Crosswalk - Data Dictionary
T-MSIS Data Dictionary Crosswalk v2.4.0 - v4.0.0 508.xlsx
[Medicaid] Transformed - Medicaid Statistical Information System (T-MSIS) (CMS-R-284)
Crosswalk - Data Dictionary
OMB: 0938-0345
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DD Crosswalk
Overview
Cover SheetDD Crosswalk
Sheet 1: Cover Sheet
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| Centers for Medicaid and CHIP Services (CMCS) | ||||
| Transformed Medicaid Statistical Information System (T-MSIS) | ||||
| T-MSIS Data Dictionary Crosswalk (Change Log) - Version 2.4.0 through Version 4.0.0 | ||||
| PRA Disclosure Statement: The Transformed Medicaid Statistical Information System (T-MSIS) is used to assist the Centers for Medicare & Medicaid Services (CMS) with monitoring and oversight of Medicaid and CHIP programs, to enable evaluation of demonstrations under section 1115 of the Social Security Act | ||||
| and to calculate quality measures and other metrics, including those reported through the new Medicaid and CHIP Scoreboard. Section 4735 of the Balanced Budget Act of 1997 included a statutory requirement for states to submit claims data, enrollee encounter data, and supporting information. Section 6504 of the Affordable Care Act strengthened | ||||
| this provision by requiring states to include data elements the Secretary determines necessary for program integrity, program oversight, and administration. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are | ||||
| required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0345 (Expires: 03/31/2026). The time required to complete this information collection is estimated to average 10 hours per response, including the time to review instructions, | ||||
| search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. | ||||
Sheet 2: DD Crosswalk
| T-MSIS Data Dictionary Crosswalk (Change Log) - Version 2.4.0 through Version 4.0.0 | |||||
| Date |
Name And/Or Number |
Field(s) |
Action |
Before |
After |
| 2021-04-09 | CHIP-CODE (ELG054) | Data Dictionary | UPDATE | CHIP-CODE (ELG054) v2.3 Definition:A code used to distinguish among Medicaid, Medicaid Expansion, and Separate CHIP populations | A code used to distinguish among Medicaid, Medicaid Expansion CHIP, and Separate CHIP populations |
| 2021-05-21 | BILLING-PROV-NUM (COT.002.112) | Data Dictionary | UPDATE | When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider IDorWhen Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1' | N/A |
| 2021-05-21 | PROCEDURE-CODE-1, PROCEDURE-CODE-2, PROCEDURE-CODE-3, PROCEDURE-CODE-4, PROCEDURE-CODE-5, PROCEDURE-CODE-6 | Data Dictionary | UPDATE | Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | N/A |
| 2021-06-11 | ELG.016.214 | Data Dictionary | ADD | N/A | If associated Race (ELG.016.213) value is not in [ "010", "015" ], then value must be null. |
| 2021-06-11 | TOT-BILLED-AMT | Data Dictionary | UPDATE | "If associated Type of Claim value is 2, 4, 5, B, D, or E, then value should not be populated" | N/A |
| 2021-07-23 | TOT-BILLED-AMT (CIP.002.112) | Data Dictionary | UPDATE | “If associated Type of Claim value is 2, 4, 5, B, D, or E, then value should not be populated" | N/A |
| 2021-07-23 | TOT-COPAY-AMT (CIP.002.115) | Data Dictionary | UPDATE | "If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated."AND"(Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided" | N/A |
| 2021-08-13 | MEDICAID-PAID-AMT | Data Dictionary | UPDATE | |Definition||The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim.| | |Definition||The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.| |
| 2021-10-15 | CLAIM-STATUS-CATEGORY (CIP103) | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||CIP103 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"||CLT055 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"||COT040 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"||CRX031 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||CIP103 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"||CLT055 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"||COT040 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"||CRX031 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"| |
| 2021-12-03 | RACE (ELG213) | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||ELG213|RACE| Not Applicable |Not Applicable |A code indicating the individual's race either in accordance with requirements of Section 4302 of the Affordable Care Act classifications Race Code clarifications: If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown." If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," "Unspecified" or "Unknown."NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese).NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||ELG213|RACE| Not Applicable |Not Applicable |A code indicating the individual's race in accordance with requirements of Section 4302 of the Affordable Care Act classifications Race Code clarifications: If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown." If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," "Unspecified" or "Unknown." If state has beneficiaries coded in their database as “Other” with no additional detail or in a category that is not available in the code set provided, then code them in T-MSIS as “Other” (valid value “018”), but only use “Other” if the use of “Other Asian” or “Other Pacific Islander” are not appropriate. DO NOT USE “Unspecified” or “Unknown”. The “Other” valid value was added to T-MSIS to better align T-MSIS with the single-streamlined application and to accommodate some atypical states, despite the requirements of Section 4302 of the ACA.NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese).NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question.| |
| 2021-12-17 | ADJUDICATION-DATE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP098|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||CLT050|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||COT035|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||CRX027|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||CIP286|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||CLT233|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||COT221|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.||CRX157|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.| | |DE No|Data Element Name|Definition||CIP098|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||CLT050|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||COT035|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||CRX027|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||CIP286|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||CLT233|ADJUDICATION-DATE|TThe date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||COT221|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.||CRX157|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.| |
| 2021-12-17 | BILLING-PROV-NUM (COT112) | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |When Type of Service (COT.003.186) not in ('119', ‘120’, ‘122’), then value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'| |
| 2021-12-17 | BILLING-PROV-NUM (COT112) | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |Not Applicable| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider IDorWhen Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1'| |
| 2021-12-17 | BILLING-PROV-NUM (COT112) | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |When Type of Service (COT..003.186) is in ['119', ‘120', '122'] value must match Plan ID Number (COT.002.066)| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |Not Applicable| |
| 2021-12-17 | PRIMARY-LANGUAGE-CODE (ELG046) | Data Dictionary | UPDATE | |DE NO|DEFINITION||ELG046|A code indicating the language the individual speaks other than English at home.| | |DE NO|DEFINITION||ELG046|A code indicating the language that is the individuals' preferred spoken or written language.| |
| 2022-01-07 | CIP025 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME |DEFINITION||CIP025|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| | |DE NO| DATA ELEMENT NAME |DEFINITION||CIP025|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
| 2022-01-07 | CLT024 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME |DEFINITION||CLT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| | |DE NO| DATA ELEMENT NAME |DEFINITION||CLT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
| 2022-01-07 | COT024 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME |DEFINITION||COT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| | |DE NO| DATA ELEMENT NAME |DEFINITION||COT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
| 2022-01-07 | CRX024 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME |DEFINITION||CRX024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| | |DE NO| DATA ELEMENT NAME |DEFINITION||CRX024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
| 2022-01-07 | ELG086 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||ELG086|PRIMARY-ELIGIBILITY-GROUP-IND| Not Applicable |Not Applicable |A person enrolled in Medicaid/CHIP should always have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.) It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES).| |
| 2022-01-07 | ELG086 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||ELG086|PRIMARY-ELIGIBILITY-GROUP-IND| Not Applicable |Not Applicable |Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0.| |
| 2022-01-07 | ELG233 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME |DEFINITION||ELG233|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| | |DE NO| DATA ELEMENT NAME |DEFINITION||ELG233|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
| 2022-01-07 | ELG260 | Data Dictionary | UPDATE | |FILE SEGMENT NAME WITH RECORD ID COMPUTING||ELIGIBLE-IDENTIFIER-ELG00022| | |FILE SEGMENT NAME WITH RECORD ID COMPUTING||ELIGIBLE-IDENTIFIERS-ELG00022| |
| 2022-01-28 | ELG095 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME |DEFINITION||ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status.| | |DE NO| DATA ELEMENT NAME |DEFINITION||ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a change in an individual's eligibility status. The end date of the segment in which the value is reported must represent the date that the change occurred. The reason for change represents the reason that the segment in which it was reported was closed.| |
| 2022-02-18 | COT191 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT191|SERVICING-PROV-TAXONOMY|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]| Conditional| Not Applicable| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT||COT191| SERVICING-PROV-TAXONOMY| The taxonomy code for the provider who treated the recipient.| Conditional | Value must be equal to a valid value.|COT191|SERVICING-PROV-TAXONOMY|Not Applicable |Not Applicable | Leave blank or space-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122)|COT191|SERVICING-PROV-TAXONOMY|Not Applicable| Not Applicable| Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.| |
| 2022-02-18 | ELG224 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY ||ELG224|DISABILITY-TYPE-CODE|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|Conditional| | |DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY ||ELG224|DISABILITY-TYPE-CODE|A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act.| Mandatory| |
| 2022-03-11 | CIP228 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME| DEFINITION|CIP228 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| | DE NO| DATA ELEMENT NAME| DEFINITION|CIP228 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header.| |
| 2022-03-11 | CLT179 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME| DEFINITION|CLT179 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| | DE NO| DATA ELEMENT NAME| DEFINITION|CLT179 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header.| |
| 2022-03-11 | COT182 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME| DEFINITION|COT182 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| | DE NO| DATA ELEMENT NAME| DEFINITION|COT182 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines.| |
| 2022-03-11 | CRX129 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME| DEFINITION|CRX129 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| | DE NO| DATA ELEMENT NAME| DEFINITION|CRX129 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines.| |
| 2022-04-01 | ELG073 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME| NECESSITY|CODING REQUIREMENT|ELG073|ELIGIBLE-PHONE-NUM|Optional|| | DE NO| DATA ELEMENT NAME| NECESSITY|CODING REQUIREMENT|ELG073|ELIGIBLE-PHONE-NUM|Conditional|Value is mandatory and must be provided when the ELIGIBLE-ADDR-TYPE (ELG.004.065) = ‘01’| |
| 2022-05-13 | CIP184, CLT006, COT006, CRX006, ELG006, MCR006, PRV006, TPL006, CIP127, CLT077, COT063, CRX054, ELG111, TPL044, TPL045, CIP093, CIP088, PRV043, PRV064, PRV076, PRV129, COT191 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME|NECESSITY|CIP184|ADMITTING-PROV-NPI-NUM||CLT006|FILE-NAME||CRX006|FILE-NAME||ELG006|FILE-NAME||MCR006|FILE-NAME||PRV006|FILE-NAME||TPL006|FILE-NAME||CIP127|FUNDING-SOURCE-NONFEDERAL-SHARE||CLT077|FUNDING-SOURCE-NONFEDERAL-SHARE||COT063|FUNDING-SOURCE-NONFEDERAL-SHARE||CRX054|FUNDING-SOURCE-NONFEDERAL-SHARE||ELG111|HEALTH-HOME-ENTITY-EFF-DATE||TPL044|POLICY-OWNER-FIRST-NAME||TPL045|POLICY-OWNER-LAST-NAME||CIP093|PROCEDURE-CODE-DATE-6||CIP088|PROCEDURE-CODE-FLAG-5||PRV043|PROV-LOCATION-ID||PRV064|PROV-LOCATION-ID||PRV076|PROV-LOCATION-ID||PRV129|PROV-LOCATION-ID||COT191|SERVICING-PROV-TAXONOMY|| | DE NO| DATA ELEMENT NAME|NECESSITY|CIP184|ADMITTING-PROV-NPI-NUM|Conditional|CLT006|FILE-NAME|Mandatory|CRX006|FILE-NAME|Mandatory|ELG006|FILE-NAME|Mandatory|MCR006|FILE-NAME|Mandatory|PRV006|FILE-NAME|Mandatory|TPL006|FILE-NAME|Mandatory|CIP127|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|CLT077|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|COT063|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|CRX054|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|ELG111|HEALTH-HOME-ENTITY-EFF-DATE|Mandatory|TPL044|POLICY-OWNER-FIRST-NAME|Mandatory|TPL045|POLICY-OWNER-LAST-NAME|Mandatory|CIP093|PROCEDURE-CODE-DATE-6|Conditional|CIP088|PROCEDURE-CODE-FLAG-5|Conditional|PRV043|PROV-LOCATION-ID|Mandatory|PRV064|PROV-LOCATION-ID|Mandatory|PRV076|PROV-LOCATION-ID|Mandatory|PRV129|PROV-LOCATION-ID|Mandatory|COT191|SERVICING-PROV-TAXONOMY|Conditional| |
| 2022-05-13 | CIP202, CLT144, COT126, CRX081 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME|DEFINITION|CIP202|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.|CLT144|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.|COT126|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.|CRX081|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.| | DE NO| DATA ELEMENT NAME|DEFINITION|CIP202|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|CLT144|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|COT126|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|CRX081|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.| |
| 2022-05-13 | CRX098 | Data Dictionary | UPDATE | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX098|THIRD-PARTY-COINSURANCE-AMOUNT-PAID|Optional|The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.|1. Value must be between -99999999999.99 and 99999999999.99, 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ), 3.Optional|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-05-13 | CRX143 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME|DEFINITION|CRX143|DRUG-UTILIZATION-CODE|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (44-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Results of Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service.Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.| | DE NO| DATA ELEMENT NAME|DEFINITION|CRX143|DRUG-UTILIZATION-CODE|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service.The NCPDP "Reason for Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service.Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.| |
