventive Services Grade A OR B, ACIP Vaccines and their Admin -1% FMAP rate for Total Computable entered at the FMAP Federal Share
rate. As a result of ACA 4106- Any clinical preventive services that are
assigned a grade of A or B by the United States Preventive Services Task
Force. States get the 1% additional FMAP upon an approved SPA. Effective
January 1, 2013

35

Nurse Mid-Wife

Line 35 - Nurse Mid-Wife (See 42 CFR 440.165) "Nurse-midwife services"
means services that are furnished within the scope or practice authorized
by State law or regulation and, in the case of inpatient or outpatient
hospital services or clinic services, are furnished by or under the direction
of a nurse mid-wife to the extent permitted by the facility. Unless required
by required by State law or regulations or a facility, are reimbursed without
regard to whether the nurse-midwife is under the supervision of, or
associated with, a physician or other health care provider. See 42 CFR
441.21 for provisions on independent provider agreements for nursemidwives.

36

Emergency Hospital Services

36. - Emergency Hospital Services (See 42 CFR 440.170) Emergency
hospital services means services that:
1.

Are necessary to prevent the death or serious impairment of the
health of the recipient; and

2.

37

Critical Access Hospitals

December 2020v4.0.0

Because of the threat to the life or health of the recipient
necessitate the use of the most accessible hospital available that
is equipped to furnish the services, even if the hospital does not
currently meet- (i) The conditions for participation under
Medicare; or (ii) The definitions of inpatient or outpatient
hospital services under 42 CFR 440.10 and 440.20. NOTE:
Emergency health services provided to undocumented aliens and
funded under an allotment established under §4723 of the
Balanced Budget Act of 1997 P.L. 105-33 should be reported on
Line 27.
Line 37 - Critical Access Hospitals (See 42 CFR 440.170) -- Critical access
hospital services that are furnished by a provider that meet the
requirements for participation in Medicare as a CAH (see subpart F of 42
CFR part 485), and (ii) are of a type that would be paid for by Medicare
when furnished to a Medicare beneficiary. Inpatient CAH services do not
include nursing facility services furnished by a CAH with a swing-bed
approval.

186

Appendix I

Line

Line - Form Display

Line - Definition

38

Nurse Practitioner Services

Line 38 - Nurse Practitioner Services (See 42 CFR 440.166) Nurse
practitioner services means services that are furnished by a registered
professional nurse who meets a State's advanced educational and clinical
practice requirements, if any, beyond the 2 to 4 years of basic nursing
education required of all registered nurses. See 42 CFR 440.166 for
requirements related to certified pediatric nurse practitioner and certified
family nurse practitioner.

39

School Based Services

39. - School Based Services (See section 1903(c) of the Act)--These services
include medical assistance for covered services (see section 1905(a))
furnished to a child with a disability because such services are included in
the child's individualized educational program established pursuant to Part
B of the Individuals with Disabilities Education Act or furnished to an infant
or toddler with a disability because such services are included in the child's
individualized family service plan.

40

Rehabilitative Services (nonschool-based)

40. - Rehabilitative Services (non-school-based) (see 42CFR440.130(d))-Except as otherwise provided under this subpart, rehabilitative services
includes any medical or remedial services recommended by a physician or
other licensed practitioner of the healing arts, with the scope of his
practice under State law, for maximum reduction of physical or mental
health condition and restoration of a recipient to his best possible
functional level.
NOTE: Do not include any costs for rehabilitative services provided under
the school based environment which should be reported on Line 39.

41

Private Duty Nursing

41. - Private Duty Nursing (see 42CFR440.80)--Nursing services for
recipients who require more individual and continuous care than is
available from a visiting nurse or routinely provided by the nursing staff of
the hospital or skilled nursing facility. These services are provided:
(a) by a registered nurse or a licensed practical nurse;
(b) under the direction of the recipient's physician; and
(c) to a recipient in one or more of the following locations at the
option of the State:
(1) his or her own home;
(2) a hospital; or
(3) a skilled nursing facility.

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Appendix I

Line

Line - Form Display

Line - Definition

42

Freestanding Birth Center

Line 42 - Freestanding Birth Center COVERAGE FOR FREESTANDING BIRTH
CENTER SERVICES Section 2301 of the Affordable Care Act amended
section 1905(a) of the Social Security Act (the Act) to provide coverage for
freestanding birth center services, as defined in section 1905(l)(3)(A) of the
Act. In that provision, the benefit is defined as services furnished at a
freestanding birth center, which is defined in new subparagraph
1905(l)(3)(B) as a health facility:







that is not a hospital;
where childbirth is planned to occur away from the
pregnant woman’s residence;
that is licensed or otherwise approved by the State to
provide prenatal, labor and delivery, or postpartum care
and other ambulatory services included in the State
plan; and
that must comply with a State’s requirements relating
to the health and safety of individuals receiving services
delivered by the facility.

In addition to payment for freestanding birth center facilities, section
1905(l)(3)(C) of the Act requires separate payment for the services
furnished by practitioners providing prenatal, labor and delivery, or
postpartum care in a freestanding birth center facility, such as nurse
midwives and birth attendants. Payment must be made to these
practitioners directly, regardless of whether the individual is under the
supervision of, or associated with, a physician or other health care
provider. It is important to note that section 2301 of the Affordable Care
Act does not require States to license or otherwise recognize freestanding
birth centers or practitioners who provide services in these facilities if they
do not already do so. Coverage and payment are limited to only those
facilities and practitioners licensed or otherwise recognized under State
law.

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Appendix I

Line

Line - Form Display

Line - Definition

42

Freestanding Birth Center

Prior to passage of the Affordable Care Act, only nurse midwife services
were mandatory services under section 1905(a)(17) of the Act and
implementing regulations at 42 CFR 440.165. In addition, States had the
option to cover the services of other practitioners who are licensed by the
State to provide midwifery services such as Certified Professional Midwives
(CPM) under section 1905(a)(6) of the Act and implementing regulations at
42 CFR 440.60. These practitioner services are now mandatory when
provided in a freestanding birth center as defined above. Further, other
practitioner services, such as those furnished by so-called direct entry or
lay midwives or birth attendants, who are not licensed but are recognized
under State law to provide these services, are now required to be covered
when provided in the freestanding birth center.
Submission of State Plan Amendments These provisions became effective
with the enactment of the Affordable Care Act, beginning March 23, 2010.
To implement these provisions, States will need to submit amendments to
their State plans that specify coverage and separate reimbursement of
freestanding birth center facility services and professional services. Unless
the compliance exception discussed below applies, or the State does not
license or otherwise recognize freestanding birth centers or practitioners
who provide services in these facilities, States must submit a State plan
amendment (SPA) not later than the end of the next calendar quarter that
follows the date of this guidance. In accordance with section 2301(c) of the
Affordable Care Act, States that require State legislation (other than
appropriation legislation) to meet the new requirements related to their
Medicaid coverage of freestanding birth center services will not be
regarded as out of compliance with the standards governing this coverage
option as long as they come into compliance not later than the first day of
the first calendar quarter beginning after the close of the first regular
session of the State legislature that begins after the date of the enactment
of the Affordable Care Act. For example, if the next regular legislative
session beginning after March 23, 2010, is from January 1 through April 30,
2011, then the State would have until September 30, 2011, to submit the
required SPA with an effective date of July 1, 2011. In the case of the State
that has a 2-year legislative session, each year is treated as a separate
regular session of the State legislature. For example, if a legislature is in
session from January 1, 2010, through December 31, 2012, then the State
would have until March 31, 2011, to submit a SPA with an effective date
that is no later than January 1, 2011. A State should promptly notify its
CMS regional office if this compliance exception is applicable.

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Appendix I

Line

Line - Form Display

Line - Definition

43

Health Home for Enrollees w
Chronic Conditions

43. Health Home for Enrollees w Chronic Conditions - Health Home services
which includes - Comprehensive care Management - Care Coordination Health promotion - Comprehensive transitional care (Planning and
coordination) - Individual and Family Support - Referral to
community/social supports - Use of Health Information Technology to link
services as feasible and appropriate

44

Tobacco Cessation for Pregnant
Women

45

Health HomesHome for
Enrollees w Substance-UseDisorder Enrollees

45 Health HomesHome for Enrollees with Substance- Use- Disorder
Enrollees per section- Pursuant to Section 1006 of the SUPPORTrecently
signed Substance Use-Disorder Prevention that Promotes Opioid Recovery
and Treatment for Patients and Communities (SUPPORT) Act of 2018.
States that have an approved Health Home Spa will receive 90% FMAP for
10 consecutive quarters from Approval Date.

49

Other Care Services

49 -- Other Care Services --These are any medical or remedial care services
recognized under State law and authorized by the approved Medicaid State
Plan. Such services do not meet the definition of, and are not classified
under, any category of service included on Lines 1 through 41.

December 2020v4.0.0

44. Tobacco Cessation for Preg Women - ACA Section 4107 Payments for
tobacco cessation counseling services for pregnant women and
smoking/tobacco cessation outpatient drugs for pregnant women.

190

Appendix J

Appendix J: MBES CBES Category of Service Line Definitions for the
21 Form
Line

Line - Form Display

Line - Definition

1A

Premiums - Up To 150%: Gross
Premiums Paid

Line 1.A. Gross Premiums Paid.--Report on line 1.A. the amount of
expenditures related to premiums paid for children whose family
income is up to 150 percent of the Federal poverty level. Use the
definition as contained in Part 2 Section 2500.2.E., lines 18.A. -18.E.
(Medicaid Health Insurance Payments-Health Maintenance
Organizations (HMO), Health Insuring Organization (HIO), Prepaid
Health Plans (PHP), Group Health Plan Payments, and Other,
respectively) of the State Medicaid Manual. Remember to report the
total amount of the premiums. DO NOT NET THE OFFSETS WITH THE
PREMIUMS. For example, it costs the State 500 per month per person
and there are 100 people under this plan. Assume that the state
receives $20 from one of the individuals covered for his share of the
cost. Report $50,000 (500 x 100) on Line 1.A. and $20 on Line 1.B.

1B

Premiums - Up To 150%: Cost
Sharing Offset

Line 1.B. Cost Sharing Offsets.--Report any cost sharing offset
amounts received with respect to the amounts reported on Line 1.A.
for children whose family income is up to 150 percent of the Federal
poverty level. As indicated above, for line 1.A, the cost sharing offset
amounts relate to the expenditures reported on line 1.A. should be
reported separately on line 1.B.

1C

I Premiums - Over 150%: Gross
Premiums Paid

Line 1.C. Gross Premiums Paid.--For children above 150% of poverty,
premiums may be imposed on a sliding scale related to family income.
Use the definition as contained in Part 2 Section 2500.2.E., lines 18.A.
-.18.E (Medicaid Health Insurance Payments-Health Maintenance
Organizations (HMO), Health Insuring Organization (HIO), Prepaid
Health Plans (PHP), Group Health Plan Payments, and Other,
respectively) of the State Medicaid Manual. DO NOT NET THE
OFFSETS WITH THE PREMIUMS For an example see item 1.A.

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Appendix J
Line

Line - Form Display

Line - Definition

1D

Premiums - Over 150%: Cost
Sharing Offset

Line 1.D. Cost Sharing Offsets.--Report any cost sharing offset
amounts received with respect to the amounts reported on line 1.C.
for children whose family income is above 150 percent of the Federal
poverty level. As indicated above for line 1.A, the cost sharing offset
amounts related to the expenditures reported on line 1.A. should be
reported separately on line 1.B. NOTE: Line items 1.A. - D. above
relate to capitated payments on behalf of CHIP recipients in Managed
Care Arrangements. Do not breakout out the amounts reported on
lines 1.A. - 1.D. in lines 2 - 26 below, as they relate to expenditures for
CHIP recipients in Fee-For-Service Plans.

2

Inpatient Hospital

Line 2. Inpatient Hospital Services - Regular Payments.--Use the
definition as contained in Part 2 Section 2500.2.E., line 1.A. (Inpatient
Hospital Services - Regular Payments) of the State Medicaid Manual.

3

Inpatient Mental Health

Line 3. Inpatient Mental Health Facility Services - Regular Payments.--Use the definition as contained in Part 2 Section 2500.2.E., line 2.A.
(Mental Health Facility Services-Regular Payments) of the State
Medicaid Manual.

4

Nursing Care Services

Line 4. Nursing Care Services. - (Other than services in an institution
for mental health conditions).---Use the definition as contained in
Part 2 Section 2500.2.E., line 29 paragraph g., (Other Care Servicesnurse midwife services), of the State Medicaid Manual.

5

Physician/Surgical

Line 5. Physician and Surgical Services.--Use the definition as
contained in Part 2 Section 2500.2.E., line 5. (Physicians’ Services) of
the State Medicaid Manual.

6

Outpatient Hospital

7

Outpatient Mental Health

December 2020v4.0.0

Line 6. Outpatient Hospital Services. .-:-Use the definition as
contained in Part 2 Section 2500.2.E., line 6. (Outpatient Hospital
Services) of the State Medicaid Manual for services related to nonmental health facilities which are reported on line 7 below.
Line 7. Outpatient Mental Health Facility Services.---Use the
definition as contained in Part 2 Section 2500.2.E., line 6 (Outpatient
Hospital Services) of the State Medicaid Manual for services related to
mental health facilities only.
192

Appendix J
Line

Line - Form Display

Line - Definition

8

Prescribed Drugs

8A

Drug Rebate

8A.1. Drug Rebate Offset.--This is a refund from the manufacturer for
single source drugs, innovator multiple source drugs, and noninnovator multiple source drugs.

9

Dental Services

Line 9. Dental Services.--Use the definition as contained in Part 2
Section 2500.2.E., lines 8 (Dental Services) and 29 paragraph e. (Other
Care Services-Dentures) of the State Medicaid Manual

10

Vision Services

Line 10. Vision Services...--Use the definition as contained in Part 2
Section 2500.2.E., line 29 paragraph e., (Other Care Serviceseyeglasses) of the State Medicaid Manual.

11

Other Practitioners

Line 11. Other Practitioners' Services. ---Use the definition as
contained in Part 2 Section 2500.2.E., lines 9. (Other Practitioners’
Services) and 29 paragraph f. (Other Care Services--diagnostic,
screening, rehabilitative, and preventive services) of the State
Medicaid Manual.

12

Clinic Services

Line 12. Clinic Services.--Use the definition as contained in Part 2
Section 2500.2.E., lines 10. (Clinic Services) and 16. (Rural Health
Clinic Services) of the State Medicaid Manual.

13

Therapy Services

14

Laboratory/Radiological

December 2020v4.0.0

Line 8. Prescribed Drugs.--Use the definition as contained in Part 2
Section 2500.2.E., line 7. (Prescribed Drugs) of the State Medicaid
Manual.

Line 13. Therapy Services. ---Use the definition as contained in Part 2
Section 2500.2.E., line 29 (Other Care Services) paragraphs b.
(Physical Therapy), c. (Occupational Therapy), and d. (Services for
individuals with speech, hearing, and language disorders) of the State
Medicaid Manual.
Line 14. Laboratory And Radiological Services.--Use the definition as
contained in Part 2 Section 2500.2.E., line 11. (Laboratory and
Radiological Services of the State Medicaid Manual.

193

Appendix J
Line

Line - Form Display

Line - Definition

15

Medical Equipment

Line 15. Durable and Disposable Medical Equipment. -Use the
definition as contained in Part 2 Section 2500.2.E., line 29. paragraph
e. (Other Care Services-prosthetic devices) of the State Medicaid
Manual

16

Family Planning

Line 16.Family Planning. --On the Form HCFA-64.21 series, the
reporting on the family planning line 16 is blocked. This is because of
the way family planning services are treated with respect to the
available FMAP rate and the application of payments against the
States’ FY CHIP allotments (refer to SMM §2500.9.I.1. and .2).

17

Other Pregnancy-related
Procedures

Line 17. Other Pregnancy-related Procedures.--Use the definition as
contained in Part 2 Section 2500.2.E., line 14 of the State Medicaid
Manual.

18

Screening Services

Line 18. Screening Services.--Use the definition as contained in Part 2
Section 2500.2.E., line 15. (EPSDT Screening Services) of the State
Medicaid Manual.

19

Home Health

Line 19. Home Health Services. --Use the definition as contained in
Part 2 Section 2500.2.E., line 12. (Home Health Services) of the State
Medicaid Manual.

20

Health Services Initiatives

December 2020v4.0.0

Line 20. Health Services Initiatives States may use funds available
under their 10 percent administrative cap to fund Health Service
Initiatives (HSIs). An HSI is an activity that protects public health,
protects the health of individuals, improves or promotes a state's
capacity to deliver public health services, or strengthens the human
and material resources necessary to accomplish public health goals
relating to improving the health of children, including targeted lowincome children and other low-income children. States are not limited
in the number of different HSIs they may fund, as long as the state
ensures that title XXI funding, within the state's 10 percent limit, is
sufficient to continue the proper administration of the CHIP program.
If such funds become less than sufficient, the state agrees to redirect
title XXI funds from the support of HSIs to the administration of the
CHIP program.

194

Appendix J
Line

Line - Form Display

Line - Definition

21

Home and Community

Line 21. Home and Community-Based Services. --Use the definition as
contained in Part 2 Section 2500.2.E., lines 19. (Home and
Community-Based Services) and 23. (Personal Care Services) of the
State Medicaid Manual.

22

Hospice

23

Medical Transportation

Line 23. Medical Transportation Services. --Use the definition as
contained in Part 2 Section 2500.2.E., line 29 paragraph a. (Other Care
Services-Transportation) of the State Medicaid Manual.

24

Case Management

Line 24. Case Management Services. --Use the definition as contained
in Part 2 Section 2500.2.E., lines 24. (Targeted Case Management
Services) and 25 (Primary Care Case Management Services) of the
State Medicaid Manual.

25

Translation and Interpretation

31

Other Services

32

Outreach

December 2020v4.0.0

Line 22. Hospice Care Services. --Use the definition as contained in
Part 2 Section 2500.2.E., line 26. (Hospice Benefits) of the State
Medicaid Manual.

Line 25. Translation and Interpretation (Section 201 CHIPRA)
Translation may be allowable as an administrative activity if it is not
included and paid for as part of a direct medical service and if it is
necessary for the proper and efficient administration of the State
plan. However, in order for translation to be claimable as
administration, it must be provided either by separate units or
separate employees performing solely translation activities and it
must facilitate access
Line 31. Other Services
Outreach Amounts reported on this line should NOT include any
amounts reported on Lines 32A or 32B

195

Appendix J
Line

Line - Form Display

Line - Definition

32A

Increased Outreach and
Enrollment of Indians

Line 32.A - Increased Outreach and Enrollment of Indians (Section 202
CHIPRA) )--Enter in Column (a) the total computable amount of
expenditures for the Increased Outreach and Enrollment of Indians
The MBES will automatically calculate the Federal Share in Columns
(b) and (e) at the CHIP rate. These expenditures are NOT applicable to
the 10% limit on Outreach and Certain other expenditures. Amounts
reported on this line should NOT include any amounts reported on
Lines 32 or 32B

32B

Increase outreach and
enrollment of children
through premium subsidies

Line 32.B - Increase Outreach and Enrollment of children through
premium subsidies Amounts reported on this line should NOT include
any amounts reported on Lines 32 or 32A

33

Administration

Line 33. Administration. (Section 2105(a)(2)(D) of the Act).--Enter the
amount of other reasonable costs incurred by the State to administer
the plan. NOTE: All of these administrative activities are subject to the
10 percent limit and must be entered in Column(c). See Section 2115
K above for a discussion of administrative costs and Section 2115 J
above for a discussion of the 10 percent limit.

34

PERM Administration

Line 34 - PERM Administration - (Section 601 CHIPRA)--Enter in
Column (a) the total computable amount of expenditures for the
administration of PERM. The MBES will automatically enter in
Columns (b) and (e) 90 percent of the amount reported in Column (a).

35

Citizenship Verification
Technology CHIPRA

35A

CVT Development

Line 35. Citizenship Verification Technology- (Section 211 CHIPRA)

Line 35A. CVT Development: (Section 211 CHIPRA)--Enter in Column
(a) the total computable amount of expenditures for the design,
development, or installation of Citizenship Verification technology.
The MBES will automatically enter in Columns (b) and (e) 90 percent
of the amount reported in Column (a).

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Appendix J
Line

Line - Form Display

Line - Definition

35B

CVT Operation

Line 35B. CVT Operation (Section 211 CHIPRA)--Enter in Column (a)
the total computable amount of expenditures for the operation of
Citizenship Verification technology. The MBES will automatically enter
in Columns (b) and (e) 75 percent of the amount reported in Column
(a).

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Appendix K

Appendix K: Crosswalk of T-MSIS to MSIS Type of Service Values
MSIS Valid
Values

T-MSIS 2.4
Valid Values

T-MSIS v2.4 Code Definitions

Inpatient Hospital

01

001

Inpatient hospital services, other than services in an
institution for mental diseases

Inpatient Hospital

01

090

Critical access hospital services – IP

Inpatient Hospital

01

091

Skilled care – hospital residing

Inpatient Hospital

01

092

Exceptional care – hospital residing

Inpatient Hospital

01

093

Non-acute care – hospital residing

Mental Health Hospital Services for the Aged

02

044

Inpatient hospital services for individuals age 65 or
older in institutions for mental diseases

Mental Health Hospital Services for the Aged

02

045

Nursing facility services for individuals age 65 or
older in institutions for mental diseases

Disproportionate Share Hospital (DSH)

03

123

Disproportionate share hospital (DSH) payments

Inpatient Psychiatric Facility Services for
Individuals Age 21 Years and Under

04

048

Inpatient psychiatric services for individuals under
age 21

ICF Services for Individuals with Mental Health
Condition

05

046

Intermediate care facility (ICF/IIDICF/IID) services

NF'S - All Other

07

009

Nursing facility services for individuals age 21 or
older (other than services in an institution for
mental disease)

NF'S - All Other

07

047

Nursing facility services, other than in institutions
for mental diseases

NF'S - All Other

07

059

Skilled nursing facility services for individuals under
age 21

Physicians

08

012

Physicians' services

Physicians

08

042

Well-baby and well-child care services as defined by
the State.

Dental

09

029

Dental Services

Dental

09

013

Medical and surgical services of a dentist

Other Practitioners

10

015

Medical or other remedial care or services, other
than physicians' services, provided by licensed
practitioners within the scope of practice as defined
under State law

*This Section Intentionally Left
Blank*MSIS Code Definitions

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Appendix K
*This Section Intentionally Left
Blank*MSIS Code Definitions

T-MSIS v2.4 Code Definitions

MSIS Valid
Values

T-MSIS 2.4
Valid Values

Other Practitioners

10

010

Early and periodic screening and diagnosis and
treatment (EPSDT) services

Outpatient Hospital

11

002

Outpatient hospital services

Outpatient Hospital

11

061

Critical access hospital services – OT

Clinic

12

028

Clinic services

Clinic

12

041

Preventive Services

Clinic

12

014

Outpatient substance abuse treatment services.

Clinic

12

003

Rural health clinic services

Home Health

13

016

Home health services - Nursing services

Home Health

13

017

Home health services - Home health aide services

Home Health

13

018

Home health services - Medical supplies,
equipment, and appliances suitable for use in the
home

Home Health

13

019

Home health services - Physical therapy provided
by a home health agency or by a facility licensed by
the State to provide medical rehabilitation services

Home Health

13

020

Home health services - Occupational therapy
provided by a home health agency or by a facility
licensed by the State to provide medical
rehabilitation services

Home Health

13

021

Home health services - Speech pathology and
audiology services provided by a home health
agency or by a facility licensed by the State to
provide medical rehabilitation services

Lab and X-Ray

15

005

Professional laboratory services, Technical
laboratory services

Lab and X-Ray

15

006

Technical laboratory services

Lab and X-Ray

15

007

Professional radiological services

Lab and X-Ray

15

008

Technical radiological services

Prescribed Drugs

16

033

Prescribed drugs

Prescribed Drugs

16

033

Over-the-counter medications.