| 2022-05-13 | CRX144 | Data Dictionary | UPDATE | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX144|DTL-METRIC-DEC-QTY|Conditional|Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter).|1. Value must be numeric, 2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.890, 3. Value must be populated when Compound Drug Indicator (CRX.002.086) equals 1, 4.Conditional|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-05-13 | ELG087 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|ELG087|ELIGIBILITY-GROUP|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE=7 and STATE-PLAN-OPTION-TYPE="06". | DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|ELG087|ELIGIBILITY-GROUP|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7". |
| 2022-05-13 | ELG097 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|ELG097|RESTRICTED-BENEFITS-CODE|| | DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|ELG097|RESTRICTED-BENEFITS-CODE|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7".| |
| 2022-05-13 | ELG163 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|ELG163|STATE-PLAN-OPTION-TYPE|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE=7 and STATE-PLAN-OPTION-TYPE="06”.| | DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|ELG163|STATE-PLAN-OPTION-TYPE|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7".| |
| 2022-06-24 | 1115A-DEMONSTRATION-IND | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP025|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP025|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional5. Value must be in [0, 1] or not populated |
| 2022-06-24 | 1115A-DEMONSTRATION-IND | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|COT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|COT024|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional5. Value must be in [0, 1] or not populated |
| 2022-06-24 | 1115A-DEMONSTRATION-IND | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CRX024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|CRX024|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional5. Value must be in [0, 1] or not populated |
| 2022-06-24 | 1115A-DEMONSTRATION-IND | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CLT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|CLT024|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|1. Value must be in 1115A Demonstration Indicator List (VVL)2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated3. Value must be 1 character4. Conditional5. Value must be in [0, 1] or not populated |
| 2022-06-24 | ADMISSION-HOUR | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CLT045|ADMISSION-HOUR |The time of admission to a psychiatric or long-term care facility.|1.(LV) value must be in Hour List (VVL)2.(S) value must be 2 characters3.(N) conditional| | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CLT045|ADMISSION-HOUR |The time of admission to a psychiatric or long-term care facility.|1.(LV) value must be in Hour List (VVL)2.(S) value must be 2 characters3.(N) conditional4.(FD1) when populated, Admission Date (CLT.002.044) must be populated| |
| 2022-06-24 | ADMITTING-DIAGNOSIS-CODE | Data Dictionary | UPDATE | |DE NO|DATA ELEMENT NAME| DEFINITION||CIP030|ADMITTING-DIAGNOSIS-CODE|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".| | |DE NO|DATA ELEMENT NAME| DEFINITION||CIP030|ADMITTING-DIAGNOSIS-CODE|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.| |
| 2022-06-24 | ADMITTING-DIAGNOSIS-CODE | Data Dictionary | UPDATE | |DE NO|DATA ELEMENT NAME| DEFINITION||CLT027|ADMITTING-DIAGNOSIS-CODE|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".| | |DE NO|DATA ELEMENT NAME| DEFINITION||CLT027|ADMITTING-DIAGNOSIS-CODE|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.| |
| 2022-06-24 | ADMITTING-DIAGNOSIS-CODE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition|CLT027|ADMITTING-DIAGNOSIS-CODE|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".1.(GS) value must satisfy the requirements of Diagnosis Code (CE)| | |DE No|Data Element Name|Definition|CLT.027|ADMITTING-DIAGNOSIS-CODE|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician.1.(GS) value must satisfy the requirements of Diagnosis Code (CE)| |
| 2022-06-24 | ADMITTING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CLT174|ADMITTING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CLT174|ADMITTING-PROV-NPI-NUM|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.| |
| 2022-06-24 | ADMITTING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP184|ADMITTING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CIP184|ADMITTING-PROV-NPI-NUM|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.| |
| 2022-06-24 | AFFILIATED-PROGRAM-ID | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||PRV120|AFFILIATED-PROGRAM-IDA data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.(health plan federalassigned) if associated Affiliated Program Type (DE) value is 1, then value must be the federal-assigned plan ID of the health plan in which a provideris enrolled to provide services.(health plan state assigned) if associated Affiliated Program Type (DE) value is 2, then value must be the state-assignedplan ID of the health plan in which a provider is enrolled to provide services.(waiver) if associated Affiliated Program Type (DE) value is 3, then valuemust be the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries.(health home entity) if associated AffiliatedProgram Type (DE) value is 4, then value must be the name of a health home in which a provider is participating.(other) if associated Affiliated ProgramType (DE) value is 5, then value must be an identifier for something other than a health plan, waiver, or health home entity. | |DE No|Data Element Name|Definition||PRV120|AFFILIATED-PROGRAM-IDA data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.If Affiliated ProgramType = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in whicha provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal WaiverID in which a provider isallowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the valuein Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in AffiliatedProgram ID is an identifier for something other than a health plan,waiver, or health home entity. |
| 2022-06-24 | AFFILIATED-PROGRAM-TYPE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||PRV119|AFFILIATED-PROGRAM-TYPE| A code to identify the category of program that the provider is affiliated.see Affiliated Program Type List (VVL.004)(health plan federal assigned) if associated Affiliated Program Type (DE) value is 1, then value must be the federal-assigned plan ID of the health plan in which a provider is enrolled to provide services.(health plan state assigned) if associated Affiliated Program Type (DE) value is 2, then value must be the state-assigned plan ID of the health plan in which a provider is enrolled to provide services.(waiver) if associated Affiliated Program Type (DE) value is 3, then value must be the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries. (health home entity) if associated AffiliatedProgram Type (DE) value is 4, then value must be the name of a health home in which a provider is participating.(other) if associated Affiliated ProgramType (DE) value is 5, then value must be an identifier for something other than a health plan, waiver, or health home entity.| | |DE No|Data Element Name|Definition||PRV119|AFFILIATED-PROGRAM-TYPE|A code to identify the category of program that the provider is affiliated.| |
| 2022-06-24 | BILLING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP180|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CIP180|BILLING-PROV-NPI-NUM|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.| |
| 2022-06-24 | BILLING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CLT131|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CLT131|BILLING-PROV-NPI-NUM|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.| |
| 2022-06-24 | BILLING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||COT113|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||COT113|BILLING-PROV-NPI-NUM|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.| |
| 2022-06-24 | BILLING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CRX071|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CRX071|BILLING-PROV-NPI-NUM|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.| |
| 2022-06-24 | CIP071 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP071|PROCEDURE-CODE-MOD-1 | N/A |
| 2022-06-24 | CIP071/ PROCEDURE-CODE-MOD-1 | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP071|PROCEDURE-CODE-MOD-1|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP075 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP075|PROCEDURE-CODE-MOD-2 | N/A |
| 2022-06-24 | CIP075/ PROCEDURE-CODE-MOD-2 | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP075|PROCEDURE-CODE-MOD-2|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP079 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP079|PROCEDURE-CODE-MOD-3 | N/A |
| 2022-06-24 | CIP079/ PROCEDURE-CODE-MOD-3 | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP079|PROCEDURE-CODE-MOD-3|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP083 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP083|PROCEDURE-CODE-MOD-4 | N/A |
| 2022-06-24 | CIP083/ PROCEDURE-CODE-MOD-4 | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP083|PROCEDURE-CODE-MOD-4|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP087 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP087|PROCEDURE-CODE-MOD-5 | N/A |
| 2022-06-24 | CIP087/ PROCEDURE-CODE-MOD-5 | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP087|PROCEDURE-CODE-MOD-5|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP091 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP091|PROCEDURE-CODE-MOD-6 | N/A |
| 2022-06-24 | CIP091/ PROCEDURE-CODE-MOD-6 | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP091|PROCEDURE-CODE-MOD-6|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP107 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP107|ALLOWED-CHARGE-SRC | N/A |
| 2022-06-24 | CIP107/ ALLOWED-CHARGE-SRC | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP107|ALLOWED-CHARGE-SRC| X(1)|CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 | N/A |
| 2022-06-24 | CIP115 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP115|TOT-COPAY-AMT | N/A |
| 2022-06-24 | CIP115/ TOT-COPAY-AMT | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP115|TOT-COPAY-AMT|S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP131 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP131|NATIONAL-HEALTH-CARE-ENTITY-ID | N/A |
| 2022-06-24 | CIP131/ NATIONAL-HEALTH-CARE-ENTITY-ID | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP131|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP191 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP191|REFERRING-PROV-TAXONOMY | N/A |
| 2022-06-24 | CIP191/ REFERRING-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP191|REFERRING-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP192 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP192|REFERRING-PROV-TYPE | N/A |
| 2022-06-24 | CIP192/ REFERRING-PROV-TYPE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP192|REFERRING-PROV-TYPE|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP193 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP193|REFERRING-PROV-SPECIALTY | N/A |
| 2022-06-24 | CIP193/ REFERRING-PROV-SPECIALTY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP193|REFERRING-PROV-SPECIALTY|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP195 | Data Dictionary | UPDATE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE SEGMENT (with RECORD-ID)CIP195|DRG-REL-WEIGHT|X(8)|CLAIM-HEADER-RECORD-IP-CIP00002 | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE SEGMENT (with RECORD-ID)CIP195|DRG-REL-WEIGHT|S9(3)V99999)|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP195/ DRG-REL-WEIGHT | Data Dictionary - Record Layout | Modify Data Type | DE_NO|DATA_ELEMENT_NAME|SIZE|CIP195|DRG-REL-WEIGHT|X(8)| | DE_NO|DATA_ELEMENT_NAME|SIZE|CIP195|DRG-REL-WEIGHT|S9(3)V99999 |
| 2022-06-24 | CIP201 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP201|BMI | N/A |
| 2022-06-24 | CIP201/ BMI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP201|BMI|S9(5)V9|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP206 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP206|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP206|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CIP206/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCIP206|BENEFICIARY-COINSURANCE-AMOUNT | DE No|Data Element Name |CIP206|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
| 2022-06-24 | CIP208 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP208|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP208|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CIP208/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCIP208|BENEFICIARY-COPAYMENT-AMOUNT | DE No|Data Element NameCIP208|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
| 2022-06-24 | CIP210 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP210|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP210|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CIP210/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCIP210|BENEFICIARY-DEDUCTIBLE-AMOUNT | DE No|Data Element NameCIP210|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
| 2022-06-24 | CIP213 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP213|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. | |DE NO| DATA ELEMENT NAME|DEFINITIONCIP213|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 2022-06-24 | CIP214 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP214|HEALTH-HOME-ENTITY-NAME||1.Value must 50 characters or less2.Value must not contain a pipe or asterisk symbols3.Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP214|HEALTH-HOME-ENTITY-NAME||1.1.(IV) value must not contain a pipe or asterisk symbols2.(S) value must 50 characters or less3.(N) conditional |
| 2022-06-24 | CIP224 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP224|UNDER-DIRECTION-OF-PROV-NPI | N/A |
| 2022-06-24 | CIP224/ UNDER-DIRECTION-OF-PROV-NPI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP224|UNDER-DIRECTION-OF-PROV-NPI|X(10)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP225 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP225|UNDER-DIRECTION-OF-PROV-TAXONOMY | N/A |
| 2022-06-24 | CIP225/ UNDER-DIRECTION-OF-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP225|UNDER-DIRECTION-OF-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP226 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP226|UNDER-SUPERVISION-OF-PROV-NPI | N/A |
| 2022-06-24 | CIP226/ UNDER-SUPERVISION-OF-PROV-NPI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP226|UNDER-SUPERVISION-OF-PROV-NPI|X(10)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP227 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP227|UNDER-SUPERVISION-OF-PROV-TAXONOMY | N/A |
| 2022-06-24 | CIP227/ UNDER-SUPERVISION-OF-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP227|UNDER-SUPERVISION-OF-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 | N/A |
| 2022-06-24 | CIP249 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCIP249|IP-LT-QUANTITY-OF-SERVICE-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCIP249|REVENUE-CENTER-QUANTITY-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field| |
| 2022-06-24 | CIP249/ REVENUE-CENTER-QUANTITY-ACTUAL | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCIP249|IP-LT-QUANTITY-OF-SERVICE-ACTUAL | DE No|Data Element NameCIP249|REVENUE-CENTER-QUANTITY-ACTUAL |
| 2022-06-24 | CIP250 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED| | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCIP250|REVENUE-CENTER-QUANTITY-ALLOWED|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field |
| 2022-06-24 | CIP250/ REVENUE-CENTER-QUANTITY-ALLOWED | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED | DE No|Data Element NameCIP250|REVENUE-CENTER-QUANTITY-ALLOWED |
| 2022-06-24 | CIP253 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP253|TPL-AMT | N/A |
| 2022-06-24 | CIP253/ TPL-AMT | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP253|TPL-AMT|S9(11)V99 | N/A |
| 2022-06-24 | CIP262 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECIP262|SERVICING-PROV-TAXONOMY | N/A |
| 2022-06-24 | CIP262/ SERVICING-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP262|SERVICING-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 | N/A |
| 2022-06-24 | CIP270/ XIX-MBESCBES-CATEGORY-OF-SERVICE | Data Dictionary - Record Layout | Modify DE Width | SIZEX(4) | SIZEX(5) |
| 2022-06-24 | CIP278/ NDC-QUANTITY | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | CIP290 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP290|BEGINNING-DATE-OF-SERVICE|Mandatory|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.|Value must be 8 characters in the form "CCYYMMDD"The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period valueValue must be less than or equal to associated Ending Date of Service valueWhen Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date valueValue must be less than or equal to associated Date of Death (ELG.002.025) value when populatedValue must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP290/ BEGINNING-DATE-OF-SERVICE | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP290|BEGINNING-DATE-OF-SERVICE|9(8)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP291 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP291|ENDING-DATE-OF-SERVICE|Mandatory|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date onwhich the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.|Value must be 8 characters in the form "CCYYMMDD"The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period valueValue must be greater than or equal to associated Beginning Date of Service valueWhen Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date valueValue must be less than or equal to associated Date of Death (ELG.002.025) value when populatedValue must be equal to or greater than associated Date of Birth (ELG.002.024) value|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP291/ ENDING-DATE-OF-SERVICE | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP291| ENDING-DATE-OF-SERVICE|9(8)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP292 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP292|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT |Conditional|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP292/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP292|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT |S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP293 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP293|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP293/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP293|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT |S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP294 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP294|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP294/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP294|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP295 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP295|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP295/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP295|COMBINED-BENE-COST-SHARING-PAID-AMOUNT |S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
| 2022-06-24 | CIP296 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECIP296|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 characterValue must be in [0, 1] or not populated|CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 |
| 2022-06-24 | CIP296/ IHS-SERVICE-IND | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCIP296|IHS-SERVICE-IND|X(1)||CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 |
| 2022-06-24 | CLAIM-STATUS-CATEGORY | Data Dictionary | UPDATE | |DE No|Data Element Name|Coding Requirement||CIP103,CLT.055,COT.040,CRX.031|CLAIM-STATUS-CATEGORY|(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2" | |DE No|Data Element Name|Coding Requirement||CIP103,CLT055,COT040,CRX031|CLAIM-STATUS-CATEGORY|(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2" |
| 2022-06-24 | CLT066 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT066|TOT-COPAY-AMT | N/A |
| 2022-06-24 | CLT066/ TOT-COPAY-AMT | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT066|TOT-COPAY-AMT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT081 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT081|NATIONAL-HEALTH-CARE-ENTITY-ID | N/A |
| 2022-06-24 | CLT081/ NATIONAL-HEALTH-CARE-ENTITY-ID | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT081|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT137 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT137|REFERRING-PROV-TAXONOMY | N/A |
| 2022-06-24 | CLT137/ REFERRING-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT137|REFERRING-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT138 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT138|REFERRING-PROV-TYPE | N/A |
| 2022-06-24 | CLT138/ REFERRING-PROV-TYPE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT138|REFERRING-PROV-TYPE|X(2)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT139 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT139|REFERRING-PROV-SPECIALTY | N/A |
| 2022-06-24 | CLT139/ REFERRING-PROV-SPECIALTY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT139|REFERRING-PROV-SPECIALTY|X(2)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT143 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT143|BMI | N/A |
| 2022-06-24 | CLT143/ BMI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT143|BMI|S9(5)V9|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT153 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT153|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT153|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CLT153/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCLT153|BENEFICIARY-COINSURANCE-AMOUNT | DE No|Data Element NameCLT153|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
| 2022-06-24 | CLT155 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT155|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT155|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CLT155/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCLT155|BENEFICIARY-COPAYMENT-AMOUNT | DE No|Data Element NameCLT155|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
| 2022-06-24 | CLT157 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT157|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT157|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CLT157/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCLT157|BENEFICIARY-DEDUCTIBLE-AMOUNT | DE No|Data Element NameCLT157|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
| 2022-06-24 | CLT160 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT160|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. | |DE NO| DATA ELEMENT NAME|DEFINITIONCLT160|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 2022-06-24 | CLT161 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CLT.161|HEALTH-HOME-ENTITY-NAME||1.(GS) value must satisfy the requirements of Health Home Entity Name (CE) | DE No|Data Element Name|Definition| CODING REQUIREMENT|CLT.161|HEALTH-HOME-ENTITY-NAME||1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)2.(S) value must 50 characters or less3.(N) conditional |
| 2022-06-24 | CLT169 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT169|UNDER-DIRECTION-OF-PROV-NPI | N/A |
| 2022-06-24 | CLT169/ UNDER-DIRECTION-OF-PROV-NPI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT169|UNDER-DIRECTION-OF-PROV-NPI|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT170 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT170|UNDER-SUPERVISION-OF-PROV-NPI | N/A |
| 2022-06-24 | CLT170/ UNDER-DIRECTION-OF-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT170|UNDER-DIRECTION-OF-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT171 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT171|UNDER-SUPERVISION-OF-PROV-NPI | N/A |
| 2022-06-24 | CLT171/ UNDER-SUPERVISION-OF-PROV-NPI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT171|UNDER-SUPERVISION-OF-PROV-NPI|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT172 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT172|UNDER-SUPERVISION-OF-PROV-TAXONOMY | N/A |
| 2022-06-24 | CLT172/ UNDER-SUPERVISION-OF-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT172|UNDER-SUPERVISION-OF-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 | N/A |
| 2022-06-24 | CLT202 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCLT202|IP-LT-QUANTITY-OF-SERVICE-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCLT202|REVENUE-CENTER-QUANTITY-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field |
| 2022-06-24 | CLT202/ REVENUE-CENTER-QUANTITY-ACTUAL | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCLT202|IP-LT-QUANTITY-OF-SERVICE-ACTUAL | DE No|Data Element NameCLT202|REVENUE-CENTER-QUANTITY-ACTUAL |
| 2022-06-24 | CLT203 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCLT203|IP-LT-QUANTITY-OF-SERVICE-ALLOWED|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCLT203|REVENUE-CENTER-QUANTITY-ALLOWED|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field |
| 2022-06-24 | CLT203/ REVENUE-CENTER-QUANTITY-ALLOWED | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCLT203|IP-LT-QUANTITY-OF-SERVICE-ALLOWED | DE No|Data Element NameCLT203|REVENUE-CENTER-QUANTITY-ALLOWED |
| 2022-06-24 | CLT214 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECLT214|SERVICING-PROV-TAXONOMY | N/A |
| 2022-06-24 | CLT214/ SERVICING-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT214|SERVICING-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-LINE-RECORD-LT-CLT00003 | N/A |
| 2022-06-24 | CLT224/ XIX-MBESCBES-CATEGORY-OF-SERVICE | Data Dictionary - Record Layout | Modify DE Width | SIZEX(4) | SIZEX(5) |
| 2022-06-24 | CLT230/ NDC-QUANTITY | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | CLT239 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECLT239|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|Conditional|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT239/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT239|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT240 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECLT240|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT240/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT-CLT240|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT241 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECLT241|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT241/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT241|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT242 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECLT242|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT242/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT242|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
| 2022-06-24 | CLT243 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECLT243|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 characterValue must be in [0, 1] or not populated|CLAIMLT|CLAIM-LINE-RECORD-LT-CLT00003 |
| 2022-06-24 | CLT243/ IHS-SERVICE-IND | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCLT243|IHS-SERVICE-IND|X(1)|CLAIMLT|CLAIM-LINE-RECORD-LT-CLT00003 |
| 2022-06-24 | COMPOUND-DRUG-IND | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|CRX086|COMPOUND-DRUG-IND|Indicator to specify if the drug is compound or not. see Compound Drug Indicator List (VVL.038)|1.(LV) value must be in Compound Drug Indicator List (VVL)2.(S) value must be 1 character3.(N) conditional | DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|CRX086|COMPOUND-DRUG-IND Indicator to specify if the drug is compound or not.|1.(S) value must be 1 character2.(LV) value must be in [0, 1] or not populated3.(LV) value must be in Compound Drug Indicator List (VVL)4.(N) conditional |
| 2022-06-24 | COT051 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT051|TOT-COPAY-AMT | N/A |
| 2022-06-24 | COT051/ TOT-COPAY-AMT | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT051|TOT-COPAY-AMT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT067 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT067|NATIONAL-HEALTH-CARE-ENTITY-ID | N/A |
| 2022-06-24 | COT067/ NATIONAL-HEALTH-CARE-ENTITY-ID | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT067|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT119 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT119|REFERRING-PROV-TAXONOMY | N/A |
| 2022-06-24 | COT119/ REFERRING-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT119|REFERRING-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT120 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT120|REFERRING-PROV-TYPE | N/A |
| 2022-06-24 | COT120/ REFERRING-PROV-TYPE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT120|REFERRING-PROV-TYPE|X(2)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT121 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT121|REFERRING-PROV-SPECIALTY | N/A |
| 2022-06-24 | COT121/ REFERRING-PROV-SPECIALTY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT121|REFERRING-PROV-SPECIALTY|X(2)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT125 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT125|BMI | N/A |
| 2022-06-24 | COT125/ BMI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT125|BMI|S9(5)V9|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT130 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT130|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT130|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | COT130/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCOT130|BENEFICIARY-COINSURANCE-AMOUNT | DE No|Data Element NameCOT130|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
| 2022-06-24 | COT132 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT132|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT132|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | COT132/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCOT132|BENEFICIARY-COPAYMENT-AMOUNT | DE No|Data Element NameCOT132|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
| 2022-06-24 | COT134 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT134|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT134|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | COT134/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCOT134|BENEFICIARY-DEDUCTIBLE-AMOUNT | DE No|Data Element NameCOT134|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
| 2022-06-24 | COT137 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT137|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. | |DE NO| DATA ELEMENT NAME|DEFINITIONCOT137|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 2022-06-24 | COT138 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|COT138|HEALTH-HOME-ENTITY-NAME||1.Value must 50 characters or less2.Value must not contain a pipe or asterisk symbols3.Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|COT138|HEALTH-HOME-ENTITY-NAME||1.1.(IV) value must not contain a pipe or asterisk symbols2.(S) value must 50 characters or less3.(N) conditional |
| 2022-06-24 | COT144 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT144|DATE-CAPITATED-AMOUNT-REQUESTED | N/A |
| 2022-06-24 | COT144/ DATE-CAPITATED-AMOUNT-REQUESTED | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT144|DATE-CAPITATED-AMOUNT-REQUESTED|9(8)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT145 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT145|CAPITATED-PAYMENT-AMT-REQUESTED | N/A |
| 2022-06-24 | COT145/ CAPITATED-PAYMENT-AMT-REQUESTED | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT145|CAPITATED-PAYMENT-AMT-REQUESTED|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT148 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT148|UNDER-DIRECTION-OF-PROV-NPI | N/A |
| 2022-06-24 | COT148/ UNDER-DIRECTION-OF-PROV-NPI | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT148|UNDER-DIRECTION-OF-PROV-NPI|X(10)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT149 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT149|UNDER-DIRECTION-OF-PROV-TAXONOMY | N/A |
| 2022-06-24 | COT149/ UNDER-DIRECTION-OF-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT COT149|UNDER-DIRECTION-OF-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT151 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT151|UNDER-SUPERVISION-OF-PROV-TAXONOMY | N/A |
| 2022-06-24 | COT151/ UNDER-SUPERVISION-OF-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT151|UNDER-SUPERVISION-OF-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 | N/A |