Prescribed Drugs

16

036

Medical Equipment/Prosthetic devices

Prescribed Drugs

16

131

Drug Rebates

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Appendix K
*This Section Intentionally Left
Blank*MSIS Code Definitions

T-MSIS v2.4 Code Definitions

MSIS Valid
Values

T-MSIS 2.4
Valid Values

Other Services

19

064

HCBS - Home health aide services

Other Services

19

035

Dentures

Other Services

19

037

Eyeglasses

Other Services

19

062

HCBS - Case management services

Other Services

19

063

HCBS - Homemaker services

Other Services

19

065

HCBS - Personal care services

Other Services

19

066

HCBS - Adult day health services

Other Services

19

067

HCBS - Habilitation services

Other Services

19

068

HCBS - Respite care services

Other Services

19

069

HCBS - Day treatment or other partial
hospitalization services, psychosocial rehabilitation
services and clinic services (whether or not
furnished in a facility) for individuals with chronic
mental illness

Other Services

19

073

HCBS - Other services requested by the agency and
approved by CMS as cost effective and necessary to
avoid institutionalization

Other Services

19

074

HCBS - Expanded habilitation services Prevocational services

Other Services

19

075

HCBS - Expanded habilitation services - Educational
services

Other Services

19

076

HCBS - Expanded habilitation services - Supported
employment services, which facilitate paid
employment

Other Services

19

077

HCBS-65-plus - Case management services

Other Services

19

078

HCBS-65-plus - Homemaker services

Other Services

19

079

HCBS-65-plus - Home health aide services

Other Services

19

080

HCBS-65-plus - Personal care services

Other Services

19

081

HCBS-65-plus - Adult day health services

Other Services

19

082

HCBS-65-plus - Respite care services

Other Services

19

083

HCBS-65-plus - Other medical and social services

Other Services

19

034

Over-the-counter medications.

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Appendix K
*This Section Intentionally Left
Blank*MSIS Code Definitions

T-MSIS v2.4 Code Definitions

MSIS Valid
Values

T-MSIS 2.4
Valid Values

Other Services

19

039

Diagnostic services

Other Services

19

040

Screening services

Other Services

19

050

Inpatient substance abuse treatment services and
residential substance abuse treatment services.

Other Services

19

057

Enabling services

Other Services

19

060

Emergency hospital services

Other Services

19

071

HCBS - Training for family members

Other Services

19

072

HCBS - Minor modification to the home

Other Services

19

085

Prenatal care and pre-pregnancy family planning
services and supplies.

Other Services

19

088

Any other health care services or items specified by
the Secretary and not excluded under regulations.

Other Services

19

089

Disposable medical supplies.

Other Services

19

135

EHR payments to provider

Capitated Payment s to HMO, HIO or PACE Plan

20

119

Capitated payments to HMOs, HIOs, or PACE plans

Capitated Payments to Prepaid Health Plans
(PHPs)

21

122

Capitated payments to prepaid health plans (PHPs)

Capitated Payments for Primary Care Case
Management (PCCM)

22

120

Capitated payments for primary care case
management (PCCM)

Capitated Payments for Private Health Insurance

23

121

Premium payments for private health insurance

Sterilizations

24

084

Sterilizations

Other Pregnancy-related Procedures

25

086

Other Pregnancy-related Procedures

Transportation Services

26

056

Transportation services

Personal Care Services

30

051

Personal care services

Targeted Case Management

31

053

Targeted case management services

Targeted Case Management

31

052

Primary care case management services

Targeted Case Management

31

054

Case Management services other than those that
meet the definition of primary care case
management services or targeted case
management services

Targeted Case Management

31

055

Care coordination services

December 2020v4.0.0

201

Appendix K
*This Section Intentionally Left
Blank*MSIS Code Definitions

T-MSIS v2.4 Code Definitions

MSIS Valid
Values

T-MSIS 2.4
Valid Values

Rehabilitation Services

33

043

Rehabilitative services

PT, OT, Speech, Hearing Language

34

030

Physical therapy services (when not provided under
home health services)

PT, OT, Speech, Hearing Language

34

031

Occupational therapy services (when not provided
under home health services)

PT, OT, Speech, Hearing Language

34

032

Speech, hearing, and language disorders services
(when not provided under home health services)

PT, OT, Speech, Hearing Language

34

038

Hearing Aids

Hospice Benefits

35

087

Hospice Benefits

Nurse Midwife Services

36

025

Nurse-midwife service

Nurse Practitioner Services

37

026

Nurse practitioner services

Nurse Practitioner Services

37

023

Advanced practice nurse services

Private Duty Nursing

38

022

Private duty nursing services

Private Duty Nursing

38

024

Pediatric nurse

Religious Non-Medical Health Care Institutions

39

058

Services furnished in a religious nonmedical health
care institution

Supplemental Payment - Inpatient

40

132

Supplemental payment – inpatient

Supplemental Payment - Nursing

41

133

Supplemental payment – nursing

Supplemental Payment - Outpatient

42

134

Supplemental payment – outpatient

Durable Medical Equipment and Supplies
(including emergency response systems and
home modifications)

51

018

Home health services - Medical supplies,
equipment, and appliances suitable for use in the
home

Durable Medical Equipment and Supplies
(including emergency response systems and
home modifications)

51

027

Respiratory care for ventilator-dependent
individuals

Residential Care

52

115

Residential Care

Psychiatric services (excluding adult day care)

53

048

Inpatient psychiatric services for individuals under
age 21

Psychiatric services (excluding adult day care)

53

049

Outpatient mental health services, other than
Outpatient substance abuse treatment services.
This TOS includes services furnished in a Stateoperated mental hospital and including communitybased services.

December 2020v4.0.0

202

Appendix K
*This Section Intentionally Left
Blank*MSIS Code Definitions

T-MSIS v2.4 Code Definitions

MSIS Valid
Values

T-MSIS 2.4
Valid Values

Adult Day Care

54

066

HCBS - Adult day health services

Adult Day Care

54

069

HCBS - Day treatment or other partial
hospitalization services, psychosocial rehabilitation
services and clinic services (whether or not
furnished in a facility) for individuals with chronic
mental illness

Adult Day Care

54

070

HCBS - Day Care

Indian Health Service (IHS) - Family Plan

60

011

Family planning services and supplies for individuals
of child-bearing age

Indian Health Service (IHS) - Family Plan

60

127

Indian Health Service (IHS) - Family Plan

Indian Health Service (IHS) - BCC

61

004

Other ambulatory services furnished by a rural
health clinic

Indian Health Service (IHS) - BIP

62

004

Other ambulatory services furnished by a rural
health clinic

December 2020v4.0.0

203

Appendix L

Appendix L: Crosswalk of WPC Provider Taxonomy Codes to Provider
Facility Type Categories
Source: X12 Reference Page

Table Pages 1 – 20
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

193200000X

Unspecified Multi-Specialty Group

100000000

Individuals or Groups (of
Individuals)

193400000X

Unspecified Single Specialty Group

100000000

Individuals or Groups (of
Individuals)

207K00000X

Allergy & Immunology

100000000

Individuals or Groups (of
Individuals)

207KA0200X

Allergy

100000000

Individuals or Groups (of
Individuals)

207KI0005X

Clinical & Laboratory Immunology

100000000

Individuals or Groups (of
Individuals)

207L00000X

Anesthesiology

100000000

Individuals or Groups (of
Individuals)

207LA0401X

Addiction Medicine

100000000

Individuals or Groups (of
Individuals)

207LC0200X

Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

207LH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

207LP2900X

Pain Medicine

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

204

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207LP3000X

Pediatric Anesthesiology

100000000

Individuals or Groups (of
Individuals)

208U00000X

Clinical Pharmacology

100000000

Individuals or Groups (of
Individuals)

208C00000X

Colon & Rectal Surgery

100000000

Individuals or Groups (of
Individuals)

207N00000X

Dermatology

100000000

Individuals or Groups (of
Individuals)

207NI0002X

Clinical & Laboratory Dermatological
Immunology

100000000

Individuals or Groups (of
Individuals)

207ND0900X

Dermatopathology

100000000

Individuals or Groups (of
Individuals)

207ND0101X

MOHS-Micrographic Surgery

100000000

Individuals or Groups (of
Individuals)

207NP0225X

Pediatric Dermatology

100000000

Individuals or Groups (of
Individuals)

207NS0135X

Procedural Dermatology

100000000

Individuals or Groups (of
Individuals)

204R00000X

Electrodiagnostic Medicine

100000000

Individuals or Groups (of
Individuals)

207P00000X

Emergency Medicine

100000000

Individuals or Groups (of
Individuals)

207PE0004X

Emergency Medical Services

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

205

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207PH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

207PT0002X

Medical Toxicology

100000000

Individuals or Groups (of
Individuals)

207PP0204X

Pediatric Emergency Medicine

100000000

Individuals or Groups (of
Individuals)

207PS0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

207PE0005X

Undersea and Hyperbaric Medicine

100000000

Individuals or Groups (of
Individuals)

207Q00000X

Family Medicine

100000000

Individuals or Groups (of
Individuals)

207QA0401X

Addiction Medicine

100000000

Individuals or Groups (of
Individuals)

207QA0000X

Adolescent Medicine

100000000

Individuals or Groups (of
Individuals)

207QA0505X

Adult Medicine

100000000

Individuals or Groups (of
Individuals)

207QB0002X

Bariatric Medicine

100000000

Individuals or Groups (of
Individuals)

207QG0300X

Geriatric Medicine

100000000

Individuals or Groups (of
Individuals)

207QH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

206

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207QS1201X

Sleep Medicine

100000000

Individuals or Groups (of
Individuals)

207QS0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

208D00000X

General Practice

100000000

Individuals or Groups (of
Individuals)

208M00000X

Hospitalist

100000000

Individuals or Groups (of
Individuals)

202C00000X

Independent Medical Examiner

100000000

Individuals or Groups (of
Individuals)

207R00000X

Internal Medicine

100000000

Individuals or Groups (of
Individuals)

207RA0401X

Addiction Medicine

100000000

Individuals or Groups (of
Individuals)

207RA0000X

Adolescent Medicine

100000000

Individuals or Groups (of
Individuals)

207RA0201X

Allergy & Immunology

100000000

Individuals or Groups (of
Individuals)

207RB0002X

Bariatric Medicine

100000000

Individuals or Groups (of
Individuals)

207RC0000X

Cardiovascular Disease

100000000

Individuals or Groups (of
Individuals)

207RI0001X

Clinical & Laboratory Immunology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

207

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207RC0001X

Clinical Cardiac Electrophysiology

100000000

Individuals or Groups (of
Individuals)

207RC0200X

Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

207RE0101X

Endocrinology, Diabetes &
Metabolism

100000000

Individuals or Groups (of
Individuals)

207RG0100X

Gastroenterology

100000000

Individuals or Groups (of
Individuals)

207RG0300X

Geriatric Medicine

100000000

Individuals or Groups (of
Individuals)

207RH0000X

Hematology

100000000

Individuals or Groups (of
Individuals)

207RH0003X

Hematology & Oncology

100000000

Individuals or Groups (of
Individuals)

207RI0008X

Hepatology

100000000

Individuals or Groups (of
Individuals)

207RH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

207RH0005X

Hypertension Specialist

100000000

Individuals or Groups (of
Individuals)

207RI0200X

Infectious Disease

100000000

Individuals or Groups (of
Individuals)

207RI0011X

Interventional Cardiology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

208

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207RM1200X

Magnetic Resonance Imaging (MRI)

100000000

Individuals or Groups (of
Individuals)

207RX0202X

Medical Oncology

100000000

Individuals or Groups (of
Individuals)

207RN0300X

Nephrology

100000000

Individuals or Groups (of
Individuals)

207RP1001X

Pulmonary Disease

100000000

Individuals or Groups (of
Individuals)

207RR0500X

Rheumatology

100000000

Individuals or Groups (of
Individuals)

207RS0012X

Sleep Medicine

100000000

Individuals or Groups (of
Individuals)

207RS0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

207RT0003X

Transplant Hepatology

100000000

Individuals or Groups (of
Individuals)

209800000X

Legal Medicine

100000000

Individuals or Groups (of
Individuals)

207SG0202X

Clinical Biochemical Genetics

100000000

Individuals or Groups (of
Individuals)

207SC0300X

Clinical Cytogenetic

100000000

Individuals or Groups (of
Individuals)

207SG0201X

Clinical Genetics (M.D.)

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

209

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207SG0203X

Clinical Molecular Genetics

100000000

Individuals or Groups (of
Individuals)

207SM0001X

Molecular Genetic Pathology

100000000

Individuals or Groups (of
Individuals)

207SG0205X

Ph.D. Medical Genetics

100000000

Individuals or Groups (of
Individuals)

207T00000X

Neurological Surgery

100000000

Individuals or Groups (of
Individuals)

207U00000X

Nuclear Medicine

100000000

Individuals or Groups (of
Individuals)

207UN0903X

In Vivo & In Vitro Nuclear Medicine

100000000

Individuals or Groups (of
Individuals)

207UN0901X

Nuclear Cardiology

100000000

Individuals or Groups (of
Individuals)

207UN0902X

Nuclear Imaging & Therapy

100000000

Individuals or Groups (of
Individuals)

204D00000X

Neuromusculoskeletal Medicine &
OMM

100000000

Individuals or Groups (of
Individuals)

204C00000X

Neuromusculoskeletal Medicine,
Sports Medicine

100000000

Individuals or Groups (of
Individuals)

207V00000X

Obstetrics & Gynecology

100000000

Individuals or Groups (of
Individuals)

207VB0002X

Bariatric Medicine

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

210

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207VC0200X

Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

207VF0040X

Female Pelvic Medicine and
Reconstructive Surgery

100000000

Individuals or Groups (of
Individuals)

207VX0201X

Gynecologic Oncology

100000000

Individuals or Groups (of
Individuals)

207VG0400X

Gynecology

100000000

Individuals or Groups (of
Individuals)

207VH0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

207VM0101X

Maternal & Fetal Medicine

100000000

Individuals or Groups (of
Individuals)

207VX0000X

Obstetrics

100000000

Individuals or Groups (of
Individuals)

207VE0102X

Reproductive Endocrinology

100000000

Individuals or Groups (of
Individuals)

207W00000X

Ophthalmology

100000000

Individuals or Groups (of
Individuals)

204E00000X

Oral & Maxillofacial Surgery

100000000

Individuals or Groups (of
Individuals)

207X00000X

Orthopaedic Surgery

100000000

Individuals or Groups (of
Individuals)

207XS0114X

Adult Reconstructive Orthopaedic
Surgery

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

211

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207XX0004X

Foot and Ankle Surgery

100000000

Individuals or Groups (of
Individuals)

207XS0106X

Hand Surgery

100000000

Individuals or Groups (of
Individuals)

207XS0117X

Orthopaedic Surgery of the Spine

100000000

Individuals or Groups (of
Individuals)

207XX0801X

Orthopaedic Trauma

100000000

Individuals or Groups (of
Individuals)

207XP3100X

Pediatric Orthopaedic Surgery

100000000

Individuals or Groups (of
Individuals)

207XX0005X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

207Y00000X

Otolaryngology

100000000

Individuals or Groups (of
Individuals)

207YS0123X

Facial Plastic Surgery

100000000

Individuals or Groups (of
Individuals)

207YX0602X

Otolaryngic Allergy

100000000

Individuals or Groups (of
Individuals)

207YX0905X

Otolaryngology/Facial Plastic Surgery

100000000

Individuals or Groups (of
Individuals)

207YX0901X

Otology & Neurotology

100000000

Individuals or Groups (of
Individuals)

207YP0228X

Pediatric Otolaryngology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

212

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207YX0007X

Plastic Surgery within the Head &
Neck

100000000

Individuals or Groups (of
Individuals)

207YS0012X

Sleep Medicine

100000000

Individuals or Groups (of
Individuals)

207ZP0101X

Anatomic Pathology

100000000

Individuals or Groups (of
Individuals)

207ZP0102X

Anatomic Pathology & Clinical
Pathology

100000000

Individuals or Groups (of
Individuals)

207ZB0001X

Blood Banking & Transfusion
Medicine

100000000

Individuals or Groups (of
Individuals)

207ZP0104X

Chemical Pathology

100000000

Individuals or Groups (of
Individuals)

207ZC0006X

Clinical Pathology

100000000

Individuals or Groups (of
Individuals)

207ZP0105X

Clinical Pathology/Laboratory
Medicine

100000000

Individuals or Groups (of
Individuals)

207ZC0500X

Cytopathology

100000000

Individuals or Groups (of
Individuals)

207ZD0900X

Dermatopathology

100000000

Individuals or Groups (of
Individuals)

207ZF0201X

Forensic Pathology

100000000

Individuals or Groups (of
Individuals)

207ZH0000X

Hematology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

213

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

207ZI0100X

Immunopathology

100000000

Individuals or Groups (of
Individuals)

207ZM0300X

Medical Microbiology

100000000

Individuals or Groups (of
Individuals)

207ZP0007X

Molecular Genetic Pathology

100000000

Individuals or Groups (of
Individuals)

207ZN0500X

Neuropathology

100000000

Individuals or Groups (of
Individuals)

207ZP0213X

Pediatric Pathology

100000000

Individuals or Groups (of
Individuals)

208000000X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

2080A0000X

Adolescent Medicine

100000000

Individuals or Groups (of
Individuals)

2080C0008X

Child Abuse Pediatrics

100000000

Individuals or Groups (of
Individuals)

2080I0007X

Clinical & Laboratory Immunology

100000000

Individuals or Groups (of
Individuals)

2080P0006X

Developmental – Behavioral
Pediatrics

100000000

Individuals or Groups (of
Individuals)

2080H0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

2080T0002X

Medical Toxicology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

214

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2080N0001X

Neonatal-Perinatal Medicine

100000000

Individuals or Groups (of
Individuals)

2080P0008X

Neurodevelopmental Disabilities

100000000

Individuals or Groups (of
Individuals)

2080P0201X

Pediatric Allergy/Immunology

100000000

Individuals or Groups (of
Individuals)

2080P0202X

Pediatric Cardiology

100000000

Individuals or Groups (of
Individuals)

2080P0203X

Pediatric Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

2080P0204X

Pediatric Emergency Medicine

100000000

Individuals or Groups (of
Individuals)

2080P0205X

Pediatric Endocrinology

100000000

Individuals or Groups (of
Individuals)

2080P0206X

Pediatric Gastroenterology

100000000

Individuals or Groups (of
Individuals)

2080P0207X

Pediatric Hematology-Oncology

100000000

Individuals or Groups (of
Individuals)

2080P0208X

Pediatric Infectious Diseases

100000000

Individuals or Groups (of
Individuals)

2080P0210X

Pediatric Nephrology

100000000

Individuals or Groups (of
Individuals)

2080P0214X

Pediatric Pulmonology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

215

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2080P0216X

Pediatric Rheumatology

100000000

Individuals or Groups (of
Individuals)

2080T0004X

Pediatric Transplant Hepatology

100000000

Individuals or Groups (of
Individuals)

2080S0012X

Sleep Medicine

100000000

Individuals or Groups (of
Individuals)

2080S0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

202K00000X

Phlebology

100000000

Individuals or Groups (of
Individuals)

208100000X

Physical Medicine & Rehabilitation

100000000

Individuals or Groups (of
Individuals)

2081H0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

2081N0008X

Neuromuscular Medicine

100000000

Individuals or Groups (of
Individuals)

2081P2900X

Pain Medicine

100000000

Individuals or Groups (of
Individuals)

2081P0010X

Pediatric Rehabilitation Medicine

100000000

Individuals or Groups (of
Individuals)

2081P0004X

Spinal Cord Injury Medicine

100000000

Individuals or Groups (of
Individuals)

2081S0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

216

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

208200000X

Plastic Surgery

100000000

Individuals or Groups (of
Individuals)

2082S0099X

Plastic Surgery Within the Head and
Neck

100000000

Individuals or Groups (of
Individuals)

2082S0105X

Surgery of the Hand

100000000

Individuals or Groups (of
Individuals)

2083A0100X

Aerospace Medicine

100000000

Individuals or Groups (of
Individuals)

2083T0002X

Medical Toxicology

100000000

Individuals or Groups (of
Individuals)

2083X0100X

Occupational Medicine

100000000

Individuals or Groups (of
Individuals)

2083P0500X

Preventive Medicine/Occupational
Environmental Medicine

100000000

Individuals or Groups (of
Individuals)

2083P0901X

Public Health & General Preventive
Medicine

100000000

Individuals or Groups (of
Individuals)

2083S0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

2083P0011X

Undersea and Hyperbaric Medicine

100000000

Individuals or Groups (of
Individuals)

2084A0401X

Addiction Medicine

100000000

Individuals or Groups (of
Individuals)

2084P0802X

Addiction Psychiatry

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

217

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2084B0002X

Bariatric Medicine

100000000

Individuals or Groups (of
Individuals)

2084B0040X

Behavioral Neurology &
Neuropsychiatry

100000000

Individuals or Groups (of
Individuals)

2084P0804X

Child & Adolescent Psychiatry

100000000

Individuals or Groups (of
Individuals)

2084N0600X

Clinical Neurophysiology

100000000

Individuals or Groups (of
Individuals)

2084D0003X

Diagnostic Neuroimaging

100000000

Individuals or Groups (of
Individuals)

2084F0202X

Forensic Psychiatry

100000000

Individuals or Groups (of
Individuals)

2084P0805X

Geriatric Psychiatry

100000000

Individuals or Groups (of
Individuals)

2084H0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

2084P0005X

Neurodevelopmental Disabilities

100000000

Individuals or Groups (of
Individuals)

2084N0400X

Neurology

100000000

Individuals or Groups (of
Individuals)

2084N0402X

Neurology with Special Qualifications
in Child Neurology

100000000

Individuals or Groups (of
Individuals)

2084N0008X

Neuromuscular Medicine

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

218

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2084P2900X

Pain Medicine

100000000

Individuals or Groups (of
Individuals)

2084P0800X

Psychiatry

100000000

Individuals or Groups (of
Individuals)

2084P0015X

Psychosomatic Medicine

100000000

Individuals or Groups (of
Individuals)

2084S0012X

Sleep Medicine

100000000

Individuals or Groups (of
Individuals)

2084S0010X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

2084V0102X

Vascular Neurology

100000000

Individuals or Groups (of
Individuals)

208VP0014X

Interventional Pain Medicine

100000000

Individuals or Groups (of
Individuals)

208VP0000X

Pain Medicine

100000000

Individuals or Groups (of
Individuals)

2085B0100X

Body Imaging

100000000

Individuals or Groups (of
Individuals)

2085D0003X

Diagnostic Neuroimaging

100000000

Individuals or Groups (of
Individuals)

2085R0202X

Diagnostic Radiology

100000000

Individuals or Groups (of
Individuals)

2085U0001X

Diagnostic Ultrasound

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

219

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2085H0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

2085N0700X

Neuroradiology

100000000

Individuals or Groups (of
Individuals)

2085N0904X

Nuclear Radiology

100000000

Individuals or Groups (of
Individuals)

2085P0229X

Pediatric Radiology

100000000

Individuals or Groups (of
Individuals)

2085R0001X

Radiation Oncology

100000000

Individuals or Groups (of
Individuals)

2085R0205X

Radiological Physics

100000000

Individuals or Groups (of
Individuals)

2085R0203X

Therapeutic Radiology

100000000

Individuals or Groups (of
Individuals)

2085R0204X

Vascular & Interventional Radiology

100000000

Individuals or Groups (of
Individuals)

208600000X

Surgery

100000000

Individuals or Groups (of
Individuals)

2086H0002X

Hospice and Palliative Medicine

100000000

Individuals or Groups (of
Individuals)

2086S0120X

Pediatric Surgery

100000000

Individuals or Groups (of
Individuals)

2086S0122X

Plastic and Reconstructive Surgery

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

220

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2086S0105X

Surgery of the Hand

100000000

Individuals or Groups (of
Individuals)

2086S0102X

Surgical Critical Care

100000000

Individuals or Groups (of
Individuals)

2086X0206X

Surgical Oncology

100000000

Individuals or Groups (of
Individuals)

2086S0127X

Trauma Surgery

100000000

Individuals or Groups (of
Individuals)

2086S0129X

Vascular Surgery

100000000

Individuals or Groups (of
Individuals)

208G00000X

Thoracic Surgery (Cardiothoracic
Vascular Surgery)

100000000

Individuals or Groups (of
Individuals)

204F00000X

Transplant Surgery

100000000

Individuals or Groups (of
Individuals)

208800000X

Urology

100000000

Individuals or Groups (of
Individuals)