| 2022-06-24 | COT176 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITIONCOT176|COPAY-AMT |Conditional|The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITIONCOT176|BENEFICIARY-COPAYMENT-PAID-AMOUNT |Optional|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. |
| 2022-06-24 | COT176/ BENEFICIARY-COPAYMENT-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCOT176|COPAY-AMT | DE No|Data Element NameCOT176|BENEFICIARY-COPAYMENT-PAID-AMOUNT |
| 2022-06-24 | COT183 | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | COT183 | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCOT183|OT-RX-CLAIM-QUANTITY-ACTUAL | DE No|Data Element NameCOT183|SERVICE-QUANTITY-ACTUAL |
| 2022-06-24 | COT183 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENTCOT183|OT-RX-CLAIM-QUANTITY-ACTUAL|The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span.|For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. The value in OT-RX-CLAIM-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units | |DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENTCOT183|SERVICE-QUANTITY-ACTUAL|The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line.| For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the SERVICE-QUANTITY-ACTUAL field.The value in SERVICE-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. |
| 2022-06-24 | COT184 | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | COT184 | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCOT184|OT-RX-CLAIM-QUANTITY-ACTUAL | DE No|Data Element NameCOT184|SERVICE-QUANTITY-ALLOWED |
| 2022-06-24 | COT184 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENTCOT184|OT-RX-CLAIM-QUANTITY-ALLOWED|The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.|For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units.The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. | |DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENTCOT184|SERVICE-QUANTITY-ALLOWED|The maximum allowable quantity of a service that may be rendered per date of service or per month.|For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units.The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. |
| 2022-06-24 | COT211/ XIX-MBESCBES-CATEGORY-OF-SERVICE | Data Dictionary - Record Layout | Modify DE Width | SIZEX(4) | SIZEX(5) |
| 2022-06-24 | COT220 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECOT220|HCPCS-RATE | N/A |
| 2022-06-24 | COT220/ HCPCS-RATE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT220|HCPCS-RATE|X(14)|CLAIMOT|CLAIM-LINE-RECORD-OT-COT00003 | N/A |
| 2022-06-24 | COT225/ NDC-QUANTITY | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | COT228 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT228|ORDERING-PROV-NUM|Conditional|The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies|Value must be 30 characters or less|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT228/ ORDERING-PROV-NUM | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT228|ORDERING-PROV-NUM|X(30)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT229 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT229|ORDERING-PROV-NPI-NUM|Conditional|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT229/ ORDERING-PROV-NPI-NUM | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT229|ORDERING-PROV-NPI-NUM|X(10)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT230 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT230|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|Conditional|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT230/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT230|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT231 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT231|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT231/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT231|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT232 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT232|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT232/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT232|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT233 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT233|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT233/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT233|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
| 2022-06-24 | COT234 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECOT234|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 characterValue must be in [0, 1] or not populated|CLAIMOT|CLAIM-LINE-RECORD-OT-COT00003 |
| 2022-06-24 | COT234/ IHS-SERVICE-IND | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCOT234|IHS-SERVICE-IND|X(1)|CLAIMOT|CLAIM-LINE-RECORD-OT-COT00003 |
| 2022-06-24 | COVERAGE-TYPE | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME DEFINITION||TPL058|COVERAGE-TYPE|This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary.see Policy Owner Code List (VVL.099)| | |DE NO| DATA ELEMENT NAME|DEFINITION||TPL058|COVERAGE-TYPE |Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier.| |
| 2022-06-24 | CRX042 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECRX042|TOT-COPAY-AMT | N/A |
| 2022-06-24 | CRX042/ TOT-COPAY-AMT | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX042|TOT-COPAY-AMT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 | N/A |
| 2022-06-24 | CRX057 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECRX057|NATIONAL-HEALTH-CARE-ENTITY-ID | N/A |
| 2022-06-24 | CRX057/ NATIONAL-HEALTH-CARE-ENTITY-ID | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX057|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 | N/A |
| 2022-06-24 | CRX076 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECRX076|PRESCRIBING-PROV-TAXONOMY | N/A |
| 2022-06-24 | CRX076/ PRESCRIBING-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX076|PRESCRIBING-PROV-TAXONOMY|X(12)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 | N/A |
| 2022-06-24 | CRX077 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECRX077|PRESCRIBING-PROV-TYPE | N/A |
| 2022-06-24 | CRX077/ PRESCRIBING-PROV-TYPE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX077|PRESCRIBING-PROV-TYPE|X(2)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 | N/A |
| 2022-06-24 | CRX078 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECRX078|PRESCRIBING-PROV-SPECIALTY | N/A |
| 2022-06-24 | CRX078/ PRESCRIBING-PROV-SPECIALTY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX078|PRESCRIBING-PROV-SPECIALTY|X(2)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 | N/A |
| 2022-06-24 | CRX087 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX087|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX087|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CRX087/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX087|BENEFICIARY-COINSURANCE-AMOUNT | DE No|Data Element NameCRX087|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
| 2022-06-24 | CRX089 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX089|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX089|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CRX089/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX089|BENEFICIARY-COPAYMENT-AMOUNT | DE No|Data Element NameCRX089|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
| 2022-06-24 | CRX092 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX092|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX092|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2022-06-24 | CRX092/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX092|BENEFICIARY-DEDUCTIBLE-AMOUNT | DE No|Data Element NameCRX092|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
| 2022-06-24 | CRX095 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX095|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. | |DE NO| DATA ELEMENT NAME|DEFINITIONCRX095|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 2022-06-24 | CRX096 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CRX.096|HEALTH-HOME-ENTITY-NAME||1.(GS) value must satisfy the requirements of Health Home Entity Name (CE) | DE No|Data Element Name|Definition| CODING REQUIREMENT|CRX.096|HEALTH-HOME-ENTITY-NAME||1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)2.(S) value must 50 characters or less3.(N) conditional |
| 2022-06-24 | CRX103 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMECRX103|DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | N/A |
| 2022-06-24 | CRX103/ DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX103|DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-RX-CRX00002 | N/A |
| 2022-06-24 | CRX123 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITIONCRX123|COPAY-AMT |Conditional|The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITIONCRX123|BENEFICIARY-COPAYMENT-PAID-AMOUNT|Optional|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. |
| 2022-06-24 | CRX123/ BENEFICIARY-COPAYMENT-PAID-AMOUNT | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX123|COPAY-AMT | DE No|Data Element NameCRX123|BENEFICIARY-COPAYMENT-PAID-AMOUNT |
| 2022-06-24 | CRX131 | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | CRX131 | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX131|OT-RX-CLAIM-QUANITY-ALLOWED | DE No|Data Element NameCRX131|PRESCRIPTION-QUANTITY-ALLOWED |
| 2022-06-24 | CRX131 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENTCRX131|OT-RX-CLAIM-QUANITY-ALLOWED||The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.|NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100. | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENTCRX131|PRESCRIPTION-QUANTITY-ALLOWED||The maximum allowable quantity of a drug that may be dispensed per prescription per date of service. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.|NOTE: One prescription for 100 250 milligram tablets results in PRESCRIPTION-QUANTITY-ALLOWED =100. |
| 2022-06-24 | CRX131 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCRX131|OT-RX-CLAIM-QUANITY-ALLOWED|The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. | |DE NO| DATA ELEMENT NAME|CODING REQUIREMENTCRX131|PRESCRIPTION-QUANTITY-ALLOWED|The value in PRESCRIPTION-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. |
| 2022-06-24 | CRX132 | Data Dictionary - Record Layout | Modify DE Width | SIZES9(6)V999 | SIZES9(8)V999 |
| 2022-06-24 | CRX132 | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX132|OT-RX-CLAIM-QUANTITY-ACTUAL | DE No|Data Element NameCRX132|PRESCRIPTION-QUANTITY-ACTUAL |
| 2022-06-24 | CRX132 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENTCRX132|OT-RX-CLAIM-QUANTITY-ACTUAL||The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span.|The value in OT-RX-CLAIM-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE. | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENTCRX132|PRESCRIPTION-QUANTITY-ACTUAL||The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line.|The value in PRESCRIPTION-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE. |
| 2022-06-24 | CRX141 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITIONCRX141|DISPENSE-FEE||The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription. | |DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITIONCRX141|DISPENSE-FEE-SUBMITTED ||The charge to cover the cost of the professional dispensing fee for the prescription. |
| 2022-06-24 | CRX141/ DISPENSE-FEE-SUBMITTED | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameCRX141|DISPENSE-FEE | DE No|Data Element NameCRX141|DISPENSE-FEE-SUBMITTED |
| 2022-06-24 | CRX150/ XIX-MBESCBES-CATEGORY-OF-SERVICE | Data Dictionary - Record Layout | Modify DE Width | SIZEX(4) | SIZEX(5) |
| 2022-06-24 | CRX162 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX162|PRESCRIPTION-ORIGIN-CODE|Conditional|How the prescription was sent to the pharmacy.|Value must be one digitValue must be 1:4|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX162/ PRESCRIPTION-ORIGIN-CODE | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX162|PRESCRIPTION-ORIGIN-CODE|X(1)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX163 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX163|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|Conditional|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX163/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX163|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX164 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX164|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX164/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX164|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX165 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX165|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX165/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX165|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX166 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX166|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX166/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX166|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
| 2022-06-24 | CRX167 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX167|INGREDIENT-COST-SUBMITTED |Conditional|The charge to cover the cost of ingredients for the prescription or drug.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX167/ INGREDIENT-COST-SUBMITTED | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX167|INGREDIENT-COST-SUBMITTED|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX168 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX168|INGREDIENT-COST-PAID-AMT |Conditional|The amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level towards the cost of ingredients for the prescription or drug.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX168/ INGREDIENT-COST-PAID-AMT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX168|INGREDIENT-COST-PAID-AMT|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX169 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX169|DISPENSE-FEE-PAID-AMT|Conditional|The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the cost of the pharmacy's professional dispensing fee for the prescription.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 |CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX169/ DISPENSE-FEE-PAID-AMT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX169|DISPENSE-FEE-PAID-AMT|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX170 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX170|PROFESSIONAL-SERVICE-FEE-SUBMITTED|Conditional|The charge to cover the clinical services, not otherwise covered under the professional dispensing fee. (Example "not filling a prescription because of therapeutic duplication")|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX170/ PROFESSIONAL-SERVICE-FEE-SUBMITTED | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX170|PROFESSIONAL-SERVICE-FEE-SUBMITTED|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX171 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX171|PROFESSIONAL-SERVICE-FEE-PAID-AMT|Conditional|The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the costs of clinical services not otherwise covered under the professional dispensing fee.|Value must be between -99999999999.99 and 99999999999.99Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX171/ PROFESSIONAL-SERVICE-FEE-PAID-AMT | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX171|PROFESSIONAL-SERVICE-FEE-PAID-AMT|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX172 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMECRX172|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 characterValue must be in [0, 1] or not populated|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | CRX172/ IHS-SERVICE-IND | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTCRX172|IHS-SERVICE-IND|X(1)|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
| 2022-06-24 | DATE-OF-BIRTH | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|PRV034|DATE-OF-BIRTH|An individual's date of birth.|1.Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. (FD1) value must be less than or equal to associated End of Time Period (PRV.001.010)4. (FD1) value must be less than or equal to associated Date File Created (PRV.001.008)5. (N) conditional6. (FDN) the difference between current value and Start of Time Period (PRV.001.009) must be between 18 and 85 years| | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|PRV034|DATE-OF-BIRTH|An individual's date of birth.|1.Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3.(FD1) value must be less than or equal to associated End of Time Period (PRV.001.010)4.(N) conditional5.(FDN) the difference between current value and Start of Time Period (PRV.001.009) must be between 18 and 85 years| |
| 2022-06-24 | DATE-OF-BIRTH | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CLT126|DATE-OF-BIRTH| An individual's date of birth.|1.Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3.(N) mandatory4.(FD) value must equal Date of Birth (ELG.002.024) when Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087)does not equal '64'| | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CLT126|DATE-OF-BIRTH| An individual's date of birth.|Description: An individual's date of birth.1.Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3.(N) mandatory| |
| 2022-06-24 | DESTINATION-STATE | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|COT207|DESTINATION-STATE |The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa.|1.(GS) value must satisfy the requirements of Address State (CE)2.(FD1) (transportation claim) value is mandatory and must be provided for all transportation claims3.(N) conditional| | DE No|Data Element Name|Definition| CODING REQUIREMENT|COT207|DESTINATION-STATE|The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa.|1.(GS) value must satisfy the requirements of Address State (CE)| |
| 2022-06-24 | DESTINATION-ZIP-CODE | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION||COT208|DESTINATION-ZIP-CODE|Description: U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)| | |DE NO| DATA ELEMENT NAME| DEFINITION||COT208|DESTINATION-ZIP-CODE|The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.| |
| 2022-06-24 | DIAGNOSIS-RELATED-GROUP-IND | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP069|DIAGNOSIS-RELATED-GROUP-IND|An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values.| | |DE No|Data Element Name|Definition||CIP069|DIAGNOSIS-RELATED-GROUP-IND|An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values.Values are generated by combining two types of information:Position 1-2, State/Group generating DRG:If state specific system, fill with two digit US postal code representation for state.If CMS Grouper, fill with 'HG'.If any other system, fill with 'XX'.Position 3-4, fill with the number that represents the DRG version used (01-98).For example, 'HG15" wouldrepresent CMS Grouper version 15. If version is unknown, fill with '99".| |
| 2022-06-24 | DISABILITY-TYPE-CODE | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG224 |DISABILITY-TYPE-CODE |Obsolete |1.(LV) value must be in Disability Type Code List (VVL)2.(S) value must be 2 characters3.(N) conditional | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG224 |DISABILITY-TYPE-CODE |A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act.|1.(LV) value must be in Disability Type Code List (VVL)2.(S) value must be 2 characters3.(N) mandatory |
| 2022-06-24 | DISPENSE-FEE | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CRX141|DISPENSE-FEE|The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription.Dispense Fee reflects the amount billed by the provider towards the professional dispensing fee.If the provider does not break out the professional dispensingfee on the NCPDP transaction, this field should be left blank in T-MSIS.There is currently no specific field in T-MSIS to capture either the professionaldispensing fee amount paid, or the amount billed or paid towards ingredient costs.|1.(S) value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.7892.(N) mandatory | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CRX141|DISPENSE-FEE|The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription.Dispense Fee reflects the amount billed by the provider towards the professional dispensing fee.If the provider does not break out the professional dispensingfee on the NCPDP transaction, this field should be left blank in T-MSIS.1.(LVR) value must be between -99999999999.99 and 99999999999.992.(S) value must be expressed as a number with 2-digit precision (e.g. 100.50 )3.(S) value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.784.(N) mandatory |
| 2022-06-24 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CRX102|DISPENSING-PRESCRIPTION-DRUG-PROV-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CRX102|DISPENSING-PRESCRIPTION-DRUG-PROV-NPI|The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug.| |
| 2022-06-24 | DRG-DESCRIPTION | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP029|DRG-DESCRIPTION|Description of the associated state-specific DRG code. If using standard MS-DRG classification system, a DRG Description is not required.| | |DE No|Data Element Name|Definition||CIP029|DRG-DESCRIPTION|Description of the associated state-specific DRG code. If using standard MS-DRG classification system, leave blank.| |
| 2022-06-24 | DRG-OUTLIER-AMT | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition| CODING REQUIREMENTCIP194 |DRG-OUTLIER-AMT|The additional payment on a claim that is associated with either a cost outlier or length of stay outlier.Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category. |1.(GS) value must satisfy the requirements of US Dollar Amount (DT)2.(N) conditional3.(FD1) value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' | |DE No|Data Element Name|Definition| CODING REQUIREMENTCIP194 |DRG-OUTLIER-AMT|The additional payment on a claim that is associated with either a cost outlier or length of stay outlier.Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category |1.(GS) value must satisfy the requirements of US Dollar Amount (DT)2.(FD1) value must not be populated, if Outlier Code (CIP.002.197) equals '00' or '09'3.(N) conditional |
| 2022-06-24 | DRG-REL-WEIGHT | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP195|DRG Relative Weight |The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annuallyin the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average.| | |DE No|Data Element Name|Definition||CIP195|DRG Relative Weight|The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000was half the average. This data element in T-MSIS is expected to capture the relative weight of the DRG in the state's system regardless of which DRG system the state uses.| |
| 2022-06-24 | DRUG-UTILIZATION-CODE | Data Dictionary | UPDATE | DE No|Data Element Name|CODING REQUIREMENT|CRX143|DRUG-UTILIZATION-CODE|1.(S) value must be 6 characters or less2.(S) characters 1 and 2 (2-character string) may be in Drug Utilization Result of Service Code List (VVL), or spaces in cases where code is unused or not available3.(S) characters 3 and 4 (2-character string) may be in Drug Utilization Professional Service Code List (VVL), or spaces in cases where code is unused or not available4.(S) characters 5 and 6 (2-character string) may be in Drug Utilization Reason For Service Code List (VVL), or not populated in cases where code is unused or not available5.(N) mandatory| | DE No|Data Element Name|CODING REQUIREMENT|CRX143|DRUG-UTILIZATION-CODE|1.(S) value must be 6 characters or less2.(S) characters 1 and 2 (2-character string) must be in Drug Utilization Reason of Service Code List (VVL)3.(S) characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL)4.(S) characters 5 and 6 (2-character string) must be in Drug Utilization Result For Service Code List (VVL)5.(N) mandatory| |
| 2022-06-24 | ELG-IDENTIFIER-ISSUING-ENTITY-ID | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG262|ELG-IDENTIFIER-ISSUING-ENTITY-ID|This data element is reserved for future use.|1.(S) value must be 18 characters or less2.(N) optional| | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG262|ELG-IDENTIFIER-ISSUING-ENTITY-ID|This data element is reserved for future use|1.(S) value must be 18 characters or less| |
| 2022-06-24 | ELG045 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMEELG045|PRIMARY-LANGUAGE-ENGL-PROF-CODE | |DE NO| DATA ELEMENT NAMEELG045|ENGL-PROF-CODE |
| 2022-06-24 | ELG045/ ENGL-PROF-CODE | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameELG045|PRIMARY-LANGUAGE-ENGL-PROF-CODE | DE No|Data Element NameELG045|ENGL-PROF-CODE |
| 2022-06-24 | ELG065 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|ELG065|ADDR-TYPE | DE NO| DATA ELEMENT NAME COMPUTING|ELG065|ELIGIBLE-ADDR-TYPE |
| 2022-06-24 | ELG095 | Data Dictionary | UPDATE | DE No|Segment Name|DE Name|DefinitionELG095|ELIGIBILITY-DETERMINANTS-ELG00005|ELIGIBILITY-CHANGE-REASON|The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status. | DE No|Segment Name|DE Name|DefinitionELG095|ELIGIBILITY-DETERMINANTS-ELG00005|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. |
| 2022-06-24 | ELG108 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG108|HEALTH-HOME-ENTITY-NAME|A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|1.(S) value must 100 characters or less2.(IV) value must not contain a pipe symbol3.(N) mandatory| | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG108|HEALTH-HOME-ENTITY-NAME|A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)2.(S) value must 100 characters or less3.(N) mandatory| |
| 2022-06-24 | ELG119 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG119|HEALTH-HOME-ENTITY-NAME| A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|1.(S) value must 100 characters or less2.(IV) value must not contain a pipe symbol3.(N) mandatory | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG119|HEALTH-HOME-ENTITY-NAME|A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)2.(S) value must 100 characters or less3.(N) mandatory |
| 2022-06-24 | ELG194 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMEELG194|NATIONAL-HEALTH-CARE-ENTITY-ID | N/A |
| 2022-06-24 | ELG194/ NATIONAL-HEALTH-CARE-ENTITY-ID | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTELG194|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|ELIGIBLE|MANAGED-CARE-PARTICIPATION-ELG00014 | N/A |
| 2022-06-24 | ELG195 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMEELG195|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | N/A |
| 2022-06-24 | ELG195/ NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTELG195|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE|X(1)|ELIGIBLE|MANAGED-CARE-PARTICIPATION-ELG00014 | N/A |
| 2022-06-24 | ELG215 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMEELG215|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR | |DE NO| DATA ELEMENT NAMEELG215|AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR |
| 2022-06-24 | ELG215/AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR | Data Dictionary - Record Layout | Rename DE | DE No|Data Element NameELG215|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR | DE No|Data Element NameELG215|AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR |
| 2022-06-24 | ELG269 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMEELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE |Conditional|The beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group.|(LVR) value must be between 0 and 400 inclusively|ELIGIBLE|VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 2022-06-24 | ELG269/ ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|9(3)|ELIGIBLE|VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
| 2022-06-24 | ELG270 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMEELG270|LOCKED-IN-SRVCS|Conditional|The type(s) of service that are locked-in|Value must be 3 characters|ELIGIBLE|LOCK-IN-INFORMATION-ELG00009 |
| 2022-06-24 | ELG270/ LOCKED-IN-SRVCS | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTELG270|LOCKED-IN-SRVCS |X(3)|ELIGIBLE|LOCK-IN-INFORMATION-ELG00009 |
| 2022-06-24 | ELG271 | Data Dictionary | ADD | N/A | |DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAMEELG271|ETHNICITY-OTHER|Conditional|A freeform field to document the ethnicity of the beneficiary when the beneficiary identifies themselves as Another Hispanic, Latino, or Spanish origin (ethnicity code 4)|If associated Ethnicity-Code (ELG.015.204) value is in [ "4"], then value must be populated.|ELIGIBLE|ETHNICITY-INFORMATION-ELG00015 |
| 2022-06-24 | ELG271/ ETHNICITY-OTHER | Data Dictionary - Record Layout | ADD DE | N/A | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTELG271|ETHNICITY-OTHER |X(25)|ELIGIBLE|ETHNICITY-INFORMATION-ELG00015 |
| 2022-06-24 | HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||ELG131|HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION|A free-text field to capture the description of the other chronic condition (or conditions) when value 'H' (Other) appears in the HEALTH-HOME-CHRONIC-CONDITION.| | |DE No|Data Element Name|Definition||ELG131|HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION|A free-text field to capture the description of the other chronic condition (or conditions) when value “H” (Other) appears in the Health Home Chronic Condition data element.| |
| 2022-06-24 | HEALTH-HOME-ENTITY-EFF-DATE | Data Dictionary | UPDATE | DE No|Data Element Name|Definition|CODING REQUIREMENT|ELG111|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|1.(GS) value must satisfy the requirements of Date (DT) | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG111|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|1.(GS) value must satisfy the requirements of Health Home Entity Effective Date (CE) |
| 2022-06-24 | HEALTH-HOME-ENTITY-EFF-DATE | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG123|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|1.Value must be 8 characters in the form "CCYYMMDD"2.(LV) the date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)2.(N) mandatory | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG123|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|1.(S) value must be 8 characters in the form 'YYYYMMDD'2.(LV) the date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3.(N) mandatory |
| 2022-06-24 | HEALTH-HOME-PROVIDER-NPI | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP221|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).||CLT167|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).||COT146|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).||CRX104|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CIP221|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.||CLT167|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.||COT146|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.||CRX104|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.| |
| 2022-06-24 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG044|IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE||1.(GS) value must satisfy the requirements of End Date (CE)2.(FD1) (U.S. Citizen) if associated Citizenship Indicator (ELG.003.040) value is '1', then value should not be populated3.(FD1) (Non U.S. Citizen) if associated Citizenship Indicator (ELG.003.040) value is '0', then value should be populated4.(N) conditional5.(FD1) (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG044|IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE||1.(GS) value must satisfy the requirements of Date (CE)2.(N) conditional3.(FD1) (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' |
| 2022-06-24 | IP-LT-QUANTITY-OF-SERVICE-ALLOWED | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition|CIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED|On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/servicebeing reported was performed.| | |DE No|Data Element Name|Definition|CIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED| On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/servicebeing reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled.| |
| 2022-06-24 | LEVEL-OF-CARE-STATUS | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG088|LEVEL-OF-CARE-STATUS||1. Value must be in Level of Care Status List (VVL)2. Value must be 3 characters3. Conditional | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG088|LEVEL-OF-CARE-STATUS||1. Value must be in Level of Care Status List (VVL)2. Value must be 3 characters3. Mandatory |
| 2022-06-24 | LICENSE-OR-ACCREDITATION-NUMBER | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||PRV069|LICENSE-OR-ACCREDITATION-NUMBER|A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the LICENSE-ISSUING-ENTITY-ID data element.| | |DE No|Data Element Name|Definition||PRV069|LICENSE-OR-ACCREDITATION-NUMBER|A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the License Issuing Entity ID data element.| |