2088F0040X

Female Pelvic Medicine and
Reconstructive Surgery

100000000

Individuals or Groups (of
Individuals)

2088P0231X

Pediatric Urology

100000000

Individuals or Groups (of
Individuals)

103K00000X

Behavioral Analyst

100000000

Individuals or Groups (of
Individuals)

103G00000X

Clinical Neuropsychologist

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

221

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

103GC0700X

Clinical

100000000

Individuals or Groups (of
Individuals)

101Y00000X

Counselor

100000000

Individuals or Groups (of
Individuals)

101YA0400X

Addiction (Substance Use Disorder)

100000000

Individuals or Groups (of
Individuals)

101YM0800X

Mental Health

100000000

Individuals or Groups (of
Individuals)

101YP1600X

Pastoral

100000000

Individuals or Groups (of
Individuals)

101YP2500X

Professional

100000000

Individuals or Groups (of
Individuals)

101YS0200X

School

100000000

Individuals or Groups (of
Individuals)

106H00000X

Marriage & Family Therapist

100000000

Individuals or Groups (of
Individuals)

102X00000X

Poetry Therapist

100000000

Individuals or Groups (of
Individuals)

102L00000X

Psychoanalyst

100000000

Individuals or Groups (of
Individuals)

103T00000X

Psychologist

100000000

Individuals or Groups (of
Individuals)

103TA0400X

Addiction (Substance Use Disorder)

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

222

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

103TA0700X

Adult Development & Aging

100000000

Individuals or Groups (of
Individuals)

103TC0700X

Clinical

100000000

Individuals or Groups (of
Individuals)

103TC2200X

Clinical Child & Adolescent

100000000

Individuals or Groups (of
Individuals)

103TB0200X

Cognitive & Behavioral

100000000

Individuals or Groups (of
Individuals)

103TC1900X

Counseling

100000000

Individuals or Groups (of
Individuals)

103TE1000X

Educational

100000000

Individuals or Groups (of
Individuals)

103TE1100X

Exercise & Sports

100000000

Individuals or Groups (of
Individuals)

103TF0000X

Family

100000000

Individuals or Groups (of
Individuals)

103TF0200X

Forensic

100000000

Individuals or Groups (of
Individuals)

103TP2701X

Group Psychotherapy

100000000

Individuals or Groups (of
Individuals)

103TH0004X

Health

100000000

Individuals or Groups (of
Individuals)

103TH0100X

Health Service

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

223

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

103TM1700X

Men & Masculinity

100000000

Individuals or Groups (of
Individuals)

103TM1800X

Mental Retardation & Developmental
Disabilities

100000000

Individuals or Groups (of
Individuals)

103TP0016X

Prescribing (Medical)

100000000

Individuals or Groups (of
Individuals)

103TP0814X

Psychoanalysis

100000000

Individuals or Groups (of
Individuals)

103TP2700X

Psychotherapy

100000000

Individuals or Groups (of
Individuals)

103TR0400X

Rehabilitation

100000000

Individuals or Groups (of
Individuals)

103TS0200X

School

100000000

Individuals or Groups (of
Individuals)

103TW0100X

Women

100000000

Individuals or Groups (of
Individuals)

104100000X

Social Worker

100000000

Individuals or Groups (of
Individuals)

1041C0700X

Clinical

100000000

Individuals or Groups (of
Individuals)

1041S0200X

School

100000000

Individuals or Groups (of
Individuals)

111N00000X

Chiropractor

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

224

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

111NI0013X

Independent Medical Examiner

100000000

Individuals or Groups (of
Individuals)

111NI0900X

Internist

100000000

Individuals or Groups (of
Individuals)

111NN0400X

Neurology

100000000

Individuals or Groups (of
Individuals)

111NN1001X

Nutrition

100000000

Individuals or Groups (of
Individuals)

111NX0100X

Occupational Health

100000000

Individuals or Groups (of
Individuals)

111NX0800X

Orthopedic

100000000

Individuals or Groups (of
Individuals)

111NP0017X

Pediatric Chiropractor

100000000

Individuals or Groups (of
Individuals)

Table Pages 21 - 40
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

111NR0200X

Radiology

100000000

Individuals or Groups (of
Individuals)

111NR0400X

Rehabilitation

100000000

Individuals or Groups (of
Individuals)

111NS0005X

Sports Physician

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

225

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

111NT0100X

Thermography

100000000

Individuals or Groups (of
Individuals)

125K00000X

Advanced Practice Dental Therapist

100000000

Individuals or Groups (of
Individuals)

126800000X

Dental Assistant

100000000

Individuals or Groups (of
Individuals)

124Q00000X

Dental Hygienist

100000000

Individuals or Groups (of
Individuals)

126900000X

Dental Laboratory Technician

100000000

Individuals or Groups (of
Individuals)

125J00000X

Dental Therapist

100000000

Individuals or Groups (of
Individuals)

122300000X

Dentist

100000000

Individuals or Groups (of
Individuals)

1223D0001X

Dental Public Health

100000000

Individuals or Groups (of
Individuals)

1223D0004X

Dentist Anesthesiologist

100000000

Individuals or Groups (of
Individuals)

1223E0200X

Endodontics

100000000

Individuals or Groups (of
Individuals)

1223G0001X

General Practice

100000000

Individuals or Groups (of
Individuals)

1223P0106X

Oral and Maxillofacial Pathology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

226

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

1223X0008X

Oral and Maxillofacial Radiology

100000000

Individuals or Groups (of
Individuals)

1223S0112X

Oral and Maxillofacial Surgery

100000000

Individuals or Groups (of
Individuals)

1223X0400X

Orthodontics and Dentofacial
Orthopedics

100000000

Individuals or Groups (of
Individuals)

1223P0221X

Pediatric Dentistry

100000000

Individuals or Groups (of
Individuals)

1223P0300X

Periodontics

100000000

Individuals or Groups (of
Individuals)

1223P0700X

Prosthodontics

100000000

Individuals or Groups (of
Individuals)

122400000X

Denturist

100000000

Individuals or Groups (of
Individuals)

132700000X

Dietary Manager

100000000

Individuals or Groups (of
Individuals)

136A00000X

Dietetic Technician, Registered

100000000

Individuals or Groups (of
Individuals)

133V00000X

Dietitian, Registered

100000000

Individuals or Groups (of
Individuals)

133VN1006X

Nutrition, Metabolic

100000000

Individuals or Groups (of
Individuals)

133VN1004X

Nutrition, Pediatric

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

227

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

133VN1005X

Nutrition, Renal

100000000

Individuals or Groups (of
Individuals)

133N00000X

Nutritionist

100000000

Individuals or Groups (of
Individuals)

133NN1002X

Nutrition, Education

100000000

Individuals or Groups (of
Individuals)

146N00000X

Emergency Medical Technician, Basic

100000000

Individuals or Groups (of
Individuals)

146M00000X

Emergency Medical Technician,
Intermediate

100000000

Individuals or Groups (of
Individuals)

146L00000X

Emergency Medical Technician,
Paramedic

100000000

Individuals or Groups (of
Individuals)

146D00000X

Personal Emergency Response
Attendant

100000000

Individuals or Groups (of
Individuals)

152W00000X

Optometrist

100000000

Individuals or Groups (of
Individuals)

152WC0802X

Corneal and Contact Management

100000000

Individuals or Groups (of
Individuals)

152WL0500X

Low Vision Rehabilitation

100000000

Individuals or Groups (of
Individuals)

152WX0102X

Occupational Vision

100000000

Individuals or Groups (of
Individuals)

152WP0200X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

228

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

152WS0006X

Sports Vision

100000000

Individuals or Groups (of
Individuals)

152WV0400X

Vision Therapy

100000000

Individuals or Groups (of
Individuals)

156F00000X

Technician/Technologist

100000000

Individuals or Groups (of
Individuals)

156FC0800X

Contact Lens

100000000

Individuals or Groups (of
Individuals)

156FC0801X

Contact Lens Fitter

100000000

Individuals or Groups (of
Individuals)

156FX1700X

Ocularist

100000000

Individuals or Groups (of
Individuals)

156FX1100X

Ophthalmic

100000000

Individuals or Groups (of
Individuals)

156FX1101X

Ophthalmic Assistant

100000000

Individuals or Groups (of
Individuals)

156FX1800X

Optician

100000000

Individuals or Groups (of
Individuals)

156FX1201X

Optometric Assistant

100000000

Individuals or Groups (of
Individuals)

156FX1202X

Optometric Technician

100000000

Individuals or Groups (of
Individuals)

156FX1900X

Orthoptist

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

229

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

164W00000X

Licensed Practical Nurse

100000000

Individuals or Groups (of
Individuals)

167G00000X

Licensed Psychiatric Technician

100000000

Individuals or Groups (of
Individuals)

164X00000X

Licensed Vocational Nurse

100000000

Individuals or Groups (of
Individuals)

163W00000X

Registered Nurse

100000000

Individuals or Groups (of
Individuals)

163WA0400X

Addiction (Substance Use Disorder)

100000000

Individuals or Groups (of
Individuals)

163WA2000X

Administrator

100000000

Individuals or Groups (of
Individuals)

163WP2201X

Ambulatory Care

100000000

Individuals or Groups (of
Individuals)

163WC3500X

Cardiac Rehabilitation

100000000

Individuals or Groups (of
Individuals)

163WC0400X

Case Management

100000000

Individuals or Groups (of
Individuals)

163WC1400X

College Health

100000000

Individuals or Groups (of
Individuals)

163WC1500X

Community Health

100000000

Individuals or Groups (of
Individuals)

163WC2100X

Continence Care

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

230

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

163WC1600X

Continuing Education/Staff
Development

100000000

Individuals or Groups (of
Individuals)

163WC0200X

Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

163WD0400X

Diabetes Educator

100000000

Individuals or Groups (of
Individuals)

163WD1100X

Dialysis, Peritoneal

100000000

Individuals or Groups (of
Individuals)

163WE0003X

Emergency

100000000

Individuals or Groups (of
Individuals)

163WE0900X

Enterostomal Therapy

100000000

Individuals or Groups (of
Individuals)

163WF0300X

Flight

100000000

Individuals or Groups (of
Individuals)

163WG0100X

Gastroenterology

100000000

Individuals or Groups (of
Individuals)

163WG0000X

General Practice

100000000

Individuals or Groups (of
Individuals)

163WG0600X

Gerontology

100000000

Individuals or Groups (of
Individuals)

163WH0500X

Hemodialysis

100000000

Individuals or Groups (of
Individuals)

163WH0200X

Home Health

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

231

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

163WH1000X

Hospice

100000000

Individuals or Groups (of
Individuals)

163WI0600X

Infection Control

100000000

Individuals or Groups (of
Individuals)

163WI0500X

Infusion Therapy

100000000

Individuals or Groups (of
Individuals)

163WL0100X

Lactation Consultant

100000000

Individuals or Groups (of
Individuals)

163WM0102X

Maternal Newborn

100000000

Individuals or Groups (of
Individuals)

163WM0705X

Medical-Surgical

100000000

Individuals or Groups (of
Individuals)

163WN0002X

Neonatal Intensive Care

100000000

Individuals or Groups (of
Individuals)

163WN0003X

Neonatal, Low-Risk

100000000

Individuals or Groups (of
Individuals)

163WN0300X

Nephrology

100000000

Individuals or Groups (of
Individuals)

163WN0800X

Neuroscience

100000000

Individuals or Groups (of
Individuals)

163WM1400X

Nurse Massage Therapist (NMT)

100000000

Individuals or Groups (of
Individuals)

163WN1003X

Nutrition Support

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

232

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

163WX0002X

Obstetric, High-Risk

100000000

Individuals or Groups (of
Individuals)

163WX0003X

Obstetric, Inpatient

100000000

Individuals or Groups (of
Individuals)

163WX0106X

Occupational Health

100000000

Individuals or Groups (of
Individuals)

163WX0200X

Oncology

100000000

Individuals or Groups (of
Individuals)

163WX1100X

Ophthalmic

100000000

Individuals or Groups (of
Individuals)

163WX0800X

Orthopedic

100000000

Individuals or Groups (of
Individuals)

163WX1500X

Ostomy Care

100000000

Individuals or Groups (of
Individuals)

163WX0601X

Otorhinolaryngology & Head-Neck

100000000

Individuals or Groups (of
Individuals)

163WP0000X

Pain Management

100000000

Individuals or Groups (of
Individuals)

163WP0218X

Pediatric Oncology

100000000

Individuals or Groups (of
Individuals)

163WP0200X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

163WP1700X

Perinatal

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

233

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

163WS0121X

Plastic Surgery

100000000

Individuals or Groups (of
Individuals)

163WP0808X

Psychiatric/Mental Health

100000000

Individuals or Groups (of
Individuals)

163WP0809X

Psychiatric/Mental Health, Adult

100000000

Individuals or Groups (of
Individuals)

163WP0807X

Psychiatric/Mental Health, Child &
Adolescent

100000000

Individuals or Groups (of
Individuals)

163WR0006X

Registered Nurse First Assistant

100000000

Individuals or Groups (of
Individuals)

163WR0400X

Rehabilitation

100000000

Individuals or Groups (of
Individuals)

163WR1000X

Reproductive
Endocrinology/Infertility

100000000

Individuals or Groups (of
Individuals)

163WS0200X

School

100000000

Individuals or Groups (of
Individuals)

163WU0100X

Urology

100000000

Individuals or Groups (of
Individuals)

163WW0101X Women's Health Care, Ambulatory

100000000

Individuals or Groups (of
Individuals)

163WW0000X Wound Care

100000000

Individuals or Groups (of
Individuals)

372600000X

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

Adult Companion

234

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

372500000X

Chore Provider

100000000

Individuals or Groups (of
Individuals)

373H00000X

Day Training/Habilitation Specialist

100000000

Individuals or Groups (of
Individuals)

374J00000X

Doula

100000000

Individuals or Groups (of
Individuals)

374U00000X

Home Health Aide

100000000

Individuals or Groups (of
Individuals)

376J00000X

Homemaker

100000000

Individuals or Groups (of
Individuals)

376K00000X

Nurse's Aide

100000000

Individuals or Groups (of
Individuals)

376G00000X

Nursing Home Administrator

100000000

Individuals or Groups (of
Individuals)

374T00000X

Religious Nonmedical Nursing
Personnel

100000000

Individuals or Groups (of
Individuals)

374K00000X

Religious Nonmedical Practitioner

100000000

Individuals or Groups (of
Individuals)

374700000X

Technician

100000000

Individuals or Groups (of
Individuals)

3747A0650X

Attendant Care Provider

100000000

Individuals or Groups (of
Individuals)

3747P1801X

Personal Care Attendant

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

235

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

171100000X

Acupuncturist

100000000

Individuals or Groups (of
Individuals)

171M00000X

Case Manager/Care Coordinator

100000000

Individuals or Groups (of
Individuals)

174V00000X

Clinical Ethicist

100000000

Individuals or Groups (of
Individuals)

172V00000X

Community Health Worker

100000000

Individuals or Groups (of
Individuals)

171W00000X

Contractor

100000000

Individuals or Groups (of
Individuals)

171WH0202X

Home Modifications

100000000

Individuals or Groups (of
Individuals)

171WV0202X

Vehicle Modifications

100000000

Individuals or Groups (of
Individuals)

172A00000X

Driver

100000000

Individuals or Groups (of
Individuals)

176P00000X

Funeral Director

100000000

Individuals or Groups (of
Individuals)

170300000X

Genetic Counselor, MS

100000000

Individuals or Groups (of
Individuals)

174H00000X

Health Educator

100000000

Individuals or Groups (of
Individuals)

175L00000X

Homeopath

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

236

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

171R00000X

Interpreter

100000000

Individuals or Groups (of
Individuals)

174N00000X

Lactation Consultant, Non-RN

100000000

Individuals or Groups (of
Individuals)

173000000X

Legal Medicine

100000000

Individuals or Groups (of
Individuals)

172M00000X

Mechanotherapist

100000000

Individuals or Groups (of
Individuals)

170100000X

Medical Genetics, Ph.D. Medical
Genetics

100000000

Individuals or Groups (of
Individuals)

176B00000X

Midwife

100000000

Individuals or Groups (of
Individuals)

175M00000X

Midwife, Lay

100000000

Individuals or Groups (of
Individuals)

171000000X

Military Health Care Provider

100000000

Individuals or Groups (of
Individuals)

1710I1002X

Independent Duty Corpsman

100000000

Individuals or Groups (of
Individuals)

1710I1003X

Independent Duty Medical
Technicians

100000000

Individuals or Groups (of
Individuals)

172P00000X

Naprapath

100000000

Individuals or Groups (of
Individuals)

175F00000X

Naturopath

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

237

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

173C00000X

Reflexologist

100000000

Individuals or Groups (of
Individuals)

173F00000X

Sleep Specialist, PhD

100000000

Individuals or Groups (of
Individuals)

174400000X

Specialist

100000000

Individuals or Groups (of
Individuals)

1744G0900X

Graphics Designer

100000000

Individuals or Groups (of
Individuals)

1744P3200X

Prosthetics Case Management

100000000

Individuals or Groups (of
Individuals)

1744R1103X

Research Data Abstracter/Coder

100000000

Individuals or Groups (of
Individuals)

1744R1102X

Research Study

100000000

Individuals or Groups (of
Individuals)

174M00000X

Veterinarian

100000000

Individuals or Groups (of
Individuals)

174MM1900X

Medical Research

100000000

Individuals or Groups (of
Individuals)

183500000X

Pharmacist

100000000

Individuals or Groups (of
Individuals)

1835G0000X

General Practice

100000000

Individuals or Groups (of
Individuals)

1835G0303X

Geriatric

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

238

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

1835N0905X

Nuclear

100000000

Individuals or Groups (of
Individuals)

1835N1003X

Nutrition Support

100000000

Individuals or Groups (of
Individuals)

1835X0200X

Oncology

100000000

Individuals or Groups (of
Individuals)

1835P0018X

Pharmacist Clinician (PhC)/ Clinical
Pharmacy Specialist

100000000

Individuals or Groups (of
Individuals)

1835P1200X

Pharmacotherapy

100000000

Individuals or Groups (of
Individuals)

1835P1300X

Psychiatric

100000000

Individuals or Groups (of
Individuals)

183700000X

Pharmacy Technician

100000000

Individuals or Groups (of
Individuals)

367A00000X

Advanced Practice Midwife

100000000

Individuals or Groups (of
Individuals)

367H00000X

Anesthesiologist Assistant

100000000

Individuals or Groups (of
Individuals)

364S00000X

Clinical Nurse Specialist

100000000

Individuals or Groups (of
Individuals)

364SA2100X

Acute Care

100000000

Individuals or Groups (of
Individuals)

364SA2200X

Adult Health

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

239

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

364SC2300X

Chronic Care

100000000

Individuals or Groups (of
Individuals)

364SC1501X

Community Health/Public Health

100000000

Individuals or Groups (of
Individuals)

364SC0200X

Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

364SE0003X

Emergency

100000000

Individuals or Groups (of
Individuals)

364SE1400X

Ethics

100000000

Individuals or Groups (of
Individuals)

364SF0001X

Family Health

100000000

Individuals or Groups (of
Individuals)

364SG0600X

Gerontology

100000000

Individuals or Groups (of
Individuals)

364SH1100X

Holistic

100000000

Individuals or Groups (of
Individuals)

364SH0200X

Home Health

100000000

Individuals or Groups (of
Individuals)

364SI0800X

Informatics

100000000

Individuals or Groups (of
Individuals)

364SL0600X

Long-Term Care

100000000

Individuals or Groups (of
Individuals)

364SM0705X

Medical-Surgical

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

240

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

364SN0000X

Neonatal

100000000

Individuals or Groups (of
Individuals)

364SN0800X

Neuroscience

100000000

Individuals or Groups (of
Individuals)

364SX0106X

Occupational Health

100000000

Individuals or Groups (of
Individuals)

364SX0200X

Oncology

100000000

Individuals or Groups (of
Individuals)

364SX0204X

Oncology, Pediatrics

100000000

Individuals or Groups (of
Individuals)

364SP0200X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

364SP1700X

Perinatal

100000000

Individuals or Groups (of
Individuals)

364SP2800X

Perioperative

100000000

Individuals or Groups (of
Individuals)

364SP0808X

Psychiatric/Mental Health

100000000

Individuals or Groups (of
Individuals)

364SP0809X

Psychiatric/Mental Health, Adult

100000000

Individuals or Groups (of
Individuals)

364SP0807X

Psychiatric/Mental Health, Child &
Adolescent

100000000

Individuals or Groups (of
Individuals)

364SP0810X

Psychiatric/Mental Health, Child &
Family

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

241

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

364SP0811X

Psychiatric/Mental Health,
Chronically Ill

100000000

Individuals or Groups (of
Individuals)

364SP0812X

Psychiatric/Mental Health,
Community

100000000

Individuals or Groups (of
Individuals)

364SP0813X

Psychiatric/Mental Health,
Geropsychiatric

100000000

Individuals or Groups (of
Individuals)

364SR0400X

Rehabilitation

100000000

Individuals or Groups (of
Individuals)

364SS0200X

School

100000000

Individuals or Groups (of
Individuals)

364ST0500X

Transplantation

100000000

Individuals or Groups (of
Individuals)

364SW0102X

Women's Health

100000000

Individuals or Groups (of
Individuals)

367500000X

Nurse Anesthetist, Certified
Registered

100000000

Individuals or Groups (of
Individuals)

363L00000X

Nurse Practitioner

100000000

Individuals or Groups (of
Individuals)

363LA2100X

Acute Care

100000000

Individuals or Groups (of
Individuals)

363LA2200X

Adult Health

100000000

Individuals or Groups (of
Individuals)

363LC1500X

Community Health

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

242

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

363LC0200X

Critical Care Medicine

100000000

Individuals or Groups (of
Individuals)

363LF0000X

Family

100000000

Individuals or Groups (of
Individuals)

363LG0600X

Gerontology

100000000

Individuals or Groups (of
Individuals)

363LN0000X

Neonatal

100000000

Individuals or Groups (of
Individuals)

363LN0005X

Neonatal, Critical Care

100000000

Individuals or Groups (of
Individuals)

363LX0001X

Obstetrics & Gynecology

100000000

Individuals or Groups (of
Individuals)

363LX0106X

Occupational Health

100000000

Individuals or Groups (of
Individuals)

363LP0200X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

363LP0222X

Pediatrics, Critical Care

100000000

Individuals or Groups (of
Individuals)

363LP1700X

Perinatal

100000000

Individuals or Groups (of
Individuals)

363LP2300X

Primary Care

100000000

Individuals or Groups (of
Individuals)

363LP0808X

Psychiatric/Mental Health

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

243

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

363LS0200X

School

100000000

Individuals or Groups (of
Individuals)

363LW0102X

Women's Health

100000000

Individuals or Groups (of
Individuals)

363A00000X

Physician Assistant

100000000

Individuals or Groups (of
Individuals)

363AM0700X

Medical

100000000

Individuals or Groups (of
Individuals)

363AS0400X

Surgical

100000000

Individuals or Groups (of
Individuals)

211D00000X

Assistant, Podiatric

100000000

Individuals or Groups (of
Individuals)

213E00000X

Podiatrist

100000000

Individuals or Groups (of
Individuals)

213ES0103X

Foot & Ankle Surgery

100000000

Individuals or Groups (of
Individuals)

213ES0131X

Foot Surgery

100000000

Individuals or Groups (of
Individuals)

213EG0000X

General Practice

100000000

Individuals or Groups (of
Individuals)

213EP1101X

Primary Podiatric Medicine

100000000

Individuals or Groups (of
Individuals)

213EP0504X

Public Medicine

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

244

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

213ER0200X

Radiology

100000000

Individuals or Groups (of
Individuals)

213ES0000X

Sports Medicine

100000000

Individuals or Groups (of
Individuals)

229N00000X

Anaplastologist

100000000

Individuals or Groups (of
Individuals)

221700000X

Art Therapist

100000000

Individuals or Groups (of
Individuals)

224Y00000X

Clinical Exercise Physiologist

100000000

Individuals or Groups (of
Individuals)

225600000X

Dance Therapist

100000000

Individuals or Groups (of
Individuals)

222Q00000X

Developmental Therapist

100000000

Individuals or Groups (of
Individuals)

226300000X

Kinesiotherapist

100000000

Individuals or Groups (of
Individuals)