| 2022-06-24 | LICENSE-TYPE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||PRV067|LICENSE-TYPE|A code to identify the kind of license or accreditation number that is captured in the LICENSE-OR-ACCREDITATION-NUMBER data element.| | |DE No|Data Element Name|Definition||PRV067|LICENSE-TYPE|A code to identify the kind of license or accreditation number that is captured in the License or Accreditation Number data element.| |
| 2022-06-24 | LOCKIN-PROV-NUM | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG140|LOCKIN-PROV-NUM| The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers,practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System.|1.Value must be 30 characters or less2.Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'3.(N) mandatory4.(DI) value must match Provider Identifier (PRV.005.081) | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG140|LOCKIN-PROV-NUM|The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers,practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System.|1.Value must be 30 characters or less2.(N) mandatory |
| 2022-06-24 | LOCKIN-PROV-TYPE | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG141|LOCKIN-PROV-TYPE||1.(LV) value must be in Lockin Provider Type List (VVL)2.Value must be 2 characters3.Mandatory | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG141|LOCKIN-PROV-TYPE||1.(LV) value must be in Provider Type Code List (VVL)2.Value must be 2 characters3.Mandatory |
| 2022-06-24 | LTSS-LEVEL-CARE | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG182|LTSS-LEVEL-CARE||1.(LV) value must be in LTSS Level Care List (VVL)| | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG182|LTSS-LEVEL-CARE||1.(LV) value must be in LTSS Level of Care List (VVL)| |
| 2022-06-24 | LTSS-PROV-NUM | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG183|LTSS-PROV-NUM|A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual.|1.Value must be 30 characters or less2. Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'3.(N) mandatory4.(DI) value must match Provider Identifier (PRV.005.081)| | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG183|LTSS-PROV-NUM|A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual.|1.Value must be 30 characters or less2.(N) mandatory| |
| 2022-06-24 | MARITAL-STATUS-OTHER-EXPLANATION | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG035|MARITAL-STATUS-OTHER-EXPLANATION||1.(FD1) if associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided2.(S) value must be 50 characters or less3.(N) conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG035|MARITAL-STATUS-OTHER-EXPLANATION||1.(FD1) if associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided2.(S) value must be 50 characters or less3.(IV) value must not contain a pipe or asterisk symbol4.(N) conditional |
| 2022-06-24 | MCR091/ RECORD-ID, MCR092/ SUBMITTING-STATE, MCR093/ RECORD-NUMBER, MCR094/ STATE-PLAN-ID-NUM, MCR095/ NATIONAL-HEALTH-CARE-ENTITY-ID, MCR096/ NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE, MCR097/ NATIONAL-HEALTH-CARE-ENTITY-NAME, MCR098/ NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE, MCR099/ NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE, MCR0100/ STATE-NOTATION, MCR0101/ FILLER | Data Dictionary - Record Layout | Deprecate Segment | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTMCR091|RECORD-ID|X(8)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR092|SUBMITTING-STATE|X(2)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR093|RECORD-NUMBER|9(11)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR094|STATE-PLAN-ID-NUM|X(12)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR095|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR096|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE|X(1)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR097|NATIONAL-HEALTH-CARE-ENTITY-NAME|X(50)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR098|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE|9(8)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR099|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE|9(8)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR0100|STATE-NOTATION|X(500)|MNGDCARE |NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008MCR0101|FILLER|X(390)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 | N/A |
| 2022-06-24 | MCR102/ RECORD-ID, MCR103/ SUBMITTING-STATE, MCR104/ RECORD-NUMBER, MCR105/ STATE-PLAN-ID-NUM, MCR106/ CHPID, MCR107/ SHPID, MCR108/ CHPID-SHPID-RELATIONSHIP-EFF-DATE, MCR109/ CHPID-SHPID-RELATIONSHIP-END-DATE, MCR110/ STATE-NOTATION, MCR111/ FILLER | Data Dictionary - Record Layout | Deprecate Segment | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTMCR102|RECORD-ID|X(8)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009MCR103|SUBMITTING-STATE|X(2)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009MCR104|RECORD-NUMBER|9(11)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009MCR105|STATE-PLAN-ID-NUM|X(12)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009MCR106|CHPID|X(8)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009MCR107|SHPID|X(10)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009MCR108|CHPID-SHPID-RELATIONSHIP-EFF-DATE|9(8)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009MCR109|CHPID-SHPID-RELATIONSHIP-END-DATE|9(8)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009MCR110|STATE-NOTATION|X(500)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009MCR111|FILLER|X(431)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009 | N/A |
| 2022-06-24 | MEDICARE-COINS-AMT | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|CRX128|MEDICARE-COINS-AMT|The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the MEDICARE-DEDUCTIBLE-AMT. See US Dollar Amount (DT)|1.Value must be between -99999999999.99 and 99999999999.992.Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3.(payments can't be separated) value 99998 is an exception to the US Dollar Amount requirements4.(N) conditional | DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|CRX128|MEDICARE-COINS-AMT|The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the Medicare Deductible Amount.|1. Value must be between -99999999999.99 and 99999999999.992. if associated Medicare Combined Deductible Indicator is '1', then value must not be populated (or must be 99998)3. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )4. Value must not be populated if Medicare Deductible Amount is not populated5. Conditional |
| 2022-06-24 | MEDICARE-DEDUCTIBLE-AMT | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CRX127|MEDICARE-DEDUCTIBLE-AMT| The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductibleamount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance anddeductible paymentscannot be separated, fill this field with the combined payment amount and MEDICARE-COINSURANCE-PAYMENT is not required.|1.(GS) value must satisfy the requirements of US Dollar Amount (DT)2.(N) conditionalThe amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductible amount can beidentified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this fieldwith thecombined payment amount and MEDICARE-COINSURANCE-PAYMENT is not required. see US Dollar Amount (TMSIS.DT.000.008) | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|CRX127|MEDICARE-DEDUCTIBLE-AMT|The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare deductibleamount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible paymentscannot be separated, fill this field with thecombined payment amount and Medicare Coinsurance Payment is not required.|1.(GS) value must satisfy the requirements of US Dollar Amount (DT)2.(N) conditional3.(FD1) value should not be populated if associated Crossover Indicator value |
| 2022-06-24 | MFP-QUALIFIED-RESIDENCE | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|ELG152|MFP-QUALIFIED-RESIDENCE|A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant.| | DE No|Data Element Name|Definition|CODING REQUIREMENT|ELG152|MFP-QUALIFIED-RESIDENCE|A code indicating the type of qualified residence.| |
| 2022-06-24 | MFP-REASON-PARTICIPATION-ENDED | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG153|MFP-REASON-PARTICIPATION-ENDED| A code describing why an individual's participation in Money Follows the Person demonstration ended.|1. (LV) value must be in MFP Reason Participation Ended List (VVL)2.(S) value must be 2 characters3.(N) conditional4.(FD1) value must not be populated when Enrollment End Date equals '9999-12-31' | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG153|MFP-REASON-PARTICIPATION-ENDED| A code describing why an individual's participation in Money Follows the Person demonstration ended.1. (LV) value must be in MFP Reason Participation Ended List (VVL)2.(S) value must be 2 characters3.(N) conditional4.(FD1) value must not be populated when Enrollment End Date equals '9999-12-31'5.(FD1) value must be populated when Enrollment End Date does not equal '9999-12-31' |
| 2022-06-24 | N/A | Data Dictionary | UPDATE | ELG00005.R.4 (FD2) an eligibility determinant segment (ELIGIBILITY-DETERMINANTS - ELG00005) with Primary Eligibility Group Indicator = 1 must exist for each timespan for which a person is eligible for Medicaid or CHIP. | ELG00005.R.4 (FD2) an eligibility determinant segment (ELG005) with Primary Eligibility Group Indicator = “1” must exist for each timespan for which a person is eligible for Medicaid or CHIP. |
| 2022-06-24 | NON-COV-DAYS | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP134|NON-COV-DAYS|The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covereddays does not refer to days not covered for any other service.1.Value must be a positive integer2.Value must be between 0:99999999999 (inclusive)3.Conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP134|NON-COV-DAYS|The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covereddays does not refer to days not covered for any other service.1. (S) value must be 5 digits or less2.(N) conditional |
| 2022-06-24 | NON-COV-DAYS | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CLT084|NON-COV-DAYS||1.(GS) value must satisfy the requirements of Non-Covered Days (CE)2.(S) value must be 5 digits or less | DE No|Data Element Name|Definition| CODING REQUIREMENT|CLT084|NON-COV-DAYS||1.(GS) value must satisfy the requirements of Non-Covered Days (CE) |
| 2022-06-24 | OPERATING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP265|OPERATING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CIP265|OPERATING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary.| |
| 2022-06-24 | ORIGINATION-ADDR-LN2 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAME| DEFINITION||COT200|ORIGINATION-ADDR-LN2|The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.| | |DE NO| DATA ELEMENT NAME| DEFINITION||COT200|ORIGINATION-ADDR-LN2|The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.| |
| 2022-06-24 | ORIGINATION-STATE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition| CODING REQUIREMENT||COT202|ORIGINATION-STATE|The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a healthcare provider to a health care provider for healthcare services or vice versa.|1.Value must be in State Code List (VVL)2. Value must be 2 characters3. conditional4. (transportation claim) value is mandatory and must be provided for all transportation claims| | |DE No|Data Element Name|Definition| CODING REQUIREMENT||COT202|ORIGINATION-STATE|The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a health care provider to a health care provider for healthcare services or vice versa.|1.Value must be in State Code List (VVL)2. Value must be 2 characters3.(N) conditional| |
| 2022-06-24 | OUTLIER-CODE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition| CODING REQUIREMENT||CIP197|OUTLIER-CODE| This code indicates the Type of Outlier Code or DRG Source. The field identifies two mutually exclusive conditions. The first, for PPS providers(codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), denotes thesource for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code1.(LV) value must be in Outlier Code List (VVL)2.(FD1) (Day Outlier) If Outlier Code is 01, then Outlier Days (CIP.002.198) must be populated.3.(S) value must be 2 characters4.(N) conditional5.(FD1) if value equals '00' or '09', then DRG Outlier Amount (CIP.002.194) must not be populated| | |DE No|Data Element Name|Definition| CODING REQUIREMENT||CIP197|OUTLIER-CODE| This code indicates the Type of Outlier Code or DRG Source. The field identifies two mutually exclusive conditions. The first, for PPS providers (codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), denotes thesource for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code1.(LV) value must be in Outlier Code List (VVL)2.(S) value must be 2 characters3.(FD1) value is mandatory if either DRG Outlier Amount (CIP.002.194) or Outlier Days (CIP.002.198) are populated4.(N) conditional| |
| 2022-06-24 | POLICY-OWNER-FIRST-NAME | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|TPL044|POLICY-OWNER-FIRST-NAME|Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name).|1.Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3.(FD1) if TPL Health Insurance Coverage Indicator (TPL.002.020) equals "1", then value is mandatory| | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|TPL044|POLICY-OWNER-FIRST-NAME|Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name).|1.Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3.(N) Mandatory| |
| 2022-06-24 | POLICY-OWNER-LAST-NAME | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|TPL045|POLICY-OWNER-LAST-NAME|Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name).1.Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3.(N) Mandatory | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|TPL045|POLICY-OWNER-LAST-NAME|Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name).1.Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3.(FD1) if TPL Health Insurance Coverage Indicator (TPL.002.020) equals "1", then value is mandatory |
| 2022-06-24 | PRESCRIBING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CRX075|PRESCRIBING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CRX075|PRESCRIBING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who prescribed a medication to a patient.| |
| 2022-06-24 | PRIMARY-LANGUAGE-ENGL-PROF-CODE | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG045|PRIMARY-LANGUAGE-ENGL-PROF-CODE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG045|ENGL-PROF-CODE |
| 2022-06-24 | PROCEDURE-CODE-1 | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP070|PROCEDURE-CODE-1||1.When populated, there must be a corresponding Procedure Code Flag2.If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6.(N) conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|CIP070|PROCEDURE-CODE-1||1.(FD1) when populated, there must be a corresponding Procedure Code Flag2.(FD2) if associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3.(FD2) if associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4.(FDN)if associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specificprocedure code list, and value must be a valid State-specific procedure code5.(S) value must be 8 characters or less6.(LV) value must be in Procedure Code List (VVL)7.(N) conditional |
| 2022-06-24 | PROV-IDENTIFIER | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||PRV081|PROV-IDENTIFIER|A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is defined in the corresponding value in the PROVIDER-IDENTIFIER-TYPE data element.| | |DE No|Data Element Name|Definition||PRV081|PROV-IDENTIFIER|A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is defined in the corresponding value in the Provider Identifier Type data element.| |
| 2022-06-24 | PROV-IDENTIFIER-ISSUING-ENTITY-ID | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||PRV078|PROV-IDENTIFIER-ISSUING-ENTITY-ID|A free text field to capture the identity of the entity that issued the provider identifier in the PROV-IDENTIFIER data element. For (State Tax ID), if associated Provider Identifier Type (DE) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (DE) value is equal to 8, thenvalue must be the name of the entity that issued the identifier.| | |DE No|Data Element Name|Definition||PRV078|PROV-IDENTIFIER-ISSUING-ENTITY-ID| A free text field to capture the identity of the entity that issued the provider identifier in the Provider Identifier (PRV.005.081) data element. For (State Tax ID), if associated Provider Identifier Type (PRV.005.077) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (PRV.005.077) value is equal to 8, then value must be the name of the entity that issued the identifier.| |