225700000X

Massage Therapist

100000000

Individuals or Groups (of
Individuals)

224900000X

Mastectomy Fitter

100000000

Individuals or Groups (of
Individuals)

225A00000X

Music Therapist

100000000

Individuals or Groups (of
Individuals)

225X00000X

Occupational Therapist

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

245

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

225XR0403X

Driving and Community Mobility

100000000

Individuals or Groups (of
Individuals)

225XE0001X

Environmental Modification

100000000

Individuals or Groups (of
Individuals)

225XE1200X

Ergonomics

100000000

Individuals or Groups (of
Individuals)

225XF0002X

Feeding, Eating & Swallowing

100000000

Individuals or Groups (of
Individuals)

225XG0600X

Gerontology

100000000

Individuals or Groups (of
Individuals)

225XH1200X

Hand

100000000

Individuals or Groups (of
Individuals)

225XH1300X

Human Factors

100000000

Individuals or Groups (of
Individuals)

225XL0004X

Low Vision

100000000

Individuals or Groups (of
Individuals)

225XM0800X

Mental Health

100000000

Individuals or Groups (of
Individuals)

225XN1300X

Neurorehabilitation

100000000

Individuals or Groups (of
Individuals)

225XP0200X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

225XP0019X

Physical Rehabilitation

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

246

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

224Z00000X

Occupational Therapy Assistant

100000000

Individuals or Groups (of
Individuals)

224ZR0403X

Driving and Community Mobility

100000000

Individuals or Groups (of
Individuals)

224ZE0001X

Environmental Modification

100000000

Individuals or Groups (of
Individuals)

224ZF0002X

Feeding, Eating & Swallowing

100000000

Individuals or Groups (of
Individuals)

Table Pages 41 - 63
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

224ZL0004X

Low Vision

100000000

Individuals or Groups (of
Individuals)

225000000X

Orthotic Fitter

100000000

Individuals or Groups (of
Individuals)

222Z00000X

Orthotist

100000000

Individuals or Groups (of
Individuals)

224L00000X

Pedorthist

100000000

Individuals or Groups (of
Individuals)

225100000X

Physical Therapist

100000000

Individuals or Groups (of
Individuals)

2251C2600X

Cardiopulmonary

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

247

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2251E1300X

Electrophysiology, Clinical

100000000

Individuals or Groups (of
Individuals)

2251E1200X

Ergonomics

100000000

Individuals or Groups (of
Individuals)

2251G0304X

Geriatrics

100000000

Individuals or Groups (of
Individuals)

2251H1200X

Hand

100000000

Individuals or Groups (of
Individuals)

2251H1300X

Human Factors

100000000

Individuals or Groups (of
Individuals)

2251N0400X

Neurology

100000000

Individuals or Groups (of
Individuals)

2251X0800X

Orthopedic

100000000

Individuals or Groups (of
Individuals)

2251P0200X

Pediatrics

100000000

Individuals or Groups (of
Individuals)

2251S0007X

Sports

100000000

Individuals or Groups (of
Individuals)

225200000X

Physical Therapy Assistant

100000000

Individuals or Groups (of
Individuals)

224P00000X

Prosthetist

100000000

Individuals or Groups (of
Individuals)

225B00000X

Pulmonary Function Technologist

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

248

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

225800000X

Recreation Therapist

100000000

Individuals or Groups (of
Individuals)

225C00000X

Rehabilitation Counselor

100000000

Individuals or Groups (of
Individuals)

225CA2400X

Assistive Technology Practitioner

100000000

Individuals or Groups (of
Individuals)

225CA2500X

Assistive Technology Supplier

100000000

Individuals or Groups (of
Individuals)

225CX0006X

Orientation and Mobility Training
Provider

100000000

Individuals or Groups (of
Individuals)

225400000X

Rehabilitation Practitioner

100000000

Individuals or Groups (of
Individuals)

227800000X

Respiratory Therapist, Certified

100000000

Individuals or Groups (of
Individuals)

2278C0205X

Critical Care

100000000

Individuals or Groups (of
Individuals)

2278E1000X

Educational

100000000

Individuals or Groups (of
Individuals)

2278E0002X

Emergency Care

100000000

Individuals or Groups (of
Individuals)

2278G1100X

General Care

100000000

Individuals or Groups (of
Individuals)

2278G0305X

Geriatric Care

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

249

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2278H0200X

Home Health

100000000

Individuals or Groups (of
Individuals)

2278P3900X

Neonatal/Pediatrics

100000000

Individuals or Groups (of
Individuals)

2278P3800X

Palliative/Hospice

100000000

Individuals or Groups (of
Individuals)

2278P4000X

Patient Transport

100000000

Individuals or Groups (of
Individuals)

2278P1004X

Pulmonary Diagnostics

100000000

Individuals or Groups (of
Individuals)

2278P1006X

Pulmonary Function Technologist

100000000

Individuals or Groups (of
Individuals)

2278P1005X

Pulmonary Rehabilitation

100000000

Individuals or Groups (of
Individuals)

2278S1500X

SNF/Subacute Care

100000000

Individuals or Groups (of
Individuals)

227900000X

Respiratory Therapist, Registered

100000000

Individuals or Groups (of
Individuals)

2279C0205X

Critical Care

100000000

Individuals or Groups (of
Individuals)

2279E1000X

Educational

100000000

Individuals or Groups (of
Individuals)

2279E0002X

Emergency Care

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

250

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2279G1100X

General Care

100000000

Individuals or Groups (of
Individuals)

2279G0305X

Geriatric Care

100000000

Individuals or Groups (of
Individuals)

2279H0200X

Home Health

100000000

Individuals or Groups (of
Individuals)

2279P3900X

Neonatal/Pediatrics

100000000

Individuals or Groups (of
Individuals)

2279P3800X

Palliative/Hospice

100000000

Individuals or Groups (of
Individuals)

2279P4000X

Patient Transport

100000000

Individuals or Groups (of
Individuals)

2279P1004X

Pulmonary Diagnostics

100000000

Individuals or Groups (of
Individuals)

2279P1006X

Pulmonary Function Technologist

100000000

Individuals or Groups (of
Individuals)

2279P1005X

Pulmonary Rehabilitation

100000000

Individuals or Groups (of
Individuals)

2279S1500X

SNF/Subacute Care

100000000

Individuals or Groups (of
Individuals)

225500000X

Specialist/Technologist

100000000

Individuals or Groups (of
Individuals)

2255A2300X

Athletic Trainer

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

251

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2255R0406X

Rehabilitation, Blind

100000000

Individuals or Groups (of
Individuals)

231H00000X

Audiologist

100000000

Individuals or Groups (of
Individuals)

231HA2400X

Assistive Technology Practitioner

100000000

Individuals or Groups (of
Individuals)

231HA2500X

Assistive Technology Supplier

100000000

Individuals or Groups (of
Individuals)

237600000X

Audiologist-Hearing Aid Fitter

100000000

Individuals or Groups (of
Individuals)

237700000X

Hearing Instrument Specialist

100000000

Individuals or Groups (of
Individuals)

235500000X

Specialist/Technologist

100000000

Individuals or Groups (of
Individuals)

2355A2700X

Audiology Assistant

100000000

Individuals or Groups (of
Individuals)

2355S0801X

Speech-Language Assistant

100000000

Individuals or Groups (of
Individuals)

235Z00000X

Speech-Language Pathologist

100000000

Individuals or Groups (of
Individuals)

390200000X

Student in an Organized Health Care
Education/Training Program

100000000

Individuals or Groups (of
Individuals)

242T00000X

Perfusionist

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

252

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

247100000X

Radiologic Technologist

100000000

Individuals or Groups (of
Individuals)

2471B0102X

Bone Densitometry

100000000

Individuals or Groups (of
Individuals)

2471C1106X

Cardiac-Interventional Technology

100000000

Individuals or Groups (of
Individuals)

2471C1101X

Cardiovascular-Interventional
Technology

100000000

Individuals or Groups (of
Individuals)

2471C3401X

Computed Tomography

100000000

Individuals or Groups (of
Individuals)

2471M1202X

Magnetic Resonance Imaging

100000000

Individuals or Groups (of
Individuals)

2471M2300X

Mammography

100000000

Individuals or Groups (of
Individuals)

2471N0900X

Nuclear Medicine Technology

100000000

Individuals or Groups (of
Individuals)

2471Q0001X

Quality Management

100000000

Individuals or Groups (of
Individuals)

2471R0002X

Radiation Therapy

100000000

Individuals or Groups (of
Individuals)

2471C3402X

Radiography

100000000

Individuals or Groups (of
Individuals)

2471S1302X

Sonography

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

253

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

2471V0105X

Vascular Sonography

100000000

Individuals or Groups (of
Individuals)

2471V0106X

Vascular-Interventional Technology

100000000

Individuals or Groups (of
Individuals)

243U00000X

Radiology Practitioner Assistant

100000000

Individuals or Groups (of
Individuals)

246X00000X

Specialist/Technologist
Cardiovascular

100000000

Individuals or Groups (of
Individuals)

246XC2901X

Cardiovascular Invasive Specialist

100000000

Individuals or Groups (of
Individuals)

246XS1301X

Sonography

100000000

Individuals or Groups (of
Individuals)

246XC2903X

Vascular Specialist

100000000

Individuals or Groups (of
Individuals)

246Y00000X

Specialist/Technologist, Health
Information

100000000

Individuals or Groups (of
Individuals)

246YC3301X

Coding Specialist, Hospital Based

100000000

Individuals or Groups (of
Individuals)

246YC3302X

Coding Specialist, Physician Office
Based

100000000

Individuals or Groups (of
Individuals)

246YR1600X

Registered Record Administrator

100000000

Individuals or Groups (of
Individuals)

246Z00000X

Specialist/Technologist, Other

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

254

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

246ZA2600X

Art, Medical

100000000

Individuals or Groups (of
Individuals)

246ZB0500X

Biochemist

100000000

Individuals or Groups (of
Individuals)

246ZB0301X

Biomedical Engineering

100000000

Individuals or Groups (of
Individuals)

246ZB0302X

Biomedical Photographer

100000000

Individuals or Groups (of
Individuals)

246ZB0600X

Biostatistician

100000000

Individuals or Groups (of
Individuals)

246ZC0007X

Certified First Assistant

100000000

Individuals or Groups (of
Individuals)

246ZE0500X

EEG

100000000

Individuals or Groups (of
Individuals)

246ZE0600X

Electroneurodiagnostic

100000000

Individuals or Groups (of
Individuals)

246ZG1000X

Geneticist, Medical (PhD)

100000000

Individuals or Groups (of
Individuals)

246ZG0701X

Graphics Methods

100000000

Individuals or Groups (of
Individuals)

246ZI1000X

Illustration, Medical

100000000

Individuals or Groups (of
Individuals)

246ZN0300X

Nephrology

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

255

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

246ZS0400X

Surgical

100000000

Individuals or Groups (of
Individuals)

246Q00000X

Specialist/Technologist, Pathology

100000000

Individuals or Groups (of
Individuals)

246QB0000X

Blood Banking

100000000

Individuals or Groups (of
Individuals)

246QC1000X

Chemistry

100000000

Individuals or Groups (of
Individuals)

246QC2700X

Cytotechnology

100000000

Individuals or Groups (of
Individuals)

246QH0401X

Hemapheresis Practitioner

100000000

Individuals or Groups (of
Individuals)

246QH0000X

Hematology

100000000

Individuals or Groups (of
Individuals)

246QH0600X

Histology

100000000

Individuals or Groups (of
Individuals)

246QI0000X

Immunology

100000000

Individuals or Groups (of
Individuals)

246QL0900X

Laboratory Management

100000000

Individuals or Groups (of
Individuals)

246QL0901X

Laboratory Management, Diplomate

100000000

Individuals or Groups (of
Individuals)

246QM0706X

Medical Technologist

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

256

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

246QM0900X

Microbiology

100000000

Individuals or Groups (of
Individuals)

246W00000X

Technician, Cardiology

100000000

Individuals or Groups (of
Individuals)

247000000X

Technician, Health Information

100000000

Individuals or Groups (of
Individuals)

2470A2800X

Assistant Record Technician

100000000

Individuals or Groups (of
Individuals)

247200000X

Technician, Other

100000000

Individuals or Groups (of
Individuals)

2472B0301X

Biomedical Engineering

100000000

Individuals or Groups (of
Individuals)

2472D0500X

Darkroom

100000000

Individuals or Groups (of
Individuals)

2472E0500X

EEG

100000000

Individuals or Groups (of
Individuals)

2472R0900X

Renal Dialysis

100000000

Individuals or Groups (of
Individuals)

2472V0600X

Veterinary

100000000

Individuals or Groups (of
Individuals)

246R00000X

Technician, Pathology

100000000

Individuals or Groups (of
Individuals)

247ZC0005X

Clinical Laboratory Director, Nonphysician

100000000

Individuals or Groups (of
Individuals)

December 2020v4.0.0

257

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

246RH0600X

Histology

100000000

Individuals or Groups (of
Individuals)

246RM2200X

Medical Laboratory

100000000

Individuals or Groups (of
Individuals)

246RP1900X

Phlebotomy

100000000

Individuals or Groups (of
Individuals)

251300000X

Local Education Agency (LEA)

250000000

Non-Individual - Agencies

251B00000X

Case Management

250000000

Non-Individual - Agencies

251S00000X

Community/Behavioral Health

250000000

Non-Individual - Agencies

251C00000X

Day Training, Developmentally
Disabled Services

250000000

Non-Individual - Agencies

252Y00000X

Early Intervention Provider Agency

250000000

Non-Individual - Agencies

253J00000X

Foster Care Agency

250000000

Non-Individual - Agencies

251E00000X

Home Health

250000000

Non-Individual - Agencies

251F00000X

Home Infusion

250000000

Non-Individual - Agencies

251G00000X

Hospice Care, Community Based

250000000

Non-Individual - Agencies

253Z00000X

In Home Supportive Care

250000000

Non-Individual - Agencies

251J00000X

Nursing Care

250000000

Non-Individual - Agencies

251T00000X

Program of All-Inclusive Care for the
Elderly (PACE) Provider Organization

250000000

Non-Individual - Agencies

251K00000X

Public Health or Welfare

250000000

Non-Individual - Agencies

251X00000X

Supports Brokerage

250000000

Non-Individual - Agencies

December 2020v4.0.0

258

Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

251V00000X

Voluntary or Charitable

250000000

Non-Individual - Agencies

261Q00000X

Clinic/Center

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM0855X

Adolescent and Children Mental
Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QA0600X

Adult Day Care

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM0850X

Adult Mental Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QA0005X

Ambulatory Family Planning Facility

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QA0006X

Ambulatory Fertility Facility

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QA1903X

Ambulatory Surgical

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QA0900X

Amputee

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QA3000X

Augmentative Communication

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QB0400X

Birthing

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QC1500X

Community Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QC1800X

Corporate Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

261QC0050X

Critical Access Hospital

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QD0000X

Dental

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QD1600X

Developmental Disabilities

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QE0002X

Emergency Care

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QE0800X

Endoscopy

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QE0700X

End-Stage Renal Disease () Treatment

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QF0050X

Family Planning, Non-Surgical

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QF0400X

Federally Qualified Health Center
(FQHC)

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QG0250X

Genetics

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QH0100X

Health Service

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QH0700X

Hearing and Speech

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QI0500X

Infusion Therapy

260000000

Non-Individual - Ambulatory
Health Care Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

261QL0400X

Lithotripsy

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1200X

Magnetic Resonance Imaging (MRI)

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM2500X

Medical Specialty

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM3000X

Medically Fragile Infants and Children
Day Care

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM0801X

Mental Health (Including Community
Mental Health Center)

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM2800X

Methadone

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1000X

Migrant Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1103X

Military Ambulatory Procedure Visits
Operational (Transportable)

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1101X

Military and U.S. Coast Guard
Ambulatory Procedure

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1102X

Military Outpatient Operational
(Transportable) Component

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1100X

Military/U.S. Coast Guard Outpatient

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QM1300X

Multi-Specialty

260000000

Non-Individual - Ambulatory
Health Care Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

261QX0100X

Occupational Medicine

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QX0200X

Oncology

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QX0203X

Oncology, Radiation

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QS0132X

Ophthalmologic Surgery

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QS0112X

Oral and Maxillofacial Surgery

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP3300X

Pain

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP2000X

Physical Therapy

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP1100X

Podiatric

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP2300X

Primary Care

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP2400X

Prison Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP0904X

Public Health, Federal

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QP0905X

Public Health, State or Local

260000000

Non-Individual - Ambulatory
Health Care Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

261QR0200X

Radiology

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0206X

Radiology, Mammography

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0208X

Radiology, Mobile

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0207X

Radiology, Mobile Mammography

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0800X

Recovery Care

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0400X

Rehabilitation

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0404X

Rehabilitation, Cardiac Facilities

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0401X

Rehabilitation, Comprehensive
Outpatient Rehabilitation Facility
(CORF)

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR0405X

Rehabilitation, Substance Use
Disorder

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR1100X

Research

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QR1300X

Rural Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QS1200X

Sleep Disorder Diagnostic

260000000

Non-Individual - Ambulatory
Health Care Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

261QS1000X

Student Health

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QU0200X

Urgent Care

260000000

Non-Individual - Ambulatory
Health Care Facilities

261QV0200X

VA

260000000

Non-Individual - Ambulatory
Health Care Facilities

273100000X

Epilepsy Unit

270000000

Non-Individual - Hospital Units

275N00000X

Medicare Defined Swing Bed Unit

270000000

Non-Individual - Hospital Units

273R00000X

Psychiatric Unit

270000000

Non-Individual - Hospital Units

273Y00000X

Rehabilitation Unit

270000000

Non-Individual - Hospital Units

276400000X

Rehabilitation, Substance Use
Disorder Unit

270000000

Non-Individual - Hospital Units

287300000X

Christian Science Sanitorium

280000000

Non-Individual - Hospitals

281P00000X

Chronic Disease Hospital

280000000

Non-Individual - Hospitals

281PC2000X

Children

280000000

Non-Individual - Hospitals

282N00000X

General Acute Care Hospital

280000000

Non-Individual - Hospitals

282NC2000X

Children

280000000

Non-Individual - Hospitals

282NC0060X

Critical Access

280000000

Non-Individual - Hospitals

282NR1301X

Rural

280000000

Non-Individual - Hospitals

282NW0100X

Women

280000000

Non-Individual - Hospitals

282E00000X

Long Term Care Hospital

280000000

Non-Individual - Hospitals

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

286500000X

Military Hospital

280000000

Non-Individual - Hospitals

2865C1500X

Community Health

280000000

Non-Individual - Hospitals

2865M2000X

Military General Acute Care Hospital

280000000

Non-Individual - Hospitals

2865X1600X

Military General Acute Care Hospital.
Operational (Transportable)

280000000

Non-Individual - Hospitals

283Q00000X

Psychiatric Hospital

280000000

Non-Individual - Hospitals

283X00000X

Rehabilitation Hospital

280000000

Non-Individual - Hospitals

283XC2000X

Children

280000000

Non-Individual - Hospitals

282J00000X

Religious Nonmedical Health Care
Institution

280000000

Non-Individual - Hospitals

284300000X

Special Hospital

280000000

Non-Individual - Hospitals

291U00000X

Clinical Medical Laboratory

290000000

Non-Individual - Laboratories

292200000X

Dental Laboratory

290000000

Non-Individual - Laboratories

291900000X

Military Clinical Medical Laboratory

290000000

Non-Individual - Laboratories

293D00000X

Physiological Laboratory

290000000

Non-Individual - Laboratories

302F00000X

Exclusive Provider Organization

300000000

Non-Individual - Managed
Care Organizations

302R00000X

Health Maintenance Organization

300000000

Non-Individual - Managed
Care Organizations

305S00000X

Point of Service

300000000

Non-Individual - Managed
Care Organizations

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

305R00000X

Preferred Provider Organization

300000000

Non-Individual - Managed
Care Organizations

311500000X

Alzheimer Center (Dementia Center)

310000000

Non-Individual - Nursing &
Custodial Care Facilities

310400000X

Assisted Living Facility

310000000

Non-Individual - Nursing &
Custodial Care Facilities

3104A0630X

Assisted Living, Behavioral
Disturbances

310000000

Non-Individual - Nursing &
Custodial Care Facilities

3104A0625X

Assisted Living, Mental Illness

310000000

Non-Individual - Nursing &
Custodial Care Facilities

317400000X

Christian Science Facility

310000000

Non-Individual - Nursing &
Custodial Care Facilities

311Z00000X

Custodial Care Facility

310000000

Non-Individual - Nursing &
Custodial Care Facilities

311ZA0620X

Adult Care Home

310000000

Non-Individual - Nursing &
Custodial Care Facilities

315D00000X

Hospice, Inpatient

310000000

Non-Individual - Nursing &
Custodial Care Facilities

310500000X

Intermediate Care Facility, Mental
Illness

310000000

Non-Individual - Nursing &
Custodial Care Facilities

315P00000X

Intermediate Care Facility, Mentally
Retarded

310000000

Non-Individual - Nursing &
Custodial Care Facilities

313M00000X

Nursing Facility/Intermediate Care
Facility

310000000

Non-Individual - Nursing &
Custodial Care Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

314000000X

Skilled Nursing Facility

310000000

Non-Individual - Nursing &
Custodial Care Facilities

3140N1450X

Nursing Care, Pediatric

310000000

Non-Individual - Nursing &
Custodial Care Facilities

177F00000X

Lodging

170000000

Non-Individual - Other Service
Providers

174200000X

Meals

170000000

Non-Individual - Other Service
Providers

320800000X

Community Based Residential
Treatment Facility, Mental Illness

320000000

Non-Individual - Residential
Treatment Facilities

320900000X

Community Based Residential
Treatment Facility, Mental
Retardation and/or Developmental
Disabilities

320000000

Non-Individual - Residential
Treatment Facilities

323P00000X

Psychiatric Residential Treatment
Facility

320000000

Non-Individual - Residential
Treatment Facilities

322D00000X

Residential Treatment Facility,
Emotionally Disturbed Children

320000000

Non-Individual - Residential
Treatment Facilities

320600000X

Residential Treatment Facility,
Mental Retardation and/or
Developmental Disabilities

320000000

Non-Individual - Residential
Treatment Facilities

320700000X

Residential Treatment Facility,
Physical Disabilities

320000000

Non-Individual - Residential
Treatment Facilities

324500000X

Substance Abuse Rehabilitation
Facility

320000000

Non-Individual - Residential
Treatment Facilities

3245S0500X

Substance Abuse Treatment, Children

320000000

Non-Individual - Residential
Treatment Facilities

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

385H00000X

Respite Care

380000000

Non-Individual - Respite Care
Facility

385HR2050X

Respite Care Camp

380000000

Non-Individual - Respite Care
Facility

385HR2055X

Respite Care, Mental Illness, Child

380000000

Non-Individual - Respite Care
Facility

385HR2060X

Respite Care, Mental Retardation
and/or Developmental Disabilities

380000000

Non-Individual - Respite Care
Facility

385HR2065X

Respite Care, Physical Disabilities,
Child

380000000

Non-Individual - Respite Care
Facility

331L00000X

Blood Bank

330000000

Non-Individual - Suppliers

332100000X

Department of Veterans Affairs (VA)
Pharmacy

330000000

Non-Individual - Suppliers

332B00000X

Durable Medical Equipment &
Medical Supplies

330000000

Non-Individual - Suppliers

332BC3200X

Customized Equipment

330000000

Non-Individual - Suppliers

332BD1200X

Dialysis Equipment & Supplies

330000000

Non-Individual - Suppliers

332BN1400X

Nursing Facility Supplies

330000000

Non-Individual - Suppliers

332BX2000X

Oxygen Equipment & Supplies

330000000

Non-Individual - Suppliers

332BP3500X

Parenteral & Enteral Nutrition

330000000

Non-Individual - Suppliers

333300000X

Emergency Response System
Companies

330000000

Non-Individual - Suppliers

332G00000X

Eye Bank

330000000

Non-Individual - Suppliers

332H00000X

Eyewear Supplier (Equipment, not
the service)