| 2022-06-24 | PROV-LOCATION-ID | Data Dictionary | UPDATE | DE No|Data Element Name| CODING REQUIREMENT|PRV043|PROV-LOCATION-ID|1.(IV) value must not contain a pipe symbol2.(S) value must be 5 characters or less | DE No|Data Element Name| CODING REQUIREMENT|PRV043|PROV-LOCATION-ID|1. (IV) value must not contain a pipe or asterisk symbols2. (S) value must be 5 characters or less3. (N) mandatory |
| 2022-06-24 | PROV-LOCATION-ID | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV064|PROV-LOCATION-ID||1.(IV) value must not contain a pipe symbol2.(S) value must be 5 characters or less | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV064|PROV-LOCATION-ID||1. (IV) value must not contain a pipe or asterisk symbols2. (S) value must be 5 characters or less3. (N) mandatory |
| 2022-06-24 | PROV-LOCATION-ID | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV.076|PROV-LOCATION-ID||1.(IV) value must not contain a pipe symbol2.(S) value must be 5 characters or less | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV.076|PROV-LOCATION-ID||1. (IV) value must not contain a pipe or asterisk symbols2. (S) value must be 5 characters or less3. (N) mandatory |
| 2022-06-24 | PROV-LOCATION-ID | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV129|PROV-LOCATION-ID||1.(IV) value must not contain a pipe symbol2.(S) value must be 5 characters or less | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV129|PROV-LOCATION-ID||1. (IV) value must not contain a pipe or asterisk symbols2. (S) value must be 5 characters or less3. (N) mandatory |
| 2022-06-24 | PRV046 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|PRV046|ADDR-TYPE | DE NO| DATA ELEMENT NAME COMPUTING|PRV046|PROV-ADDR-TYPE |
| 2022-06-24 | PRV081/ PROV-IDENTIFIER | Data Dictionary - Record Layout | Modify DE Width | SIZEX(12) | SIZEX(30) |
| 2022-06-24 | PRV110/ SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY | Data Dictionary - Record Layout | Modify DE Width | SIZEX(12) | SIZEX(30) |
| 2022-06-24 | REASON-FOR-CHANGE | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||ELG266|REASON-FOR-CHANGE|A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for ELG-IDENTIFIER-TYPE '2-OldMSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID' or 'Unmerge'.| | |DE No|Data Element Name|Definition||ELG266|REASON-FOR-CHANGE|A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligibile Identifier Type = '2-Old MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID' or 'Unmerge'.| |
| 2022-06-24 | REFERRING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP190|REFERRING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).||CLT136|REFERRING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).||COT118|REFERRING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CIP190|REFERRING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.||CLT136|REFERRING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.||COT118|REFERRING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.| |
| 2022-06-24 | SERVICING-PROV-NPI-NUM | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CLT213|SERVICING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).||COT190|SERVICING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| | |DE No|Data Element Name|Definition||CLT213|SERVICING-PROV-NPI-NUM|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.||COT190|SERVICING-PROV-NPI-NUM|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.| |
| 2022-06-24 | SSI-IND | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENTELG090|SSI-IND| A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).| 1.(LV) value must be in SSI Indicator List (VVL)2.(S) value must be 1 character3.(N) conditional4.(FD1) value must equal '0' when SSI Status equals '003' or is not populated| | DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENTELG090|SSI-IND| A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).|1.(GS) value must satisfy the requirements of Boolean (DT)2.(LV) value must be in SSI Indicator List (VVL)3.(S) value must be 1 character4.(N) conditional5.(FD1) value must equal '0' when SSI status (ELG.005.092) equals '000' or '003' or is not populated6.(FD1) value must equal '1' when SSI status (ELG.005.092) equals '001' or '002'| |
| 2022-06-24 | SSI-STATE-SUPPLEMENT-STATUS-CODE | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG091|SSI-STATE-SUPPLEMENT-STATUS-CODE|Indicates the individual's State Supplemental Income Status.|1.(LV) value must be in SSI State Supplement Status Code List (VVL)2.(FD1) (individual not receiving Federal SSI) If SSI State Supplemental Status Code is "001" or "002", then SSI Status cannot be "000" or "003"3.(S) value must be 3 characters4.(N) conditional5.(FD1) value must not be populated when SSI Status is not populated | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG091|SSI-STATE-SUPPLEMENT-STATUS-CODE|Indicates the individual's State Supplemental Income Status.|1.(LV) value must be in SSI State Supplement Status Code List (VVL)2.(S) value must be 3 characters3.(FD1) (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4.(FD1) (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be '1'5.(FD1) value must not be populated or must be '000' when SSI Status (ELG.005.092) is not populated or is '000' |
| 2022-06-24 | SSI-STATUS | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG092|SSI-STATUS|Indicates the individual's SSI Status.|1.(LV) value must be in SSI Status List (VVL)2.(S) value must be 3 characters3.(N) conditional4.(FD1) value must be populated when SSI Indicator equals '1' | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|ELG092|SSI-STATUS|Indicates the individual's SSI Status.|1.(LV) value must be in SSI Status List (VVL)2.(S) value must be 3 characters3.(N) conditional4.(FD1) when value is '001' or '002', then SSI Indicator must be '1'5. (FD1) when value is '000' or '003' or not populate, then SSI Indicator must be '0' |
| 2022-06-24 | STATE-SPEC-ELIG-GROUP | Data Dictionary | UPDATE | DE No|Data Element Name|CODING REQUIREMENT|ELG093|STATE-SPEC-ELIG-GROUP|If value is in the range [ 000000 .. 999999 ], then associated Date of Death value must not be before the start of the reporting period.| | DE No|Data Element Name|CODING REQUIREMENT|ELG093|STATE-SPEC-ELIG-GROUP|| |
| 2022-06-24 | TEACHING-IND | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV027|TEACHING-IND||1.(LV) value must be in Teaching Indicator List (VVL)2.(S) value must be 1 character3.(N) conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|PRV027|TEACHING-IND||1.(LV) value must be in Teaching Indicator List (VVL)2.(S) value must be 1 character3. (FD) value must be '0' when Facility Group Individual Code (PRV.002.026) equals '02' or '03'4.(N) conditional |
| 2022-06-24 | TOT-COPAY-AMT | Data Dictionary | UPDATE | |DE No|Data Element Name|Definition||CIP115|TOT-COPAY-AMT|The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP.1.(GS) value must satisfy the requirements of Total Medicare Deductible Amount (CE) | |DE No|Data Element Name|Definition||CIP115|TOT-COPAY-AMT|The total amount paid by Medicaid/CHIP enrollee towards a copayment for the service.1.(GS) value must satisfy the requirements of Total Copayment Amount (CE) |
| 2022-06-24 | TPL-ENTITY-ADDR-TYPE | Data Dictionary | UPDATE | DE No|Data Element Name|Definition| CODING REQUIREMENT|TPL.076|TPL-ENTITY-ADDR-TYPE||1.(LV) value must be in TPL Entity Address Type List (VVL)2.(S) value must be 2 characters3.(N) conditional | DE No|Data Element Name|Definition| CODING REQUIREMENT|TPL.076|TPL-ENTITY-ADDR-TYPE||1.(LV) value must be in TPL Entity Address Type List (VVL)2.(S) value must be 2 characters3.(N) mandatory |
| 2022-06-24 | TPL092 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMETPL092|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | N/A |
| 2022-06-24 | TPL092/ NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTTPL092|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE|X(1)|TPL|TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | N/A |
| 2022-06-24 | TPL093 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMETPL093|NATIONAL-HEALTH-CARE-ENTITY-ID | N/A |
| 2022-06-24 | TPL093/ NATIONAL-HEALTH-CARE-ENTITY-ID | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTTPL093|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|TPL|TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | N/A |
| 2022-06-24 | TPL094 | Data Dictionary | UPDATE | |DE NO| DATA ELEMENT NAMETPL094|NATIONAL-HEALTH-CARE-ENTITY-NAME | N/A |
| 2022-06-24 | TPL094/ NATIONAL-HEALTH-CARE-ENTITY-NAME | Data Dictionary - Record Layout | Deprecate DE | DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENTTPL094|NATIONAL-HEALTH-CARE-ENTITY-NAME|X(50)|TPL|TPL-ENTITY-CONTACT-INFORMATION-TPL00006 | N/A |
| 2022-06-24 | TYPE-OF-OTHER-THIRD-PARTY-LIABILITY | Data Dictionary | UPDATE | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|TPL067|TYPE-OF-OTHER-THIRD-PARTY-LIABILITY|This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed INSURANCE-TYPE-PLAN.|1.(FDN) If value equals "Other". then Policy Owner (TPL.003.044-047) information is not required2.(S) value must be 1 character3.(LV) value must be in Type of Other Third Party Liability List (VVL)4.(N) mandatory | DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|TPL067 |TYPE-OF-OTHER-THIRD-PARTY-LIABILITY|This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed Insurance Type Plan.|1.(S) value must be 1 character2.(LV) value must be in Type of Other Third Party Liability List (VVL)3.(N) mandatory |
| 2022-07-15 | CIP100 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP100|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP100|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2022-07-15 | CIP104 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP104|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP104|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 2022-07-15 | CIP112 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP112|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP112|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CIP113 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP113|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP113|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CIP114 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP114|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP114|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CIP251 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP251|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP251|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to themanaged care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CIP252 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP252|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP252|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CIP254 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP254|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCIP254|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CLT052 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT052|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT052|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2022-07-15 | CLT056 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT056|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT056|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 2022-07-15 | CLT063 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT063|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT063|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CLT064 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT064|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT064|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CLT065 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT065|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT065|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CLT204 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT204|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT204|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to themanaged care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CLT205 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT205|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT205|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CLT208 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT208|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCLT208|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | COT033 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT033|BEGINNING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT033|BEGINNING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 2022-07-15 | COT034 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT034|ENDING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT034|ENDING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 2022-07-15 | COT037 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT037|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT037|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
| 2022-07-15 | COT041 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT041|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT041|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
| 2022-07-15 | COT048 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT048|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT048|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | COT049 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT049|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT049|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | COT050 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT050|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT050|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
| 2022-07-15 | COT066 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT066|PLAN-ID-NUMBER|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT066|PLAN-ID-NUMBER|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider.For sub-capitation payments, report the PLAN-ID-NUMBER for the managed care plan making the payment to the sub-capitated entity. |
| 2022-07-15 | COT112 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT112|BILLING-PROV-NUM|A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT112|BILLING-PROV-NUM|A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
| 2022-07-15 | COT113 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT113|BILLING-PROV-NPI-NUM|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT113|BILLING-PROV-NPI-NUM|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |
| 2022-07-15 | COT166 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT166|BEGINNING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT166|BEGINNING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 2022-07-15 | COT167 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT167|ENDING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT167|ENDING-DATE-OF-SERVICE|For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 2022-07-15 | COT174 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT174|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT174|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | COT175 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT175|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT175|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | COT178 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT178|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT178|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | COT186 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT186|TYPE-OF-SERVICE|A code to categorize the services provided to a Medicaid or CHIP enrollee. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCOT186|TYPE-OF-SERVICE|A code to categorize the services provided to a Medicaid or CHIP enrollee.For sub-capitation payments, report a TYPE-OF-SERVICE value 119, 120, or 122. |