330000000

Non-Individual - Suppliers

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

332S00000X

Hearing Aid Equipment

330000000

Non-Individual - Suppliers

332U00000X

Home Delivered Meals

330000000

Non-Individual - Suppliers

332800000X

Indian Health Service/Tribal/Urban
Indian Health (I/T/U) Pharmacy

330000000

Non-Individual - Suppliers

335G00000X

Medical Foods Supplier

330000000

Non-Individual - Suppliers

332000000X

Military/U.S. Coast Guard Pharmacy

330000000

Non-Individual - Suppliers

332900000X

Non-Pharmacy Dispensing Site

330000000

Non-Individual - Suppliers

335U00000X

Organ Procurement Organization

330000000

Non-Individual - Suppliers

333600000X

Pharmacy

330000000

Non-Individual - Suppliers

3336C0002X

Clinic Pharmacy

330000000

Non-Individual - Suppliers

3336C0003X

Community/Retail Pharmacy

330000000

Non-Individual - Suppliers

3336C0004X

Compounding Pharmacy

330000000

Non-Individual - Suppliers

3336H0001X

Home Infusion Therapy Pharmacy

330000000

Non-Individual - Suppliers

3336I0012X

Institutional Pharmacy

330000000

Non-Individual - Suppliers

3336L0003X

Long Term Care Pharmacy

330000000

Non-Individual - Suppliers

3336M0002X

Mail Order Pharmacy

330000000

Non-Individual - Suppliers

3336M0003X

Managed Care Organization
Pharmacy

330000000

Non-Individual - Suppliers

3336N0007X

Nuclear Pharmacy

330000000

Non-Individual - Suppliers

3336S0011X

Specialty Pharmacy

330000000

Non-Individual - Suppliers

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

335V00000X

Portable X-Ray Supplier

330000000

Non-Individual - Suppliers

335E00000X

Prosthetic/Orthotic Supplier

330000000

Non-Individual - Suppliers

344800000X

Air Carrier

340000000

Non-Individual Transportation Services

341600000X

Ambulance

340000000

Non-Individual Transportation Services

3416A0800X

Air Transport

340000000

Non-Individual Transportation Services

3416L0300X

Land Transport

340000000

Non-Individual Transportation Services

3416S0300X

Water Transport

340000000

Non-Individual Transportation Services

347B00000X

Bus

340000000

Non-Individual Transportation Services

341800000X

Military/U.S. Coast Guard Transport

340000000

Non-Individual Transportation Services

3418M1120X

Military or U.S. Coast Guard
Ambulance, Air Transport

340000000

Non-Individual Transportation Services

3418M1110X

Military or U.S. Coast Guard
Ambulance, Ground Transport

340000000

Non-Individual Transportation Services

3418M1130X

Military or U.S. Coast Guard
Ambulance, Water Transport

340000000

Non-Individual Transportation Services

343900000X

Non-emergency Medical Transport
(VAN)

340000000

Non-Individual Transportation Services

December 2020v4.0.0

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Appendix L
Provider
Taxonomy
Code

Provider Taxonomy Description

Provider Facility
Type Code

Provider Facility Type
Description

347C00000X

Private Vehicle

340000000

Non-Individual Transportation Services

343800000X

Secured Medical Transport (VAN)

340000000

Non-Individual Transportation Services

344600000X

Taxi

340000000

Non-Individual Transportation Services

347D00000X

Train

340000000

Non-Individual Transportation Services

347E00000X

Transportation Broker

340000000

Non-Individual Transportation Services

December 2020v4.0.0

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Appendix M

Appendix M

December 2020v4.0.0

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Appendix N

Appendix N: Coding Specific Data Elements for Claim Files
Clarification of the use of the PROCEDURE-CODE, REVENUE-CODE, HCPCS-RATE, BEGINNING-DATE-OFSERVICE, and ENDING-DATE-OF-SERVICE fields in the CLAIMOT File.
Because the CLAIMOT file is a catch-all file that includes outpatient facility claims, professional claims and
financial transactions, states are having confusion over when to populate the PROCEDURE-CODE, REVENUECODE, HCPCS-RATE , BEGINNING-DATE-OF-SERVICE, ENDING-DATE-OF-SERVICE, PROCEDURE-CODE-DATE,
PROCEDURE-CODE-FLAG, and PROCEDURE-CODE-MOD-1 thru -4 fields. To assist them we have prepared the
following guidelines.
For professional claims:









REVENUE-CODE should be 8-filled, left blank or space-filled.
HCPCS-RATE should be 8-filled, left blank or space-filled.
PROCEDURE-CODE-FLAG should be populated with either “01 (CPT-4), “06” (HCPCS), or “10” through “87”
(to indicate other coding schemas).
PROCEDURE-CODE should be used to capture the CPT/HCPCS service codes.
PROCEDURE-CODE-MOD-1 thru -4 should be populated as needed.
BEGINNING-DATE-OF-SERVICE should show the 1st DOS associated with the service code in the
PROCEDURE-CODE field.
ENDING-DATE-OF-SERVICE should show the last DOS associated with the service code in the PROCEDURECODE field.
PROCEDURE-CODE-DATE should be 8-filled, left blank or space-filled (This field is superfluous. Beginning/Ending-Date-of-Service captures the same information and provides more flexibility if the service is
provided repeatedly over a period of time.)

For institutional claims for ambulatory care (reported on CLAIMOT file):









REVENUE-CODE should be used to capture the services provided.
HCPCS-RATE should be used to capture HCPCS details whenever they are needed to support the value in
the REVENUE-CODE field. Otherwise, the field should be 8-filled, left blank or space-filled.
PROCEDURE-CODE-FLAG should be 8-filled, left blank or space-filled.
PROCEDURE-CODE field should be 8-filled, left blank or space-filled.
PROCEDURE-CODE-MOD-1 thru -4 should be 8-filled, left blank or space-filled.
BEGINNING-DATE-OF-SERVICE should show the 1st DOS associated with the service code in the REVENUECODE field.
ENDING-DATE-OF-SERVICE should show the last DOS associated with the service code in the REVENUECODE field.
PROCEDURE-CODE-DATE should be 8-filled, left blank or space-filled (This field is superfluous. Beginning/Ending-Date-of-Service captures the same information and provides more flexibility if the service is
provided repeatedly over a period of time.)

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Appendix N
For financial transactions9:









9

REVENUE-CODE field should be 8-filled, left blank or space-filled.
HCPCS-RATE should be 8-filled, left blank or space-filled.
PROCEDURE-CODE-FLAG should be 8-filled, left blank or space-filled, or populated with “10” through “87”
(to indicate other coding schemas if state-specific codes are used).
PROCEDURE-CODE field should be 8-filled, left blank or space-filled unless the State has state-specific codes
it uses to provide further detail (e.g., codes to split capitation payments into subcategories).
PROCEDURE-CODE-MOD-1 thru -4 should be 8-filled, left blank or space-filled.
BEGINNING-DATE-OF-SERVICE should show the 1st day of the time period covered by this financial
transaction.
ENDING-DATE-OF-SERVICE should show the last day of the time period covered by this financial
transaction.
PROCEDURE-CODE-DATE should be 8-filled, left blank or space-filled (This field is superfluous. Beginning/Ending-Date-of-Service captures the same information and provides more flexibility if the service is
provided repeatedly over a period of time.)

CMS Guidance – Reporting Financial Transactions in T-MSIS – 2014-04-23

December 2020v4.0.0

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Appendix N
*This Section Intentionally Left Blank*

December 2020v4.0.0

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Appendix O

Appendix O
*This Section Intentionally Left Blank

December 2020v4.0.0

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Appendix NP
*

December 2020v4.0.0

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Appendix P

Appendix P: CMS Guidance Library

December 2020v4.0.0

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Appendix P.01

Appendix P.01: Submitting Adjustment Claims to T-MSIS
Brief Issue Description
There are two ways original claims, and their subsequent adjustments can be linked into a claim family – either
through all adjustments linking back to the original claim or each subsequent adjustment linking back to the
prior claim (i.e.., “daisy chain”). Identifying the members of a claim family is necessary in order to evaluate the
changes to a claim that occur throughout its life.
Background Discussion
Before delving into CMS’ guidance on how to populate the ICN-ORIG and ICN-ADJ fields, some background
discussion is needed on terminology and concepts.
What claim transactions should be submitted to T-MSIS?
Every “final adjudicated version of the claim/encounter” should be submitted to T-MSIS.
A “final adjudicated version of the claim/encounter” is a claim that has completed the adjudication process and
the paid/denied process. The claim and each claim line will have one of the finalized claim status categories
listed in Table 1, below. The actual disposition of the claim can be either “paid” or “denied.”
Table 1: Finalized Claim Status Categories
Code Finalized Claim Status Category Description
F0

Finalized-The encounter has completed the adjudication cycle and no more action will
be taken. (Used on encounter records)

F1

Finalized/Payment-The claim/line has been paid.

F2

Finalized/Denial-The claim/line has been denied.

F3

Finalized/Revised - Adjudication information has been changed.

Both original claims (or encounters) and adjusted claims (or encounters) can be a “final adjudicated version of
the claim/encounter.” Whenever a claim/encounter flows through the adjudication and payment processes (if
applicable) and falls into one of the claim status categories in Table 1, the state should send the claim/encounter
to T-MSIS.
If a claim flows through the adjudication and payment processes and falls into one of the finalized claim status
categories multiple times within a single T-MSIS reporting period, CMS expects each of these final adjudicated
versions of the claim/encounter to be submitted to T-MSIS, not just the one effective on the last day of the
reporting period.
If the claim has not been through the final adjudication process or is “pending” (or in “suspense”), the claim
should not be sent to T-MSIS until disposition has been settled to one of the finalized claim status categories.
Table 2 provides examples and CMS’ expectations.

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Appendix P.01
Table 2: Scenarios for When to Submit Claims
Claim Submission Scenario

CMS’ Expectation

Adjudicated and paid in the same
reporting month

CMS expects the claim to be sent to T-MSIS in the reporting month.

Adjudicated in one reporting
period, but paid in another
reporting month

CMS expects the claim to be sent to T-MSIS in the month that the claim was paid.

Adjudicated and paid in one
reporting month, and then readjudicated and paid in a
subsequent month

The claim should be reported in the month it is paid, regardless of whether it is an
original claim or an adjustment. Therefore, in this scenario, CMS expects the original
to be reported in month one and the adjustment to be reported in the subsequent
month.

Adjudicated and paid, and then readjudicated and paid in the same
reporting month

In this scenario, if a claim flows through the adjudication and payment processes and
falls into one of the claim status categories in Table 1 multiple times within a single TMSIS reporting period, CMS expects each of these final adjudicated versions of the
claim/encounter to be submitted to T-MSIS, not just the one effective on the last day
of the reporting period.

Re-adjudicated and paid multiple
times in the same reporting month

In this scenario, if a claim flows through the adjudication and payment processes and
falls into one of the claim status categories in Table 1 multiple times within a single TMSIS reporting period, CMS expects each of these final adjudicated versions of the
claim/encounter to be submitted to T-MSIS, not just the one effective on the last day
of the reporting period.

What is a claim family?
A “claim family” (a.k.a. “adjustment set”) is defined as a set of post-adjudication claim transactions in paid or
denied status that relate to the same provider/enrollee/services/dates of service. This grouping of the original
claim and all of its subsequent adjustment and/or void claims shows the progression of changes that have
occurred since it was first submitted.
How should ADJUSTMENT-IND codes be used?
The table below lists each of the adjustment indicator codes contained in the T-MSIS Data Dictionary version 1.1
and describes when it should be used.
Table 3: Adjustment Indicator Codes and Their Uses
Code

Description of Use

0

Original Claim/Encounter/Payment – Indicates that this is the first (and, when applicable, only) fully adjudicated
transaction in a claim family (one or more claims with the related ICN-ORIG and/or ICN-ADJ and typically the same MSIS
ID and provider ID(s) also).

December 2020v4.0.0

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Appendix P.01
Code

Description of Use

1

Void/Reversal/Cancel of a prior submission – Use this code to convey that the purpose of the transaction is to
void/reverse/cancel a previously paid/approved claim/encounter/payment where the claim/encounter/payment is not
being replaced by a new paid/approved version of the claim/encounter/payment. Typically this would be the last
claim/encounter/payment that would ever be associated with a given claim family. These records must have the same
ICN-ORIG or ICN-ADJ as the claim/encounter being voided. CMS expects a void transaction to also have the same MSIS
ID and provider ID(s) as the claim/encounter/payment being voided/reversed/canceled.

4

Replacement/Resubmission of a previously paid/approved claim/encounter/payment – Use when the purpose of the
transaction is to replace a previously paid/approved claim/encounter/payment with a new paid/approved version of the
claim/encounter/payment. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being
replaced. CMS expects a replacement transaction to also have the same MSIS ID and provider ID(s) as the
claim/encounter/payment being replaced/resubmitted.

5

Credit Gross Adjustment – Use this code to indicate an aggregate provider-level recoupment of payments (e.g., not
attributable to a single beneficiary). Amounts on these claims should be expressed as negative numbers. If a credit
gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then
CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should
completely replace the preceding related gross adjustment. If the ICNs of a credit gross adjustment are not related to
any other gross adjustments (credit or debit) then the credit gross adjustment will always be treated as a distinct
financial transaction.

6

Debit Gross Adjustment – Use this code to indicate an aggregate provider-level payment to a provider (e.g., not
attributable to a single beneficiary). Amounts on these claims should be expressed as positive numbers. If a debit gross
adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS
will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely
replace the preceding related gross adjustment. If the ICNs of a debit gross adjustment are not related to any other
gross adjustments (credit or debit) then the debit gross adjustment will always be treated as a distinct financial
transaction.

Are gross adjustments considered claims/encounters?
While the gross adjustment adjudication indicator codes (values “5” and “6” in Table 3) are reported to T-MSIS
in the CLAIM-OT file, they are not technically “claims” or “encounters.” Each of these transactions does not
relate to a specific service-provider/enrollee episode of care. Instead, these transactions represent payments
made by the state for services rendered to multiple enrollees (as in the case of a provider providing screening
services for a group of enrollees), DSH payments, or a recoupment of funds previously dispensed in a debit gross
adjustment. Therefore, the concept of “claims family” does not apply. Each of these transactions stands on its
own, and does not constitute a subsequent transaction being a replacement of the earlier transaction.
Refer to T-MSIS Coding Blog entry “Reporting Adjustment Indicator (ADJUSTMENT-IND) for Financial
Transactions (Claims)” for additional detailed information.
What alternatives are there for tying the members of a claim family together?
The Original ICN Approach
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Under this approach, the state assigns an ICN to the initial final adjudicated version of the claim/encounter and
records this identifier in the ICN-ORIG field. If adjustment claims subsequently are created, the ICN assigned to
the initial final adjudicated version of the claim/encounter is carried forward on every subsequent adjustment
claim. Table 43 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are
populated when the original ICN approach is used.
Table 43: ICN-ORIG/ICN-ADJ Relationships Under the Original ICN Approach
ADJUDICATIONEvent
DATE

ICNORIG

ICNADJ

ADJUSTMENT
-IND

On 5/1/2014, the state completes the adjudication process on
the initial version of the claim

5/1/2014

1

-

0

On 7/15/2014, the state completes a claim re-adjudication /
adjustment

7/15/2014

1

2

4

On 8/12/2014, the state completes a 2nd claim re-adjudication /
adjustment

8/12/2014

1

3

4

On 9/5/2014, the state completes a 3rd claim re-adjudication /
adjustment

9/5/2014

1

4

4

The Daisy-Chain ICN Approach
Under this approach, the state records the ICN of the previous final adjudicated version of the claim/encounter
in the ICN-ORIG field of the adjustment claim record. If additional adjustment claims are subsequently created,
the ICN-ORIG on the new adjustment claim only points back one generation. Table 54 illustrates how the ICNORIG and ICN-ADJ values on the members of a claim family are populated when the daisy-chain ICN approach is
used.
Table 54: ICN-ORIG/ICN-ADJ Relationships Under the Daisy-Chain ICN Approach
Event
ADJUDICATIONDATE

ICNORIG

ICNADJ

ADJUSTMENT
-IND

On 6/1/2014, the state completes the adjudication process on
the initial version of the claim

6/1/2014

11

-

0

On 8/15/2014, the state completes a claim readjudication/adjustment

8/15/2014

11

12

4

On 9/12/2014, the state completes a 2nd claim readjudication/adjustment

9/12/2014

12

13

4

On 10/5/2014, the state completes a 3rd claim readjudication/adjustment

10/5/2014

13

14

4

How are ICN-ORIG and ICN-ADJ fields impacted when voids are submitted?
The primary purpose of void transactions (ADJUSTMENT-IND = 1) is to nullify a claim/encounter from T-MSIS
when the state does not wish to replace it with an adjusted claim/encounter record. These records must have
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the same claim key data element values as the claim/encounter being voided. Dollar and quantity fields should
be set to zero. The ADJUDICATION-DATE on these records should be set to the date that the state voided the
claim. Table 6 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated
when the state wishes to void a claim.
Table 6Refer to T-MSIS Coding Blog entry “Populating T-MSIS Claims File Data Elements on Void/Reversal/Cancel

Records” for additional detailed information.
Table 5 illustrates an example of how the dollar and quantity fields on the members of a claim family are
populated when the state wishes to void a claim.
Table 5: ICN-ORIG/ICN-ADJ – Impact of Voids
ADJUDICATIONEvent
DATE

ICNORIG

ICNADJ

ADJUSTMENT
-IND

Dollar
Fields

Quantity
Fields

On 6/1/2014, the state completes the
adjudication process on the initial
version of the claim

6/1/2014

51

-

0

100.00

5

On 8/15/2014, the state completes a
claim re-adjudication/adjustment

8/15/2014

51

52

4

80.00

5

On 8/19/2014, the claim is voided

8/19/2014

51

52

1

0.00

0

If a state uses a process to record adjustments whereby, they void the previous version of the claim and then
follow-up with the creation of a new original transaction, and the state can identify that the void and the new
original claim are from the same adjudication set, the state should link them together into one claims family
using the ICN-ORIG. CMS recognizes that some states may not be able to link a resubmitted claim after a void to
the original claim. Table 76 illustrates how CMS is expecting the states to populate the ICN-ORIG/ICN-ADJ fields
when the state processes a void/new original when adjusting claims.
Table 76: ICN-ORIG/ICN-ADJ – Keeping the Claim Family Intact When the “Void/New Original” Scenario Occurs
Event
ADJUDICATIONICNICNADJUSTMENT
Dollar
DATE
ORIG
ADJ
-IND
Fields

Quantity
Fields

On 6/1/2014, the state completes the
adjudication process on the initial
version of the claim

6/1/2014

51

-

0

100.00

5

On 8/15/2014, the state completes the
adjudication process of a void and
associated new original

8/15/2014

51

-

1

0.00

0

On 8/15/2014, the state completes the
adjudication process of a void and
associated new original

8/15/2014

51

-

0

80.00

5

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Event

ADJUDICATIONDATE

ICNORIG

ICNADJ

ADJUSTMENT
-IND

Dollar
Fields

Quantity
Fields

On 9/20/2014, the state completes the
adjudication process of a void and
associated new original

9/20/2014

51

-

1

0.00

0

On 9/20/2014, the state completes the
adjudication process of a void and
associated new original

9/20/2014

51

-

0

60.00

5

How Adjustment Records will be Applied by CMS
There is an inherent limitation in the way that CMS can interpret what to do with two claim transactions having
the same ICN-ORIG and ADJUDICATION-DATE when both transactions are received in a single submission file.
The processing rules that T-MSIS will follow are outlined below. It is up to each state to assure that claim
transactions are processed in the appropriate sequence. If the rules below do not result in the sequence of
transactions that the state desires, it is up to the state to submit transactions in separate files so that the desired
sequence is attained.
Rules for inserting claim transactions into the T-MSIS database
When two or more claim transactions with the same ICN-ORIG and ADJUDICATION-DATE are in the same
submission file
If two or more transactions in an incoming claim file have the same ICN-ORIG and ADJUDICATION-DATE values,
T-MSIS will evaluate the ADJUSTMENT-IND values and insert the transactions into the T-MSIS database as
follows:
1.

If more than two transactions in the incoming claim file have the same ICN-ORIG and
ADJUDICATION-DATE values, then T-MSIS will reject all of the incoming transactions;.

2.

If the ADJUSTMENT-IND values of both incoming transactions are the same (but not ‘5’ or ‘6’), then
T-MSIS will reject both incoming transactions;.

3.

If the ADJUSTMENT-IND values of both incoming transactions are some combination of ‘5’ and ‘6’
and if there is no active existing transaction in the T-MSIS DB, then T-MSIS will insert both incoming
transactions into the T-MSIS DB (note, since neither transaction supersedes the other, the order in
which they are inserted does not matter);).

4.

If the ADJUSTMENT-IND values of both incoming transactions are some combination of ‘5’ and ‘6’
and if there is an active existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘5’
or ‘6’, then T-MSIS will insert both incoming transactions into the T-MSIS DB (note, since neither
transaction supersedes the other, the order in which they are inserted does not matter);).

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5.

If the ADJUSTMENT-IND values of both incoming transactions is a ‘5’ or ‘6’ and if there is an active
existing transaction in the T-MSIS DB with an ADJUSTMENT-IND value of ‘0’, ‘1’, or ‘4’, then T-MSIS
will reject both the incoming transactions;.

6.

If the ADJUSTMENT-IND value of one incoming transaction is a ‘5’ or ‘6’ and the ADJUSTMENT-IND
of the other transaction is ‘0’, ‘1’, or ‘4’ and if there is an active existing transaction in the T-MSIS DB
with an ADJUSTMENT-IND value of ‘5’ or ‘6’, then T-MSIS will insert the incoming transaction with
ADJUDICATION-IND of ‘5’ or ‘6’ and reject the incoming transaction with ADJUSTMENT-IND value ‘0’,
‘1’, or ‘4’;.

7.

If the ADJUSTMENT-IND value of one incoming transaction is a ‘5’ or ‘6’ and the ADJUSTMENT-IND
of the other transaction is ‘0’, ‘1’, or ‘4’ and there is an active existing transaction in the T-MSIS DB
with an ADJUSTMENT-IND value of ‘0’, ‘1’, or ‘4’, then T-MSIS will reject the incoming transaction
with ADJUSTMENT-IND value ‘5’ or ‘6’ and evaluate the remaining incoming transaction as follows:
a. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the
active existing transaction is ‘0’, then T-MSIS will reject the incoming transaction;.
b. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the
active existing transaction is ‘1’, then T-MSIS will insert the incoming transaction;.
c. ADJUSTMENT-IND of the remaining incoming transaction is ‘0’ and the ADJUSTMENT-IND of the
active existing transaction is ‘4’, then T-MSIS will reject the incoming transaction;.
d. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
active existing transaction is ‘0’, then T-MSIS will insert the incoming transaction;.
e. ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
active existing transaction is ‘1’, then T-MSIS will reject the incoming transaction;.
f.

ADJUSTMENT-IND of the remaining incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
active existing transaction is ‘4’, then T-MSIS will insert the incoming transaction;.

g. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the
active existing transaction is ‘0’, then T-MSIS will insert the incoming transaction;.
h. ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the
active existing transaction is ‘1’, then T-MSIS will insert the incoming transaction;.
i.

ADJUSTMENT-IND of the remaining incoming transaction is ‘4’ and the ADJUSTMENT-IND of the
active existing transaction is ‘4’, then T-MSIS will insert the incoming transaction;.

8.

If the ADJUSTMENT-IND value of one incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
other transaction is ‘0’ or ‘4’ and the ADJUSTMENT-IND of the active existing transaction in the TMSIS DB is ‘0’ or ‘4’, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND = ‘1’
first, and then insert the other transaction;.

9.

If the ADJUSTMENT-IND value of one incoming transaction is ‘1’ and the ADJUSTMENT-IND of the
other transaction is ‘0’ or ‘4’ and the ADJUSTMENT-IND of the active transaction in the T-MSIS DB is

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Appendix P.01
‘1’, then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND value of ‘0’ or ‘4’ first
and then insert the incoming transaction with ADJUSTMENT-IND = ‘1’;.
10.

If the ADJUSTMENT-IND value of one incoming transaction is ‘0’ and the ADJUSTMENT-IND value of
the other incoming transaction is ‘4’ and there is no active existing transaction in the T-MSIS DB,
then T-MSIS will insert the incoming transaction with ADJUSTMENT-IND value of ‘0’ first and then
insert the incoming transaction with ADJUSTMENT-IND = ‘4’;.

11.

If any other combination of ADJUSTMENT-IND values occurs, then T-MSIS will reject all of the
transactions.

CMS Guidance
The state can use either the original ICN approach or the daisy-chain ICN approach to populate the ICN-ORIG
field on each member of the claims family. T-MSIS will group claim transactions into claim families as part of the
ETL process.

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Appendix P.02: Reporting Financial Transactions in T-MSIS
How to populate T-MSIS claim files when reporting non-claim expenditures and recoupments
Brief Issue Description:
The purpose of this guidance document is to clarify the appropriate way to report non-claim expenditure and
recoupment transactions, since many of the data elements on the claim records (CLAIMIP, CLAIMLT, CLAIMOT,
and CLAIMRX) do not seem appropriate for these types of transactions.
Background Discussion
Definition of a financial transaction:
For purposes of this guidance, CMS defines a financial transaction as an expenditure transaction or a
recoupment of a previously made expenditure that does not flow through the usual claim
adjudication/adjustment process.
The cause or effect of this may be that these types of transactions do not contain the same level of detail as
other types of transactions in the state’s system. For example, a state might not assign a service code to a
capitation claim. Payments made in lump sums, such as Disproportionate Share Hospital (DSH) payments,
because they cannot be attributed to a single beneficiary would not contain a beneficiary identifier.
For some states, examples of financial transactions might include capitation payments made to managed care
organizations, supplemental payments (i.e., payments that are above a capitation fee or for a sum above a
negotiated rate, such as an FQHC additional reimbursement), drug rebates, DSH payments, cost settlements
(e.g., program cost reconciliations and settlements, year-end reconciliation of risk pools), aggregate-level
payments to providers (e.g., for a set of enrollees, claims, etc.) rather than payments made on a specific claim.
Financial Transactions may be reported on CLAIMIP, CLAIMLT, CLAIMOT, or CLAIMRX depending on the type and
circumstances of the financial transaction. “Table 1 – Financial Transactions and the appropriate T-MSIS file for
reporting them” identifies which T-MSIS files are appropriate for the various types of financial transactions.
Table 1 – Financial transactions and the appropriate T-MSIS file for reporting them
At Enrollee Level (col. 1-4)
Cap Pymt
CLAIMOT

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)

Drug
Rebate

Cost Stlmnt

Spplmntl
Pymt

Cap Pymt

Drug
Rebate

Cost Stlmnt

Spplmntl
Pymt

DSH Pymt

Other Pymt

CLAIMOT
CLAIMRX

CLAIMIP
CLAIMLT
CLAIMOT
CLAIMRX

CLAIMIP
CLAIMLT
CLAIMOT
CLAIMRX

CLAIMOT

CLAIMOT
CLAIMRX

CLAIMIP
CLAIMLT
CLAIMOT
CLAIMRX

CLAIMIP
CLAIMLT
CLAIMOT
CLAIMRX

CLAIMIP
CLAIMOT

CLAIMIP
CLAIMLT
CLAIMOT
CLAIMRX

Financial transactions can be contained within the same files as fee-for-service claims and encounter
records.
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CMS Guidance
When and how to populate data elements for financial transactions:
The data elements listed on the following pages are ones that should be populated on financial transactions.
Additional verbiage is provided for those data elements that CMS believes need explicit instructions for building
T-MSIS files. States should contact their T-MSIS technical assistant or state liaison if they have questions or
concerns. Data elements not specifically listed below can be 8-filled, left blank or space-filled.
CLAIM-HEADER-RECORD data elements

a.
b.
c.
d.

e.
f.
g.
h.

i.
j.
k.
l.
m.
n.
o.
p.
q.

RECORD-ID
SUBMITTING-STATE
RECORD-NUMBER
MSIS-IDENTIFICATION-NUM – Populate with beneficiary’s MSIS ID for any beneficiaryspecific financial transactions. Otherwise first character of MSIS-IDENTIFICATION-NUM
must be “&” to indicate that any characters that might follow do not represent an individual
beneficiary’s identifier.
ICN-ORIG – See the document entitled CMS Guidance: T-MSIS Adjustment Claim RecordsPopulating ICN-ORG and ICN-ADJ Fields posted on 2/18/2014 to the T-MSIS State Support.
ICN-ADJ – See the document entitled CMS Guidance: T-MSIS Adjustment Claim RecordsPopulating ICN-ORG and ICN-ADJ Fields posted on 2/18/2014 to the T-MSIS State Support
ADJUDICATION-DATE – Date the transaction's approval and payment processes were
completed.
CHECK-EFF-DATE – Populate with the date that Medicaid funds were disbursed. (Note: Even
though the TOT-MEDICAID-PAID-AMT field may be set to zero in some circumstances,
Medicaid funds were disbursed – and are captured in the SERVICE-TRACKING-PAYMENTAMT data element.)
ADMISSION-DATE – Populate with the first day of the time period covered by this financial
transaction (CLAIMIP and CLAIMLT).
DISCHARGE-DATE – Populate with the last day of the time period covered by this financial
transaction (CLAIMIP and CLAIMLT).
BEGINNING-DATE-OF-SERVICE – Populate with the first day of the time period covered by
this financial transaction (CLAIMOT).
ENDING-DATE-OF-SERVICE – Populate with the last day of the time period covered by this
financial transaction (CLAIMOT).
DATE-PRESCRIBED – Populate with the first day of the time period covered by this financial
transaction (CLAIMRX).
PRESCRIPTION-FILL-DATE – Populate with the last day of the time period covered by this
financial transaction (CLAIMRX).
WAIVER-TYPE – Populate if applicable and available
WAIVER-ID – Populate if applicable and available
PLAN-ID-NUMBER – Populate with the managed care plan ID for capitation payments made
to managed care plans. 8-fill, leave Leave blank or space-fill if transaction does not involve
a manage care plan.

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r. BILLING-PROV-NPI-NUM – Populate with the provider or entity that the financial transaction
was addressed to. 8-fill,, leave blank or space-fill if transaction involves a manage care
plan.
s. TOT-MEDICAID-PAID-AMT – If TYPE-OF-CLAIM is 4, D, or X, then set to zero – service
tracking payment amount will be populated instead. Otherwise populate with the amount
paid to the provider or health plan.
t. SERVICE-TRACKING-PAYMENT-AMT – If TYPE-OF-CLAIM is 4, D, or X, then populate this with
the amount paid, otherwise 0-fill.
u. TYPE-OF-CLAIM – valid values appropriate for each type of financial transaction are shown
in Table 255. (The descriptions of the TYPE-OF-CLAIM values are shown in Table 354. The
values appropriate for financial transactions are highlighted in yellow.)
Valid Values
Table 2 – TYPE-OF-CLAIM values for financial transactions
At Enrollee Level (col. 1-4)
Cap
Pymt
2, B, V

Drug
Rebate
5, E, Y

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)

Cost
Stlmnt
5, E, Y

Spplmntl
Pymt
5, E, Y

Cap Pymt
4, D, X

Drug
Rebate
4, D, X

Cost
Stlmnt
4, D, X

Spplmntl
Pymt
4, D, X

DSH
Pymt
4, D, X

Other Pymt
4, D, X

Table 3 – Descriptions of TYPE-OF-CLAIM values
Claim Type (col. 1-3)
Medicaid
or
Medicaid
Expansion

Separate
CHIP
(Title
XXI)

Other

Description

1

A

U

Fee-For-Service
Claim

2

B

V

Capitation
Payment

3

C

W

Encounter Record

Purpose
Used to report services billed & payments made for
specific services rendered to a specific enrollee by a
specific provider during a specific period of time.
Payment is made only for services actually rendered.
Used to report periodic payments made in return for a
contractual commitment by the recipient to provide a
specified set of services to a specified set of enrollees for
a specified period of time. The volume of services actually
provided to any given individual is not a factor in the
amount of the capitation payment.
Used to report services provided under a capitated
payment arrangement.
This includes billing records submitted by providers to
non-state entities (e.g., MCOs, health plans) for which the
State has no financial liability, since the risk entity has
already received a capitated payment from the State.

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Appendix P.02
Medicaid
or
Medicaid
Expansion

Separate
CHIP
(Title
XXI)

Other

Description

Purpose

4

D

X

Service Tracking
Claim

Use to report payments made for services rendered to
enrollees when the services are not billed and paid at the
single enrollee/provider/visit level of detail.

5

E

Y

Supplemental
Payment

Used to identify payments that are above a capitation fee
or for a sum above a negotiated rate, such as an FQHC
additional reimbursement.

v. SOURCE-LOCATION– valid values appropriate for each type of financial transaction are shown in
Table 457.
Table 4 – Descriptions of SOURCE-LOCATION values
Code
01

Description
MMIS

02

Non-MMIS CHIP Payment System

03

Pharmacy Benefits Manager (PBM) Vendor

04

Dental Benefits Manager Vendor

05

Transportation Provider System

06

Mental Health Claims Payment System

07

Financial Transaction/Accounting System

08

Other State Agency Claims Payment System

09

County/Local Government Claims Payment System

10

Other Vendor/Other Claims Payment System

20

Managed Care Organization (MCO)

w. SERVICE-TRACKING-TYPE – The appropriate values for financial transactions are shown in Table
5. (The descriptions of the SERVICE-TRACKING-TYPE values are shown in Table 658.)
Table 5 – SERVICE-TRACKING-TYPE values for financial transactions
At Enrollee Level (col. 1-4)
Cap
Pymt
00

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Drug
Rebate
00

Cost
Stlmnt
00

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)
Spplmntl
Pymt
00

Cap Pymt
03

Drug
Rebate
01

Cost
Stlmnt
04

Spplmntl
Pymt
05

DSH
Pymt
02

Other Pymt
03, 06

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Appendix P.02
Table 6 – Descriptions of SERVICE-TRACKING-TYPE values
Code
Description
00

Not a Service Tracking Claim – Use this code when codes 01 through 06 do not apply

01

Drug Rebate

02

DSH Payment

03

Lump Sum Payment (The "lump sum payment" code identifies payments made for
specific services rendered to individual patients, when the state accepts a lump sum
bill from a provider that covered similar services delivered to more than one patient
(e.g., a group screening for EPSDT).

04

Cost Settlement

05

Supplemental (The "supplemental payment" code identifies payments that are above a
capitation fee or sum above a negotiated rate (e.g., FQHC additional reimbursement).)

06

Other

x. FUNDING-CODE – The appropriate values for financial transactions are shown in Table 7. (The

descriptions of the FUNDING-CODE values are shown in Table 860.)
Table 7 – FUNDING-CODE values for financial transactions
At Enrollee Level (col. 1-4)
Cap
Pymt
A or B as
appropriate

Drug
Rebate
A
through
E

Cost
Stlmnt
A
through
I as
appropriate

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)
Spplmnt
l Pymt
A
through
I as
appropriate

Cap
Pymt
A or B as
appropriate

Drug
Rebate
A
through
E

Cost
Stlmnt
A
through
I as
appropriate

Spplmntl
Pymt
A through
I as
appropriate

DSH
Pymt
A
through
I as
appropriate

Other Pymt
A through I
as appropriate

Table 8 – Descriptions of FUNDING-CODE values
Code
A

Description
Medicaid Agency

B

CHIP Agency

C

Mental Health Service Agency

D

Education Agency

E

Child and Family Services Agency

F

County

G

City

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Appendix P.02
Code
H
I

Description
Providers
Other

CLAIM-LINE-RECORD data elements

a.
b.
c.
d.
e.
f.
g.
h.

SUBMITTING-STATE
RECORD-NUMBER
MSIS-IDENTIFICATION-NUM
ICN-ORIG
ICN-ADJ
LINE-NUM-ORIG
LINE-NUM-ADJ
ADJUDICATION-DATE – Date the line-level transaction's approval and payment processes
were completed
REVENUE-CODE – 8leave blank or space-fill,
i. PROCEDURE-CODE – leave blank or space-fill
j. PROCEDURE-CODE – 8-fill, leave blank or space-fill
k. NATIONAL-DRUG-CODE – 8-fill, leave blank or space-fill
l. MEDICAID-PAID-AMT – Because there is no data element on the claim line record segment
specifically designated to capture service tracking payment amounts at the claim line level,
states should populate MEDICAID-PAID-AMT with the amount of Medicaid funds disbursed.
For service tracking claims, the sum of the claim line MEDICAID-PAID-AMT values on a
claim’s claim line record segments should equal the amount reported in the SERVICETRACKING-PAYMENT-AMT data element on the claim’s claim header record segment.
m. TYPE-OF-SERVICE – The appropriate values for financial transactions are shown in Table
962.

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Appendix P.02

Table 9 – TYPE-OF-SERVICE values for financial transactions
At Enrollee Level (col. 1-4)
Cap
Pymt
119,
120,
121,
122,
138,
139,
140,
141,
142,
143, 144

Drug
Rebate
131

Cost
Stlmnt
132,
133,
134, 135

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)
Spplmntl
Pymt
Any TOS
except
119, 120,
121, 122,
123, 131,
132, 133,
134, 135,
138, 139,
140, 141,
142, 143,
144

Cap
Pymt
119,
120,
121,
122,
138,
139,
140,
141,
142,
143,
144

Drug
Rebate
131

Cost
Stlmnt
132,
133,
134, 135

Spplmntl
Pymt
Any TOS
except
119, 120,
121, 122,
123, 131,
132, 133,
134, 135,
138, 139,
140, 141,
142, 143,
144

DSH
Pymt
123

Other Pymt
Any TOS
except 119,
120, 121,
122, 123,
131, 132,
133, 134,
135, 138,
139, 140,
141, 142,
143, 144

Table 62-TYPE-OF-SERVICE values for financial transactions

n. CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT – The appropriate values for financial
transactions are shown in Table 1063.
Table 10 – CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT values for financial transactions
At Enrollee Level (col. 1-4)

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)

Cap
Pymt

Drug
Rebate

Cost
Stlmnt

Spplmntl
Pymt

Cap
Pymt

Drug
Rebate

Cost
Stlmnt

Spplmntl
Pymt

DSH
Pymt

Other
Pymt

If TYPEOF-CLAIM
= 2, then
01
If TYPEOF-CLAIM
= B then
02
If TYPEOF-CLAIM
= V then
03 or 04
as appropriate

If TYPEOF-CLAIM
= 5, then
01
If TYPEOF-CLAIM
= E then
02
If TYPEOF-CLAIM
= Y then
03 or 04
as appropriate

If TYPEOF-CLAIM
= 5, then
01
If TYPEOF-CLAIM
= E then
02
If TYPEOF-CLAIM
= Y then
03 or 04
as appropriate

If TYPE-OFCLAIM = 5,
then 01
If TYPE-OFCLAIM = E
then 02
If TYPE-OFCLAIM = Y
then 03 or
04 as
appropriate

If TYPEOF-CLAIM
= 4, then
01
If TYPEOF-CLAIM
= D then
02
If TYPEOF-CLAIM
= X then
03 or 04
as appropriate

If TYPEOF-CLAIM
= 4, then
01
If TYPEOF-CLAIM
= D then
02
If TYPEOF-CLAIM
= X then
03 or 04
as appropriate

If TYPEOF-CLAIM
= 4, then
01
If TYPEOF-CLAIM
= D then
02
If TYPEOF-CLAIM
= X then
03 or 04
as appropriate

If TYPE-OFCLAIM = 4,
then 01
If TYPE-OFCLAIM = D
then 02
If TYPE-OFCLAIM = X
then 03 or
04 as
appropriate

If TYPEOF-CLAIM
= 4, then
01
If TYPEOF-CLAIM
= D then
02
If TYPEOF-CLAIM
= X then
03 or 04
as appropriate

If TYPE-OFCLAIM = 4,
then 01
If TYPE-OFCLAIM = D
then 02
If TYPE-OFCLAIM = X
then 03 or
04 as
appropriate

Table 63-CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT values for financial
transactions

o. XIX-MBESCBES-CATEGORY-OF-SERVICE – The appropriate values for financial transactions are
shown in Table 1164.
Table 11 – XIX-MBESCBES-CATEGORY-OF-SERVICE values for financial transactions
At Enrollee Level (col. 1-4)

December 2020v4.0.0

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)

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Appendix P.02
Cap
Pymt
17A,
17B,
17C1,
18A,
18B1,
18B2,
18C,
18E, 22

Drug
Rebate
7A1,
7A2,
7A3,
7A4,
7A5, 7A6

Cost
Stlmnt
Any
code

Spplmntl
Pymt
1C, 1D,
3B, 4C,
5B, 6B, 9B

Cap
Pymt
17A,
17B,
17C1,
18A,
18B1,
18B2,
18C,
18E, 22

Drug
Rebate
7A1,
7A2,
7A3,
7A4,
7A5, 7A6

Cost
Stlmnt
Any
code

Spplmntl
Pymt
1C, 1D,
3B, 4C,
5B, 6B, 9B

DSH
Pymt
1B, 2B

Other
Pymt
Any code
except 1B,
1C, 1D,
2B, 3B, 4C,
5B, 6B, 9B,
7A1, 7A2,
7A3, 7A4,
7A5, 7A6,
17A, 17B,
17C1, 18A,
18B1,
18B2 18C,
18E, 22

Table 64-XIX-MBESCBES-CATEGORY-OF-SERVICE values for financial transactions

p. XXI-MBESCBES-CATEGORY-OF-SERVICE – The appropriate values for financial transactions are
shown in Table 1265.
Table 12 – XXI-MBESCBES-CATEGORY-OF-SERVICE values for financial transactions
At Enrollee Level (col. 1-4)
Cap
Pymt
1A, 1B,
1C, 1D,
or 32B

December 2020v4.0.0

Drug
Rebate
8A

Cost
Stlmnt
Any
code

For Multiple Enrollees (i.e., a Service Tracking Claim) (col. 5-10)
Spplmntl
Pymt
8-fill,
leave
blank or
space-fill

Cap
Pymt
1A, 1B,
1C, 1D,
or 32B

Drug
Rebate
8A

Cost
Stlmnt
Any
code

Spplmntl
Pymt
8-fill,
leave
blank or
space-fill

DSH
Pymt
8-fill,
leave
blank or
space-fill

Other
Pymt
Any code
except 1A,
1B, 1C,
1D, 32B,
or 8A

296

Appendix P.03

Appendix P.03 CMS Guidance: Revised and Consolidated Guidance
for Building Non-Claims T-MSIS Files
Brief Issue Description
CMS has made systems upgrades in T-MSIS data storage and file processing methodologies to reduce the
complexity and size of full historical refresh data for months in which no data have changed. Essentially, we
have removed the necessity for states to resubmit data month-after-month even though nothing changed. This
has several benefits:


Significant reduction of non-claim file sizes;



Significant reduction in the logic necessary to compile the data required to populate the non-claim files.

There are now two methods that states can use when building their non-claim files – the “full-file refresh”
method and the “changed-segments-only” method (both described below) and states can use either method.
States can also change from one method to the other if they determine that it is to their advantage to do so.
States that have already constructed their T-MSIS non-claim-file-building processes to generate rolling history
records and wish to continue with this approach may do so as long as it is in full conformance with CMS’ T-MSIS
non-claims files expectations as delineated in this document.

CMS Guidance: Building Non-Claim Records
Methods for Submitting non-claim files to T-MSIS
States can utilize either the “full-file refresh” method or the “changed-segment-only” method for submitting
non-claim files to T-MSIS.
Full-File Refresh Method
As the name suggests, “full-file refresh” files contain a complete set of historical segments for each record,
regardless of whether the data on a segment has changed since the last submission, or not. The only exception
to this is archived records. Archived records are ones the state considers to be permanently static, are no longer
actively used in the state’s system, and which the state has moved to a separate data storage area for long-term
retention. Once the state archives a record, it no longer needs to report the record in the state’s T-MSIS files.
Even though these records are no longer included in the state’s “full-file refresh” submissions, they will be
maintained in the underlying T-MSIS repository as active records.
Changed-Segment-Only Method
States that chose to use the “changed-segment-only” method only need to submit a segment when one or more
of its data element values changes. Under the “changed-segment-only” method, once submitted, a segment will
remain active in the T-MSIS data repository until the state takes some action to inactivate it. Under the
“changed-segment-only” method, it is not necessary for a state to include unchanged segments in its T-MSIS
submissions month after month.
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Appendix P.03
Important Concepts Governing the Submission of Non-Claim Files – REGARDLESS OF SUBMISSION METHOD
Regardless of the chosen approach, all states need to keep five important concepts in mind:
1. T-MSIS makes no changes to segment effective and end dates of its own volition.
2. If the state does not set segment effective- and end-dates appropriately, unintended overlapping
segments with ambiguous data will occur.
3. It is the state’s responsibility to tell T-MSIS the revised segment end date on existing segments
whenever values on the segment change.
4. Every instance of a segment has a primary key that uniquely identifies it. To do anything to an existing
segment, the primary key field values (which includes the segment effective date) on the incoming
segment MUST MATCH the primary key field values of the existing segment in T-MSIS. The primary key
of each segment is listed in the “Rec Segment Keys & Constraints” tab of the T-MSIS Data Dictionary.
(See Appendix A: Examples of Non-Claim File Segment and/or Record Modification Scenarios for more
information on using primary keys.)
5. Record segments that are not applicable to a state or to a particular entity (i.e., an eligible person,
provider, managed care entity, or TPL instance) do not need to be submitted.

Amount of Historical Data That Must Be Submitted
CMS no longer requires states to submit seven years of rolling history in its non-claim T-MSIS files. Table A:
Minimum Historical Record Expectations for Non-Claim File Submissions outlines CMS’ revised expectations. This
is true for submissions under both the “Full-File Refresh” method and “Changed-Segment-Only” method for
submitting non-claim files. If a state wishes to submit more historical data than is outlined in Table A, it may do
so.

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Appendix P.04

Appendix P.04
*This Section Intentionally Left Blank*

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299

Appendix P.05

Appendix P.05: Populating Qualifier Fields and Their Associated Value
Fields
Brief Issue Description
The purpose of this guidance document is to when record segments need to be created for all valid values in a
qualifier field’s valid value set and when it is appropriate to create a record segment for only one of the valid
values.
Background Discussion
Definitions
Simple Qualifier Field – is a data element that contains a code (a.k.a. “flag”) that defines/qualifies the coding
schema used when populating a set of corresponding data elements. This is necessary because there are several
different schemas that a state could use and it needs to be clear which of the schemas is actually used.
Examples of “simple qualifier fields” are the DIAGNOSIS-CODE-FLAG-1 through -12 on the CLAIM-HEADERRECORD-IP record segment (CIP00002). The valid value set for these fields is:
1 ICD-9
2 ICD-10
3 Other
The state would indicate which coding schema is being used to populate the corresponding data elements
DIAGNOSIS-CODE-1 through -12.
Complex Qualifier Field – is a data element that not only defines/qualifies the contents of its corresponding
data elements (similar to a “simple qualifier field”), but also represents a situation where the state needs to
create a record segment for each valid value that applies to the record’s subject.
An example of a “complex qualifier field is LICENSE-TYPE on the PROV-LICENSING-INFO record segment
(PRV00004). The valid value set for this field is:
1. State, county, or municipality professional or business license
2. DEA license
3. Professional society accreditation
4. CLIA accreditation
5. Other
The state would create a PROV-LICENSING-INFO record segment and populate the corresponding data elements
for each LICENSE-TYPE valid value that applies to the provider.
Corresponding Data Elements – Are data elements that contain values as defined by the qualifier field.
Fully Populated Record Segment – Means that all data elements in the record segment will be populated, not
just the qualifier field and its corresponding data elements. These additional data elements are necessary to
enable CMS to tie the record segment to its parent segment. These data elements comprise the segment’s
natural key. Generally these data elements are the ones bulleted below, but there could potentially be
additional ones, depending on the record segment. See the “Record Keys & Constraints” tab in the T-MSIS Data
Dictionary if there are questions concerning a record segment’s natural key.
December 2020v4.0.0

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Appendix P.05





RECORD-ID
SUBMITTING-STATE
RECORD-NUMBER
MSIS-IDENTIFICATION-NUM / STATE-PLAN-ID-NUM / SUBMITTING-STATE-PROV-ID

Record Subject – This is the individual/entity around which the record segments in a file are built. The
Medicaid/CHIP enrollee is the subject of Eligible Files. In Provider Files, the subject is the provider. The
managed care entity is the subject of Managed Care Files, and third party payers and their associated
beneficiaries are the subjects of TPL Files.
Overview
The complex qualifier fields are included in the T-MSIS record layouts so that a given record segment layout can
be used to capture a standard set of data elements (i.e., the corresponding data elements) for a category of data
(i.e., the complex qualifier field’s valid values list) when more than one category may be applicable to the record
subject.
The complex qualifier fields’ valid values lists are not “select one value from the valid values list and provide the
corresponding data element values (which is the case for simple qualifier fields).” A separate record segment
should be created and fully populated for every “complex qualifier field” valid value or unique combination of
“complex qualifier field” valid value and corresponding data element value (in accordance with the Record Keys
& Constraints) that applies to the record subject. Table 1 illustrates what CMS is expecting, using LICENSE-TYPE
in the PROV-LICENSING-INFO record segment (PRV00004) as an example.
Example Scenario
The purpose of the PROV-LICENSING-INFO segment is to capture licensing and accreditation information
relevant to a provider. The valid value list for the LICENSE-TYPE data element shows the types of information
that CMS is interested in collecting in this record segment:
1. State, county, or municipality professional or business license
2. DEA license
3. Professional society accreditation
4. CLIA accreditation
5. Other
For our example, assume three of these categories are applicable to provider # P0123: (a) a professional license
issued by the state’s Board of Physicians (valid value # 1); (b.1) a board certification from the ABMS (valid value
# 3); (b.2) a board certification from the AOA (also valid value # 3); and (c) a DEA number (valid value # 2). Table
1 and 1a lists the data elements in the PRV00004 record segment, and shows the contents of each data element
in the four PRV00004 segments that would be required by this example.
Table 1: Examples of fully populated record segments supplying “complex qualifier field” corresponding data. While these data elements
aren't strictly "corresponding data elements," they are necessary to tie the segments to their parent segment.
Data Element Use

Data Element

Tie segments to parent
segment

RECORD-ID

Tie segments to parent
segment

SUBMITTING-STATE

December 2020v4.0.0

Physician
License

ABMS Board
Certification

AOA Board
Certification

DEA
Number

PRV00004

PRV00004

PRV00004

PRV00004

24

24

24

24

301

Appendix P.05
Tie segments to parent
segment

RECORD-NUMBER

4506

4507

4508

4509

Tie segments to parent
segment

SUBMITTING-STATEPROV-ID

P0123

P0123

P0123

P0123

Tie segments to parent
segment

PROV-LOCATION-ID

0

0

0

0

Table 1a: Examples of fully populated record segments supplying “complex qualifier field” corresponding data.
Data Element Use

Data Element

Physician
License

ABMS Board
Certification

AOA Board
Certification

DEA Number

Corresponding Data
Element

PROV-LICENSE-EFF-DATE

19921119

20100101

20120701

20131001

Corresponding Data
Element

PROV-LICENSE-END-DATE

20150930

20191231

20150630

20160930

"Complex Qualifier”

LICENSE-TYPE

1

3

3

2

Corresponding Data
Element

LICENSE-ISSUING-ENTITY-ID

24

American Board
of Medical
Specialties

American
Osteopathic
Association

DEA

Corresponding Data
Element

LICENSE-OR-ACCREDITATIONNUMBER

D98765

IM012345

A5546

FD1234563

NA

STATE-NOTATION

NA

NA

Data Element

NA
NA

NA

FILLER

NA

NA

NA

NA

CMS Guidance
CMS is instructing States to provide information corresponding to each of a complex qualifier field’s valid values
to the extent that the valid value is applicable to the record subject. Additionally, States should fully populate
the affected record segments.
In its first four columns, Table 2 displays the T-MSIS file name, record segment name, complex qualifier field
name and the complex qualifier field’s list of valid values for each of the complex qualifier fields in the T-MSIS
data set. The last two columns identify the corresponding data elements (along with the file segments where
they reside) that need to be populated for every applicable valid value in the “complex qualifier field’s” valid
value list.
Table 2: “Complex Qualifier fields” their valid values, and the corresponding data elements that need to be populated

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Appendix P.05
File Name

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

Corresponding
Data Elements To
Be Populated:

Record
Segment

Data Element
Name

Valid Value
and
Description

Record Segment

Corresponding Data Elements To Be
Populated:

Data Element Name

ELIGIBLE

ELIGIBLECONTACTINFORMATION
(ELG00004)

December 2020v4.0.0

ADDR-TYPE

01 - Primary home
address and
contact
information (used
for the eligibility
determination
process); 02 Primary work
address and
contact
information; 03 Secondary
residence and
contact
information; 04 Secondary work
address and
contact
information; 05 Other category of
address and
contact
information; 06 Eligible person’s
official mailing
address

ELIGIBLE-CONTACTINFORMATIONELG00004

ELIGIBLE-ADDR-LN1; ELIGIBLE-ADDR-LN2;
ELIGIBLE-ADDR-LN3; ELIGIBLE-CITY;
ELIGIBLE-STATE; ELIGIBLE-ZIP-CODE;
ELIGIBLE-COUNTY-CODE; ELIGIBLE-PHONENUM; TYPE-OF-LIVING-ARRANGEMENT;
ELIGIBLE-ADDR-EFF-DATE; ELIGIBLE-ADDREND-DATE

303

Appendix P.05
File Name

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

Corresponding
Data Elements To
Be Populated:

Record
Segment

Data Element
Name

Valid Value
and
Description

Record Segment

Corresponding Data Elements To Be
Populated:

Data Element Name

MNGDCARE

MANAGED-CAREMAIN (MCR00002)

December 2020v4.0.0

MANAGED-CARESERVICE-AREA

1 - Statewide: The
managed care
entity provides
services to
beneficiaries
throughout the
entire state; 2 County: The
managed care
entity provides
services to
beneficiaries in
specified counties;
3 - City: The
managed care
entity provides
services to
beneficiaries in
specified cities; 4 Region: The
managed care
entity provides
services to
beneficiaries in
specified regions,
not defined by
individual
counties within
the state
(“region” is statedefined); 5 - Zip
Code: The
managed care
entity program
provides services
to beneficiaries in
specified zip
codes; 6 - Other:
The managed care
entity provides
services to
beneficiaries in
"other" area(s),
not Statewide,
County, City, or
Region.

MANAGED-CARESERVICE-AREAMCR00004

MANAGED-CARE-SERVICE-AREA-NAME;
MANAGED-CARE-SERVICE-AREA-EFFDATE; MANAGEDDATE; MANAGED-CARESERVICE-AREA-END-DATE

304

Appendix P.05
File Name

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

Corresponding
Data Elements To
Be Populated:

Record
Segment

Data Element
Name

Valid Value
and
Description

Record Segment

Corresponding Data Elements To Be
Populated:

Data Element Name

MNGDCARE

MANAGED-CARELOCATION-ANDCONTACT-INFO
(MCR00003)

MANAGED-CAREADDR-TYPE

1 - MCO’s
corporate address
and contact
information; 2 MCO’s mailing
address; 3 MCO’s service
location address;
4 - MCO’s Billing
address and
contact
information; 5 CEO’s address and
contact
information; 6 CFO’s address and
contact
information; 7 Other

MANAGED-CARELOCATION-ANDCONTACT-INFOMCR00003

MANAGED-CARE-LOCATION-ID; MANAGEDCARE-ADDR-LN1; MANAGED-CARE-ADDRLN2; MANAGED-CARE-ADDR-LN3;
MANAGED-CARE-CITY; MANAGED-CARESTATE; MANAGED-CARE-ZIP-CODE;
MANAGED-CARE-COUNTY; MANAGED-CARETELEPHONE; MANAGED-CARE-EMAIL;
MANAGED-CARE-FAX-NUMBER; MANAGEDCARE-LOCATION-AND-CONTACT-INFO-EFFDATE

MNGDCARE

NATIONALHEALTH-CAREENTITY-ID-INFO
(MCR00008)

NATIONAL-HEALTHCARE-ENTITY-ID-TYPE

1 - Controlling
Health Plan (CHP)
ID; 2 - Subhealth
Plan (SHP) ID; 3 Other Entity
Identifier (OEID)

NATIONAL-HEALTHCARE-ENTITY-IDINFO-MCR00008

STATE-PLAN-ID-NUM; NATIONAL-HEALTHCARE-ENTITY-ID; NATIONAL-HEALTH-CAREENTITY-NAME; NATIONAL-HEALTH-CAREENTITY-ID-INFO-EFF-DATE; NATIONALHEALTH-CARE-ENTITY-ID-INFO-END-DATE

MNGDCARE

MANAGED-CAREID (MCR00010)

MANAGED-CAREPLAN-OTHER-ID-TYPE

01 – Federal Tax
ID; 02 – State Tax
ID

MANAGED-CARE-ID
(MCR00010)

MANAGED-CARE-PLAN-OTHER-ID,
MANAGED-CARE-PLAN-ID-EFF-DATE,
MANAGED-CARE-PLAN-ID-END-DATE

PROVIDER

PROV-LOCATIONAND-CONTACTINFO (PRV00003)

ADDR-TYPE

1 - Billing
Provider; 2 Provider Mailing;
3 - Provider
Practice; 4 Provider Service
Location

PROV-LOCATIONAND-CONTACT-INFOPRV00003

PROV-LOCATION-ID; ADDR-LN1; ADDR-LN2;
ADDR-LN3; ADDR-CITY; ADDR-STATE; ADDRZIP-CODE; ADDR-TELEPHONE; ADDR-EMAIL;
ADDR-FAX-NUM; ADDR-BORDER-STATE-IND;
ADDR-COUNTY; PROV-LOCATION-ANDCONTACT-INFO-EFF-DATE; PROV-LOCATIONAND-CONTACT-INFO-END-DATE

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Appendix P.05
File Name

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

Corresponding
Data Elements To
Be Populated:

Record
Segment

Data Element
Name

Valid Value
and
Description

Record Segment

Corresponding Data Elements To Be
Populated:

Data Element Name

PROVIDER

PROV-LICENSINGINFO (PRV00004)

LICENSE-TYPE

1 - State, county,
or municipality
professional or
business license; 2
-DEA license; 3Professional
society
accreditation; 4 CLIA
accreditation; 5Other

PROV-LICENSINGINFO-PRV00004

LICENSE-OR-ACCREDITATION-NUMBER;
LICENSE-ISSUING-ENTITY-ID; PROV-LICENSEEFF-DATE; PROV-LICENSE-END-DATE

PROVIDER

PROV-IDENTIFIERS
(PRV00005)

PROV-IDENTIFIERTYPE

1 - State-specific
Medicaid Provider
ID; 2 – NPI; 3 Medicare ID; 4 NCPDP ID; 5 Federal Tax ID; 6 State Tax ID; 7 –
SSN; 8 -– Other; 9
- Old State
Provider ID

PROV-IDENTIFIERSPRV00005

PROV-IDENTIFIER; PROV-IDENTIFIERISSUING-ENTITY-ID; PROV-IDENTIFIER-EFFDATE; PROV-IDENTIFIER-END-DATE

PROVIDER

PROVTAXONOMYCLASSIFICATION
(PRV00006)

PROVCLASSIFICATION-TYPE

1 - Taxonomy
code; 2 - Provider
specialty code; 3 Provider type
code; 4 Authorized
category of
service code

PROV-TAXONOMYCLASSIFICATIONPRV00006

PROV-CLASSIFICATION-CODE; PROVTAXONOMY-CLASSIFICATION-EFF-DATE;
PROV-TAXONOMY-CLASSIFICATION-ENDDATE

PROVIDER

PROV-AFFILIATEDPROGRAMS
(PRV00009)PROVAFFILIATEDPROGRAMS
(PRV00009)

AFFILIATEDPROGRAM-TYPE

1 - Health Plan
(NHP-ID); 2 Health Plan (stateassigned health
plan ID); 3 –
Waiver; 4 - Health
Home Entity; 5 -–
Other; 6 – Subcapitated Entity; 7
– Fee-for-service
(FFS)

PROV-AFFILIATEDPROGRAMSPRV00009

AFFILIATED-PROGRAM-ID; PROVAFFILIATED-PROGRAM-EFF-DATE; PROVAFFILIATED-PROGRAM-END-DATE

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Appendix P.05
File Name

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

“Complex
Qualifier Field”
Information:

Corresponding
Data Elements To
Be Populated:

Record
Segment

Data Element
Name

Valid Value
and
Description

Record Segment

Corresponding Data Elements To Be
Populated:

Data Element Name

TPL

TPL-ENTITYCONTACTINFORMATION
(TPL00006)

December 2020v4.0.0

TPL-ENTITY-ADDRTYPE

06 - TPL-Entity
Corporate
Location; 07 - TPLEntity Mailing; 08
- TPL-Entity
Satellite Location;
09 - TPL-Entity
Billing; 10 - TPLEntity
Correspondence;
11 - TPL-Other

TPL-ENTITYCONTACTINFORMATIONTPL00006

INSURANCE-CARRIER-ADDR-LN1;
INSURANCE-CARRIER-ADDR-LN2;
INSURANCE-CARRIER-ADDR-LN3;
INSURANCE-CARRIER-CITY; INSURANCECARRIER-STATE; INSURANCE-CARRIER-ZIPCODE; INSURANCE-CARRIER-PHONE-NUM;
INSURANCE-CARRIER-NAIC-CODE;
INSURANCE-CARRIER-NAME; NATIONALHEALTH-CARE-ENTITY-ID-TYPE; NATIONALHEALTH-CARE-ENTITY-ID; NATIONALHEALTH-CARE-ENTITY-NAME; TPL-ENTITYCONTACT-INFO-EFF-DATE; TPL-ENTITYCONTACT-INFO-END-DATE

307

Appendix P.06

Appendix P.06

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Appendix P.07

Appendix P.07: Finding Provider Roles on StandardTD
Transactions
How to use this guidance document
This guidance document is not intended to slow down or derail existing state development
initiatives. The intent is to provide clarification and standardization across the nation in key areas raised
by state partners. Should guidance introduce rework in ongoing development, please bring this to the
attention of your TA and CMS analyst to direct you to the most appropriate path that minimizes impact
to your progress.
Brief Issue Description
Some States have requested assistance with identifying where to find in the X-12 claim transaction sets
the NPIs and taxonomy codes of providers who performed various roles associated with the
claim/encounter.

Background Discussion
Definitions
Provider role – The function that a specific provider performed for a particular patient on specified
dates of service, and which are contained on fee-for-service claims or reported on encounter records.
The particular roles that CMS would like to track on T-MSIS claims are:
 Admitting (attending) provider
 Billing provider
 Dispensing provider
 Operating provider
 Prescribing provider
 Referring provider
 Servicing (rendering) provider
 Ordering provider
 Under supervision of provider
Provider role information needed for the T-MSIS claim files can be extracted from the standard X-12
transactions. The five tables in the “CMS Guidance” section of this document provide T-MSIS-to-X-12
crosswalks for each provider role. The five tables are:
Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12
transactions
Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12
transactions
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Appendix P.07
Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations
on the X-12 transactions
Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding
locations on the X-12 transactions
Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations
on the X-12 transactions
Table F: Provider roles on T-MSIS CLAIMRX files and their corresponding locations on the X-12
transactions
In each table, the first column identifies the provider role. The second and third columns identify the
specific T-MSIS record segments and data elements used to capture the NPI and taxonomy of the
provider performing the specified role. The fourth, fifth, sixth, and seventh columns in tables “A”
through “E” provide the X-12 transaction name, data element identifier, data element description and
loop id that map to the T-MSIS data element. The fourth, fifth, sixth, and seventh columns in table “F”
provide the segment name, field identifier, field name and definition of the applicable NCPDP D.0 data
set fields.
CMS Guidance
Use tables “A” through “F” to map the provider roles that are contained in the T-MSIS claim record
layouts to their corresponding X-12 standard transaction data elements.
If the T-MSIS data element does not exist in the X-12 transaction set (shown as “N/A” in the tables
below), 8-fill, leave blank or space-fill the T-MSIS data element when building T-MSIS claim files.

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Appendix P.07
Table A: Provider roles on T-MSIS CLAIMIP files and their corresponding locations on the X-12 transactions
Provider
IP-T-MSIS Data
X-12
IP-T-MSIS Record Segment
X-12
Role
Element
Transaction
Element
Identifier

X-12
Description

X-12 Loop

Conditional Rules

Admitting
(Attending)

ADMITTING-PROV-NPINUM

CLAIM-HEADER-RECORD-IPCIP00002

5010 A2 837-I
Institutional Claim

NM109

Attending
Provider Identifier

2310A

N/A

Admitting
(Attending)

ADMITTING-PROVTAXONOMY

CLAIM-HEADER-RECORD-IPCIP00002

5010 A2 837-I
Institutional Claim

PRV03

Provider
Taxonomy Code

2310A

N/A

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-IPCIP00002

5010 A2 837-I
Institutional Claim

NM109

Billing Provider
Identifier

2010AA

N/A

Billing

BILLING-PROVTAXONOMY

CLAIM-HEADER-RECORD-IPCIP00002

5010 A2 837-I
Institutional Claim

PRV03

Provider
Taxonomy Code

2000A

N/A

Operating

OPERATING-PROV-NPINUM

CLAIM-LINE-RECORD-IP-CIP00003

5010 A2 837-I
Institutional Claim

NM109

Operating
Physician
Identifier

2310B or
2420A

The identifier in the 837i loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a different
identifier in loop 2420A at the line level of
the 837i. If there is a different identifier
in 837i loop 2420A then the identifier
from loop 2420A should be reported as
the operating provider identifier.

Operating

OPERATING-PROVTAXONOMY

CLAIM-HEADER-RECORD-IPCIP00002

N/A

N/A

N/A

N/A

N/AThe identifier in the 837i loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a different
identifier in loop 2420A at the line level of
the 837i. If there is a different identifier
in 837i loop 2420A then the identifier
from loop 2420A should be reported as
the operating provider identifier.

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Appendix P.07
Provider
Role

IP-T-MSIS Data
Element

IP-T-MSIS Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12
Description

X-12 Loop

Conditional Rules

Referring

REFERRING-PROV-NPINUM

CLAIM-HEADER-RECORD-IPCIP00002

5010 A2 837-I
Institutional Claim

NM109

Referring Provider
Identifier

2310F or
2420D

The identifier in the 837i loop 2310F could
be applied to each line in T-MSIS except
for lines where there is a different
identifier in 2420D at the line level of the
837i. If there is a different identifier in
837i loop 2420D then the identifier from
2420D should be reported as the referring
provider identifier. N/A

Referring

REFERRING-PROVTAXONOMY

CLAIM-HEADER-RECORD-IPCIP00002

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F could
be applied to each line in T-MSIS except
for lines where there is a different
identifier in 2420D at the line level of the
837i. If there is a different identifier in
837i loop 2420D then the identifier from
2420D should be reported as the referring
provider identifier.

Referring

REFERRING-PROV-NPINUM

CLAIM-LINE-RECORD-IP-CIP00003

5010 A2 837-I
Institutional Claim

NM109

Referring Provider
Identifier

2420D

Servicing
(Rendering)

SERVICING-PROV-NPINUM

CLAIM-LINE-RECORD-IP-CIP00003

5010 A2 837-I
Institutional Claim

NM109

Rendering
Provider Identifier

2310D or
2420C

Servicing
(Rendering)

SERVICING-PROVTAXONOMY

CLAIM-LINE-RECORD-IP-CIP00003

N/A

N/A

N/A

N/A

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N/A

The identifier in the 837i loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a different
identifier in 2420C at the line level of the
837i. If there is a different identifier in
837i loop 2420C then the identifier from
loop 2420C should be reported as the
servicing/rendering provider identifier.
N/A

Appendix P.07
Provider
Role

IP-T-MSIS Data
Element

IP-T-MSIS Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12
Description

X-12 Loop

Conditional Rules

UnderDirection-of

UNDER-DIRECTION-OFPROV-NPI

CLAIM-HEADER-RECORD-IPCIP00002

N/A

N/A

N/A

N/A

N/A

UnderDirection-of

UNDER-DIRECTION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-IPCIP00002

N/A

N/A

N/A

N/A

N/A

UnderSupervisionof

UNDER-SUPERVISIONOF-PROV-NPI

CLAIM-HEADER-RECORD-IPCIP00002

N/A

N/A

N/A

N/A

N/A

UnderSupervisionof

UNDER-SUPERVISIONOF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-IPCIP00002

N/A

N/A

N/A

N/A

N/A

Table B: Provider roles on T-MSIS CLAIMLT files and their corresponding locations on the X-12 transactions
Provider
X-12
X-12
LT-T-MSIS Data Element
LT-T-MSIS Record Segment
Element
Role
Transaction
Identifier
Admitting
(Attending)

ADMITTING-PROV-NPI-NUM

December 2020v4.0.0

CLAIM-HEADER-RECORD-LTCLT00002

5010 A2 837-I
Institutional
Claim

NM109

X-12 Description

X-12 Loop

Conditional Rules

Attending Provider
Identifier

2310A

N/AThe identifier in the 837i loop
2310F could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420D at the
line level of the 837i. If there is a
different identifier in 837i loop 2420D
then the identifier from 2420D should
be reported as the referring provider
identifier.

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Appendix P.07
Provider
Role

LT-T-MSIS Data Element

LT-T-MSIS Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12 Description

X-12 Loop

Conditional Rules

Admitting
(Attending)

ADMITTING-PROVTAXONOMY

CLAIM-HEADER-RECORD-LTCLT00002

5010 A2 837-I
Institutional
Claim

PRV03

Provider Taxonomy
Code

2310A

N/AThe identifier in the 837i loop
2310F could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420D at the
line level of the 837i. If there is a
different identifier in 837i loop 2420D
then the identifier from 2420D should
be reported as the referring provider
identifier.

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-LTCLT00002

5010 A2 837-I
Institutional
Claim

NM109

Billing Provider
Identifier

2010AA

N/AThe identifier in the 837i loop
2310F could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420D at the
line level of the 837i. If there is a
different identifier in 837i loop 2420D
then the identifier from 2420D should
be reported as the referring provider
identifier.

Billing

BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-LTCLT00002

5010 A2 837-I
Institutional
Claim

PRV03

Provider Taxonomy
Code

2000A

N/AThe identifier in the 837i loop
2310F could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420D at the
line level of the 837i. If there is a
different identifier in 837i loop 2420D
then the identifier from 2420D should
be reported as the referring provider
identifier.

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Appendix P.07
Provider
Role

LT-T-MSIS Data Element

LT-T-MSIS Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12 Description

X-12 Loop

Conditional Rules

Referring

REFERRING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-LTCLT00002

5010 A2 837-I
Institutional
Claim

NM109

Referring Provider
Identifier

2310F or
2420D

N/AThe identifier in the 837i loop
2310F could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420D at the
line level of the 837i. If there is a
different identifier in 837i loop 2420D
then the identifier from 2420D should
be reported as the referring provider
identifier.

Referring

REFERRING-PROVTAXONOMY

CLAIM-HEADER-RECORD-LTCLT00002

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420D at the line
level of the 837i. If there is a different
identifier in 837i loop 2420D then the
identifier from 2420D should be
reported as the referring provider
identifier.

Referring

REFERRING-PROV-NPI-NUM

CLAIM-LINE-RECORD-LTCLT00003

5010 A2 837-I
Institutional
Claim

NM109

Referring Provider
Identifier

2420D

Servicing
(Rendering)

SERVICING-PROV-NPI-NUM

CLAIM-LINE-RECORD-LTCLT00003

5010 A2 837-I
Institutional
Claim

NM109

Rendering Provider
Identifier

2310D or
2420C

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N/A

The identifier in the 837i loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in loop 2420C at
the line level of the 837i. If there is a
different identifier in 837i loop 2420C
then the identifier from loop 2420C
should be reported as the
servicing/rendering provider identifier.

Appendix P.07
Provider
Role

Servicing

LT-T-MSIS Data Element

LT-T-MSIS Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12 Description

X-12 Loop

Conditional Rules

SERVICING-PROVTAXONOMY

CLAIM-LINE-RECORD-LTCLT00003

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420D at the line
level of the 837i. If there is a different
identifier in 837i loop 2420D then the
identifier from 2420D should be
reported as the referring provider
identifier.

UNDER-DIRECTION-OFPROV-NPI

CLAIM-HEADER-RECORD-LTCLT00002

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420D at the line
level of the 837i. If there is a different
identifier in 837i loop 2420D then the
identifier from 2420D should be
reported as the referring provider
identifier.

UNDER-DIRECTION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-LTCLT00002

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420D at the line
level of the 837i. If there is a different
identifier in 837i loop 2420D then the
identifier from 2420D should be
reported as the referring provider
identifier.

(Rendering)

UnderDirection-of

UnderDirection-of

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Appendix P.07
Provider
Role

LT-T-MSIS Data Element

LT-T-MSIS Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12 Description

X-12 Loop

Conditional Rules

UnderSupervisionof

UNDER-SUPERVISION-OFPROV-NPI

CLAIM-HEADER-RECORD-LTCLT00002

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420D at the line
level of the 837i. If there is a different
identifier in 837i loop 2420D then the
identifier from 2420D should be
reported as the referring provider
identifier.

UnderSupervisionof

UNDER-SUPERVISION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-LTCLT00002

N/A

N/A

N/A

N/A

The identifier in the 837i loop 2310F
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420D at the line
level of the 837i. If there is a different
identifier in 837i loop 2420D then the
identifier from 2420D should be
reported as the referring provider
identifier.

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Appendix P.07

Table C: Provider roles on T-MSIS CLAIMOT (facility claims) files and their corresponding locations on the X-12 transactions
Provider
OT (facility)-T-MSIS
OT (facility)-T-MSIS
X-12 Transaction
X-12
X-12 Description
Element
Role
Data Element
Record Segment
Identifier

X-12

Conditional Rules

Loop

Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-OTCOT00002

5010 A2 837-I
Institutional Claim

NM109

Billing Provider Identifier

2010AA

N/AThe identifier in the 837i
loop 2310F could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420D
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420D
then the identifier from
2420D should be reported as
the referring provider
identifier.

Billing

BILLING-PROVTAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

5010 A2 837-I
Institutional Claim

PRV03

Provider Taxonomy Code

2000A

N/AThe identifier in the 837i
loop 2310F could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420D
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420D
then the identifier from
2420D should be reported as
the referring provider
identifier.

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Appendix P.07
Provider
Role

OT (facility)-T-MSIS

OT (facility)-T-MSIS

Data Element

Record Segment

X-12 Transaction

X-12
Element
Identifier

X-12 Description

X-12

Conditional Rules

Loop

Referring

REFERRING-PROV-NPINUM

CLAIM-HEADER-RECORD-OTCOT00002

5010 A2 837-I
Institutional Claim

NM109

Referring Provider
Identifier

2310F or
2420D

The identifier in the 837i
loop 2310F could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420D
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420D
then the identifier from
2420D should be reported as
the referring provider
identifier. N/A

Referring

REFERRING-PROVTAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier.

Referring

REFERRING-PROV-NPINUM

CLAIM-LINE-RECORD-OT-COT00003

5010 A2 837-I
Institutional Claim

NM109

Referring Provider
Identifier

2420D

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N/A

Appendix P.07
Provider
Role

Servicing
(Rendering)

OT (facility)-T-MSIS

OT (facility)-T-MSIS

Data Element

Record Segment

SERVICING-PROV-NPINUM

CLAIM-LINE-RECORD-OT-COT00003

X-12 Transaction

5010 A2 837-I
Institutional Claim

X-12
Element
Identifier

X-12 Description

NM109

Attending Provider
Identifier

X-12
Loop
2310A

Or
Or

Rendering Provider
Identifier

Service
(Rendering)

SERVICING-PROVTAXONOMY

December 2020v4.0.0

CLAIM-LINE-RECORD-OT-COT00003

N/A

N/A

Conditional Rules

N/A

320

2310D
or 2420C

N/A

The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier. If 2310D
and 2420C are not populated
but 2310A is populated, then
apply 2310D here.
The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier.

Appendix P.07
Provider
Role

OT (facility)-T-MSIS

OT (facility)-T-MSIS

Data Element

Record Segment

X-12 Transaction

X-12
Element
Identifier

X-12 Description

X-12

Conditional Rules

Loop

UnderDirection-of

UNDER-DIRECTION-OFPROV-NPI

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier.

UnderDirection-of

UNDER-DIRECTION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier.

UnderSupervisionof

UNDER-SUPERVISION-OFPROV-NPI

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier.

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Appendix P.07
Provider
Role

OT (facility)-T-MSIS

OT (facility)-T-MSIS

Data Element

Record Segment

UnderSupervisionof

UNDER-SUPERVISION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

X-12 Transaction

N/A

X-12
Element
Identifier

X-12 Description

N/A

N/A

X-12

Conditional Rules

Loop

Table D: Provider roles on T-MSIS CLAIMOT (professional claims) files and their corresponding locations on the X-12 transactions
OT (professional)-TX-12
X-12 Element
X-12
Provider
OT (professional)-T-MSIS
MSIS Data Element
Transaction
Identifier
Description
Role
Record Segment

N/A

The identifier in the 837i
loop 2310D could be applied
to each line in T-MSIS except
for lines where there is a
different identifier in 2420C
at the line level of the 837i.
If there is a different
identifier in 837i loop 2420C
then the identifier from loop
2420C should be reported as
the servicing/rendering
provider identifier.

X-12
Loop

Conditional Rules

Billing

BILLING-PROV-NPINUM

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-P
Professional
Claim

NM109

Billing Provider
Identifier

2010AA

N/AThe identifier in the 837p loop
2310A could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420F at the
line level of the 837p. If there is a
different identifier in 837p loop 2420F
then the identifier from 2420F should
be reported as the referring provider
identifier.

Billing

BILLING-PROVTAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-P
Professional
Claim

PRV03

Provider
Taxonomy Code

2000A

N/AThe identifier in the 837p loop
2310A could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420F at the
line level of the 837p. If there is a
different identifier in 837p loop 2420F
then the identifier from 2420F should
be reported as the referring provider
identifier.

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Appendix P.07
Provider
Role

OT (professional)-TMSIS Data Element

OT (professional)-T-MSIS
Record Segment

X-12
Transaction

X-12 Element
Identifier

X-12
Description

X-12
Loop

Conditional Rules

Referring

REFERRING-PROV-NPINUM

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-P
Professional
Claim

NM109

Referring
Provider
Identifier

2310A or
2420F

N/AThe identifier in the 837p loop
2310A could be applied to each line in
T-MSIS except for lines where there is
a different identifier in 2420F at the
line level of the 837p. If there is a
different identifier in 837p loop 2420F
then the identifier from 2420F should
be reported as the referring provider
identifier.

Referring

REFERRING-PROVTAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837p loop 2310A
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420F at the line
level of the 837p. If there is a different
identifier in 837p loop 2420F then the
identifier from 2420F should be
reported as the referring provider
identifier.

Referring

REFERRING-PROV-NPINUM

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-P
Professional
Claim

NM109

Referring
Provider
Identifier

2420F

N/A

Referring

REFERRING-PROV-NPINUM-2

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-P
Professional
Claim

NM109

Referring
Provider
Identifier

2420F

If there is a 2nd loop of 2420F
containing an NPI for a given claim,
apply the NPI from that second loop
here.

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Appendix P.07
Provider
Role

OT (professional)-TMSIS Data Element

OT (professional)-T-MSIS
Record Segment

X-12
Transaction

X-12 Element
Identifier

X-12
Description

X-12
Loop

Conditional Rules

Servicing
(Rendering)

SERVICING-PROV-NPINUM

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-P
Professional
Claim

NM109

Rendering
Provider
Identifier

2310B or
2420A

The identifier in the 837p loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in 2420A at the line
level of the 837p. If there is a different
identifier in 837p loop 2420A then the
identifier from 2420A should be
reported as the servicing/rendering
provider identifier.

Servicing
(Rendering)

SERVICING-PROVTAXONOMY

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-P
Professional
Claim

PRV03

Provider
Taxonomy Code

2310B or
2420A

The taxonomy in the 837p loop 2310B
could be applied to each line in T-MSIS
except for lines where there is a
different taxonomy in 2420A at the
line level of the 837p. If there is a
different taxonomy in 837p loop
2420A then the taxonomy from 2420A
should be reported as the
servicing/rendering provider
taxonomy.

Ordering

ORDERING-PROV-NPINUM

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-P
Professional
Claim

NM109

Ordering
Provider
Identifier

2420E

UnderDirection-of

UNDER-DIRECTION-OFPROV-NPI

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

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N/A

The identifier in the 837p loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in loop 2420D at
the line level of the 837p. If there is a
different identifier in loop 2420D then
the identifier from loop 2420D should
be reported as the under-supervisionof provider identifier.

Appendix P.07
Provider
Role

OT (professional)-TMSIS Data Element

OT (professional)-T-MSIS
Record Segment

X-12
Transaction

X-12 Element
Identifier

X-12
Description

X-12
Loop

Conditional Rules

UnderDirection-of

UNDER-DIRECTION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837p loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in loop 2420D at
the line level of the 837p. If there is a
different identifier in loop 2420D then
the identifier from loop 2420D should
be reported as the under-supervisionof provider identifier.

UnderSupervisionof

UNDER-SUPERVISIONOF-PROV-NPI

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-P
Professional
Claim

NM109

Supervising
Provider
Identifier

2310D or
2420D

The identifier in the 837p loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in loop 2420D at
the line level of the 837p. If there is a
different identifier in loop 2420D then
the identifier from loop 2420D should
be reported as the under-supervisionof provider identifier.

UnderSupervisionof

UNDER-SUPERVISIONOF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837p loop 2310D
could be applied to each line in T-MSIS
except for lines where there is a
different identifier in loop 2420D at
the line level of the 837p. If there is a
different identifier in loop 2420D then
the identifier from loop 2420D should
be reported as the under-supervisionof provider identifier.

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Appendix P.07

Table E: Provider roles on T-MSIS CLAIMOT (dental claims) files and their corresponding locations on the X-12 transactions
Provider
OT (dental)-T-MSIS
OT (dental)-T-MSIS
X-12
X-12
X-12
Transaction
Description
Role
Data Element
Record Segment
Element
Identifier

X-12
Loop

Conditional Rules

Billing

BILLING-PROV-NPINUM

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-D
Dental Claim

NM109

Billing Provider
Identifier

2010AA

N/AThe identifier in 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different identifier in
2420A at the line level of the 837d. If there is
a different identifier in 837d) loop 2420A
then the identifier from 2420A should be
reported as the servicing/rendering provider
identifier.

Billing

BILLING-PROVTAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-D
Dental Claim

PRV03

Provider
Taxonomy Code

2000A

N/AThe identifier in 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different identifier in
2420A at the line level of the 837d. If there is
a different identifier in 837d) loop 2420A
then the identifier from 2420A should be
reported as the servicing/rendering provider
identifier.

Referring

REFERRING-PROV-NPINUM

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-D
Dental Claim

NM109

Referring
Provider
Identifier

2310A

N/AThe identifier in 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different identifier in
2420A at the line level of the 837d. If there is
a different identifier in 837d) loop 2420A
then the identifier from 2420A should be
reported as the servicing/rendering provider
identifier.

Referring

REFERRING-PROVTAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

N/AThe identifier in 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different identifier in
2420A at the line level of the 837d. If there is
a different identifier in 837d) loop 2420A
then the identifier from 2420A should be
reported as the servicing/rendering provider
identifier.

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Appendix P.07
Provider

OT (dental)-T-MSIS

OT (dental)-T-MSIS

Role

Data Element

Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12
Description

X-12
Loop

Conditional Rules

Servicing
(Rendering)

SERVICING-PROV-NPINUM

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-D
Dental Claim

NM109

Rendering
Provider
Identifier

2310B or
2420A

The identifier in 837d loop 2310B could be
applied to each line in T-MSIS except for lines
where there is a different identifier in 2420A
at the line level of the 837d. If there is a
different identifier in 837d) loop 2420A then
the identifier from 2420A should be reported
as the servicing/rendering provider identifier.

Servicing
(Rendering)

SERVICING-PROVTAXONOMY

CLAIM-LINE-RECORD-OTCOT00003

5010 A1 837-D
Dental Claim

PRV03

Provider
Taxonomy Code

2310B or
2420A

The taxonomy in the 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different taxonomy in
2420A at the line level of the 837p. If there is
a different taxonomy in 837p loop 2420A
then the taxonomy from 2420A should be
reported as the servicing/rendering provider
taxonomy.

UnderDirection-of

UNDER-DIRECTION-OFPROV-NPI

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The taxonomy in the 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different taxonomy in
2420A at the line level of the 837p. If there is
a different taxonomy in 837p loop 2420A
then the taxonomy from 2420A should be
reported as the servicing/rendering provider
taxonomy.

UnderDirection-of

UNDER-DIRECTION-OFPROV-TAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The taxonomy in the 837d loop 2310B could
be applied to each line in T-MSIS except for
lines where there is a different taxonomy in
2420A at the line level of the 837p. If there is
a different taxonomy in 837p loop 2420A
then the taxonomy from 2420A should be
reported as the servicing/rendering provider
taxonomy.

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Appendix P.07
Provider

OT (dental)-T-MSIS

OT (dental)-T-MSIS

Role

Data Element

Record Segment

X-12
Transaction

X-12
Element
Identifier

X-12
Description

X-12
Loop

Conditional Rules

UnderSupervisionof

UNDER-SUPERVISIONOF-PROV-NPI

CLAIM-HEADER-RECORD-OTCOT00002

5010 A1 837-D
Dental Claim

NM109

Supervising
Provider
Identifier

2310E or
2420C

The identifier in the 837d loop 2310E could
be applied to each line in T-MSIS except for
lines where there is a different identifier in
loop 2420C at the line level of the 837d. If
there is a different identifier in loop 2420C
then the identifier from loop 2420C should be
reported as the under-supervision-of provider
identifier.

UnderSupervisionof

UNDER-SUPERVISIONOF-PROV-TAXONOMY

CLAIM-HEADER-RECORD-OTCOT00002

N/A

N/A

N/A

N/A

The identifier in the 837d loop 2310E could
be applied to each line in T-MSIS except for
lines where there is a different identifier in
loop 2420C at the line level of the 837d. If
there is a different identifier in loop 2420C
then the identifier from loop 2420C should be
reported as the under-supervision-of provider
identifier.

Table F: Provider roles on T-MSIS CLAIMRX (prescription drug) files and their corresponding locations on the X-12 transactions
Provider
RX-T-MSIS Data Element
RX-T-MSIS Record Segment
X-12 Segment
X-12
X-12 Field Name
Field
Role
Billing

BILLING-PROV-NPI-NUM

CLAIM-HEADER-RECORD-RX-CRX00002

NCPDP D.0 Transaction Header
Segment

201-B1

Service Provider ID

Billing

BILLING-PROV-TAXONOMY

CLAIM-HEADER-RECORD-RX-CRX00002

N/A

N/A

N/A

Dispensing

DISPENSING-PRESCRIPTIONDRUG-PROV-NPI

CLAIM-HEADER-RECORD-RX-CRX00002

NCPDP D.0 - Pharmacy
Provider Segment

444-E9

Provider ID

Dispensing

DISPENSING-PRESCRIPTIONDRUG-PROV-TAXONOMY

CLAIM-HEADER-RECORD-RX-CRX00002

N/A

N/A

N/A

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X-12 Definition

ID assigned to a pharmacy or provider

N/A
ID assigned to a pharmacy or provider
individual responsible for dispensing the
prescription
N/A

Appendix P.07
Provider

RX-T-MSIS Data Element

RX-T-MSIS Record Segment

X-12 Segment

X-12
Field

X-12 Field Name

Role
Prescribing

PRESCRIBING-PROV-NPINUM

CLAIM-HEADER-RECORD-RX-CRX00002

NCPDP D.0 - Prescriber
Segment

411-DB

Prescriber ID

Prescribing

PRESCRIBING-PROVTAXONOMY

CLAIM-HEADER-RECORD-RX-CRX00002

N/A

N/A

N/A

*This Section Intentionally Left Blank*

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X-12 Definition

ID assigned to the prescriber

N/A

Appendix Q

Appendix Q: Terms and Abbreviations
Definitions
Acronym/Abbreviation
AAAHC

Description
Accreditation Association for Ambulatory Health Care, Inc.

ABD

Aged, Blind and Disabled

ACA

Affordable Care Act

ADA

American Dental Association

ADDR

Address

AFDC

Aid to Families with Dependent Children

AIDS

Acquired Immunodeficiency Syndrome

AMT

Amount

ANSI

American National Standards Institute

APC

Ambulatory payment classifications

APPL

Application

ARNP

Advanced Registered Nurse Practitioner

ASC

Ambulatory Surgical Center

ASCII

American Standard Code for Information Interchange

ATP

Ability-To-Pay

BIP

Balancing Incentive Program

BMI

Body Mass Index

BOE

Basis of Eligibility

CBSA

Core Based Statistical Area

CD

Code

CDIB

Certificate of Degree of Indian or Alaska Native Blood

CEO

Chief Executive Officer

CFO

Chief Financial Officer

CFR

Code of Federal Regulations

CHIP

Children’s Health Insurance Program

CHIPRA

Children’s Health Insurance Program Reauthorization Act

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Appendix Q
Page 2 Acronym/Abbreviation
CHPID

Description
Controlling Health Plan Identifiers

CLIA

Clinical Laboratory Improvement Amendment

CMCS

Center for Medicaid, CHIP and Surveys and Certifications

CMHC

Community Mental Health Center

CMMI

Center for Medicare and Medicaid Innovation

CMS

Centers for Medicare & Medicaid Services

COBOL

Common Business Oriented Language

COBRA

Consolidated Omnibus Budget Reconciliation Act of 1986

COLA

Cost-of-Living Adjustment

CORF

Comprehensive Outpatient Rehabilitation Facility

COV

Covered

CPE

Certified Public Expenditures

CPT

Current Procedural Terminology

CRNA

Certified Registered Nurse Anesthetists

CRVS

California Relative Value Study

CWF

Common Working File

DBA

Doing Business As

DEA

Drug Enforcement Agency

DED

Deductible

DME

Durable Medical Equipment

DO

Doctor of osteopathy

DRG

Diagnosis Related Group

DSH

Disproportionate Share Hospital

DSN

Data Set Name

DTL

Detail

DUR

Drug Utilization Review

EBCDIC

Extended Binary-Coded-Decimal Interchange Code

EDI

Electronic Data Interchange

EFF

Effective

EFT

Electronic Funds Transfer; or Electronic File Transfer

EPSDT

Early and Periodic Screening, Diagnosis, and Treatment

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Appendix Q
Page 3 Acronym/Abbreviation
ESI

Description
Employer Sponsored Insurance

ESRD

End Stage Renal Disease

FFP

Federal Financial Participation

FFS

Fee-for-Service

FFY

Federal Fiscal Year

FFYQ

Federal Fiscal Year Quarter

FI

Fiscal Intermediary

FL

Form Locator

FLF

Fixed Length Format

FPL

Federal Poverty Level

FQHC

Federally Qualified Health Center

GME

Graduate Medical Education

HCBS

Home and Community-Based Services

HCC RA

Hierarchical Condition Category Risk Assessment

HCFA

Health Care Financing Administration

HCPCS

Health Care Procedural Coding System

HETS

HIPAA Eligibility Transaction System

HHA

Home Health Agency

HHPPS

Home Health Prospective Payment System

Hib

Haemophilus influenza type b

HIC

Health Insurance Claim

HICN

Health Insurance Claim Number

HIFA

Health Insurance and Flexibility and Accountability

HIO

Health Insuring Organization

HIPAA

Health Insurance Portability and Accountably Act of 1996

HIV

Human immunodeficiency virus

HMO

Health Maintenance Organization

HPV

Human Papillomavirus

IBM

International Business Machines, Inc.

ICD

International Classification of Diseases

ICD-10-CM

The 10th revision of the ICD

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Appendix Q
Page 4 Acronym/Abbreviation
ICD-9-CM

Description
The 9th revision of the ICD

ICF

Intermediate Care Facility

ICF-IID

Intermediate Care Facility for Individuals with Intellectual Disabilities

ICN

Item Control Number

IGT

Intergovernmental Transfers

IHS

Indian Health Service

IHS-BCC

IHS-B

IHS-BIP

IHS-B

IMD

Institution for Mental Disease

INA

Immigration and Nationality Act

IND

Indicator

IP

Inpatient

IPFPPS

Inpatient Psychiatric Facility Prospective Payment System

IPPS

Acute Inpatient Prospective Payment System

IRFPPS

Inpatient Rehabilitation Facility Prospective Payment System

LN

Line

LPN

Licensed Practical Nurse

LPR

Lawful permanent residents

LT

Long Term

LTC

Long Term Care

LTCHPPS

Long Term Care Hospital Prospective Payment System

LTCLA

Long Term Care Living Arrangement

LTSS

Long Term Services and Support

MACPro

Medicaid and CHIP Program Data System

MAGI

Modified Adjusted Gross Income

MAS

Maintenance Assistance Status

MBI

Medicare Beneficiary Identifier

M-CHIP

Medicaid Expansion CHIP

MCO

Managed Care Organization

MCR

Managed Care Record

MD

Medical Doctor

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Appendix Q
Page 5 Acronym/Abbreviation
MFP

Description
Money Follows the Person

MH

Mental Health

MMA

Medicare Modernization Act

MMIS

Medicaid Management Information System

MOD

Modifiers

MRI

Magnetic resonance imaging

MS-DRG

Medicare Severity – Diagnosis Related Group

MSIS

Medicaid Statistical Information System

MSP

Medicare Secondary Payer

NAIC

National Association of Insurance Commissioners

NCPDP

National Council for Prescription Drug Programs

NDC

National Drug Code

NF

Nursing Facility

NHP-ID

National Health Plan Identifier

NPI

National Provider ID

OASDI

Old-Age, Survivors, and Disability Insurance

OEID

Other Entity Identifier

OIG

Office of Inspector General

OIS

Office of Information Services

OMB

Office of Management and Budget

OPPS

Outpatient Prospective Payment System

ORF

Other Rehabilitation Facility

OS

Operating System

OT

Other Type [of claim]

OTC

Over the counter

PACE

Program for All-Inclusive Care for the Elderly

PAHP

Prepaid Ambulatory Health Plan

PBM

Pharmacy Benefits Manager

PCCM

Primary Care Case Management

PERS

Personal Emergency Response System

PHP

Prepaid Health Plan

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Appendix Q
Page 6 Acronym/Abbreviation
PHS

Description
Public Health Service Act

PIHP

Prepaid Inpatient Health Plan

PL

Public Law

POA

Present on Admission

POP

Population

PPS

Prospective Payment System

PROV

Provider

PRTF

Psychiatric Residential Treatment Facilities Demonstration Grant
Program

PRWORA

Personal Responsibility and Work Opportunity Reconciliation Act of
1996

PT/OT/ST

Physical Therapy/Occupational Therapy/Speech Therapy

QDWI

Qualified Disabled Working Individuals

QI

Qualified Individual

QIO

Quality Improvement Organization

QMB

Qualified Medicare Beneficiaries

RA

Remittance Advice

RBRVS

Resource-based relative value scale

REC

Record

RHC

Rural health clinic

RN

Registered Nurse

RRB

Railroad Retirement Board

RX

Prescription

SCHIP

State Children’s Health Insurance Program

SHPID

Sub-Health Plan Identifiers

SLMB

Specified Low-Income Medicare Beneficiaries

SNF

Skilled Nursing Facility

SNFPPS

Skilled Nursing Facility Prospective Payment System

SPA

State Plan Amendment

SSA

Social Security Administration

SSDI

Social Security Disability Insurance

SSI

Supplemental Security Income

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Appendix Q
Page 7 Acronym/Abbreviation
SSP

Description
State Supplemental Program

SSN

Social Security Number

SUD

Substance Use Disorders

T-18 SNF

Title 18 Skilled Nursing Facility

TANF

Temporary Assistance for Needy Families

TB

Tuberculosis

TEFRA

Tax Equity and Fiscal Responsibility Act of 1982

TIN

Tax Identifier Number

T-MSIS

Transformed Medicaid Statistical Information System

TOT

Total

TPL

Third Party Liability

TWWIIA

Ticket to Work and Work Incentives Improvement Act

UB

Uniform Billing

URAC

Utilization Review Accreditation Commission

USC

United States Code

VA

Veterans Administration

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