| 2022-07-15 | CRX029 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX029|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX029|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2022-07-15 | CRX032 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX032|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX032|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 2022-07-15 | CRX039 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX039|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX039|TOT-BILLED-AMT|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CRX040 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX040|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX040|TOT-ALLOWED-AMT|The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CRX041 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX041|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX041|TOT-MEDICAID-PAID-AMT|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CRX121 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX121|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX121|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CRX122 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX122|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX122|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-07-15 | CRX125 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX125|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITIONCRX125|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2022-08-05 | CIP194 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENTCIP194|DRG-OUTLIER-AMT|Value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENTCIP194|DRG-OUTLIER-AMT|Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' |
| 2022-08-05 | CIP202 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCIP202|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCIP202|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2022-08-05 | CLT144 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCLT144|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detaile dexplanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCLT144|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2022-08-05 | COT126 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCOT126|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCOT126|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2022-08-05 | CRX081 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCRX081|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENTCRX081|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2022-08-26 | CIP132 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP132|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP132|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2022-08-26 | CLT082 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CLT082|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CLT082|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2022-08-26 | COT068 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|COT068|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|COT068|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2022-08-26 | CRX058 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CRX058|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CRX058|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2022-08-26 | ELG252 | Data Dictionary | ADD | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG252|ENROLLMENT-TYPE| | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG252|ENROLLMENT-TYPE|A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.) |
| 2022-10-07 | CIP293, CLT240, COT231, CRX164 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP293|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.CLT240|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.COT231|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment.CRX164|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP293|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.CLT240|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.COT231|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.CRX164|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 2022-10-07 | CIP294, CLT241, COT232, CRX165 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP294|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.CLT241|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.COT232|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible.CRX165|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP294|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.CLT241|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.COT232|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.CRX165|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 2022-10-07 | ELG040 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG040|CITIZENSHIP-IND|Value must be in [0, 1] or not populated | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG040|CITIZENSHIP-IND|Value must be in [0, 1, 2] or not populated |
| 2022-10-07 | PRV024 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|PRV024|PROV-ORGANIZATION-NAME|The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|PRV024|PROV-ORGANIZATION-NAME|The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. Provider Organization Name should be same as provider last name when provider is an individual. |
| 2022-10-28 | CIP099, CLT051, COT036, CRX028 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP099|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment.CLT051|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment.COT036|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment.CRX028|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP099|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.CLT051|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.COT036|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.CRX028|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 2022-10-28 | ELG095 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
| 2022-11-18 | ELG097 | Data Dictionary | ADD | N/A | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG097|RESTRICTED-BENEFITS-CODE|(Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 2022-11-18 | ELG270 | Data Dictionary | ADD | N/A | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG270|LOCKED-IN-SRVCS|Must be a 3 digit value from the Type-of-Service valid value list |
| 2022-11-18 | MCR020 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|MCR020|MANAGED-CARE-CONTRACT-EFF-DATE|The first calendar day on which all of the other data elements in the same segment were effective. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|MCR020|MANAGED-CARE-CONTRACT-EFF-DATE|The start date of the managed care contract period with the state. |
| 2022-12-30 | IHS-SERVICE-IND (CIP296, CLT243, COT234, CRX172) | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP296|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.CLT243|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.COT234|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.CRX172|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CIP296|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.CLT243|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.COT234|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.CRX172|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 2023-01-05 | CIP.002.099 | Definition | UPDATE | The date Medicaid paid this claim or adjustment. | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 2023-01-05 | CLT.002.051 | Definition | UPDATE | The date Medicaid paid this claim or adjustment. | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 2023-01-05 | COT.002.036 | Definition | UPDATE | The date Medicaid paid this claim or adjustment. | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 2023-01-05 | CRX.002.028 | Definition | UPDATE | The date Medicaid paid this claim or adjustment. | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 2023-01-09 | ELG.005.095 | Definition | UPDATE | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual, there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
| 2023-01-26 | PRV.006.088 | Definition | UPDATE | A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47562 A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. | A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
| 2023-02-16 | CIP.003.296 | Definition | UPDATE | This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 2023-02-16 | CIP.003.296 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated | 1. Value must be 1 character2. Value must be in [0, 1] |
| 2023-02-16 | CLT.003.243 | Definition | UPDATE | This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 2023-02-16 | CLT.003.243 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated | 1. Value must be 1 character2. Value must be in [0, 1] |
| 2023-02-16 | COT.003.234 | Definition | UPDATE | This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 2023-02-16 | COT.003.234 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated | 1. Value must be 1 character2. Value must be in [0, 1] |
| 2023-02-16 | CRX.003.172 | Definition | UPDATE | This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. | To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 2023-02-16 | CRX.003.172 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated | 1. Value must be 1 character2. Value must be in [0, 1] |
| 2023-02-23 | CIP.002.099 | Definition | UPDATE | The date Medicaid paid this claim or adjustment. | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
| 2023-02-23 | CIP.002.099 | Definition | UPDATE | The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. | The date Medicaid paid this claim or adjustment. |
| 2023-03-10 | ELG034 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG034|MARITAL-STATUS|A code to classify eligible individual's marital/domestic-relationship status. An eligible individual who is younger than 12 years should have a marital status of never married orunknown. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).| | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG034|MARITAL-STATUS|A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value.| |
| 2023-03-10 | ELG074 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG074|TYPE-OF-LIVING-ARRANGEMENT|A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid value lists.| | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG074|TYPE-OF-LIVING-ARRANGEMENT|A free-form text field to describe the type of living arrangement used for the eligibility determination process.| |
| 2023-03-10 | ELG095 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another.| | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
| 2023-03-24 | CRX - CLAIM PRESCRIPTION | File name | UPDATE | CRX - CLAIM PERSCRIPTION | CRX - CLAIM PRESCRIPTION |
| 2023-03-24 | CRX - CLAIM PRESCRIPTION | Title | UPDATE | CRX - CLAIM PERSCRIPTION | CRX - CLAIM PRESCRIPTION |
| 2023-05-10 | ELG.003.038 | Necessity | UPDATE | Mandatory | Conditional |
| 2023-05-10 | ELG.003.038 | Coding requirement | UPDATE | 1. Value must be in Income Code List (VVL)2. Value must be 2 characters3. Mandatory | 1. Value must be in Income Code List (VVL)2. Value must be 2 characters3. Conditional |
| 2023-05-31 | CIP.002.126 | Necessity | UPDATE | Mandatory | Conditional |
| 2023-05-31 | CIP.002.126 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 2023-05-31 | CIP.003.257 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must satisfy the requirements of Type of Service (Inpatient Claim) List (VVL) | Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
| 2023-05-31 | CLT.002.076 | Necessity | UPDATE | Mandatory | Conditional |
| 2023-05-31 | CLT.002.076 | Coding requirement | UPDATE | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 2023-05-31 | CLT.002.076 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 2023-05-31 | CLT.003.211 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. Value must satisfy the requirements of Type of Service (Long Term Claim) List (VVL) | 1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] when associated Claim Type is CLT (Long Term Claim) |
| 2023-05-31 | COT.002.062 | Necessity | UPDATE | Mandatory | Conditional |
| 2023-05-31 | COT.002.062 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 2023-05-31 | COT.002.228 | Definition | UPDATE | The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies | The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. [Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 2023-05-31 | COT.002.229 | Definition | UPDATE | The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm).The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 2023-05-31 | COT.003.186 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must satisfy the requirements of Type of Service (Other Claim) List (VVL)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated | 1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147'] when associated Claim Type is COT (Other Claim)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 2023-05-31 | CRX.002.053 | Necessity | UPDATE | Mandatory | Conditional |
| 2023-05-31 | CRX.002.053 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 2023-05-31 | ELG.005.085 | Necessity | UPDATE | Conditional | Mandatory |
| 2023-05-31 | ELG.005.085 | Coding requirement | UPDATE | 1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Conditional6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" | 1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 2023-06-01 | CIP.002.126 | Coding requirement | UPDATE | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | CIP.002.127 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | CLT.002.076 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | CLT.002.077 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | COT.002.062 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | COT.002.063 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | COT.002.229 | Definition | UPDATE | A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm).The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] | The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 2023-06-01 | CRX.002.053 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | CRX.002.054 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-01 | CRX.003.134 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. Value must satisfy the requirements of Type of Service (RX Claim) List (VVL) | 1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] when associated Claim Type is CRX (RX Claim) |
| 2023-06-02 | CIP.002.126 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | CIP.002.127 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | CIP.003.257 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) | 1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] |
| 2023-06-02 | CIP.003.257 | Coding requirement | UPDATE | Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) | 1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
| 2023-06-02 | CLT.002.076 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | CLT.002.076 | Coding requirement | UPDATE | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-02 | CLT.002.077 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | CLT.003.211 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] when associated Claim Type is CLT (Long Term Claim) | 1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] |
| 2023-06-02 | COT.002.062 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | COT.002.063 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | COT.003.186 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147'] when associated Claim Type is COT (Other Claim)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated | 1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147']5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 2023-06-02 | CRX.002.053 | Coding requirement | UPDATE | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | CRX.002.053 | Coding requirement | UPDATE | Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 2023-06-02 | CRX.002.054 | Coding requirement | UPDATE | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional | 1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 2023-06-02 | CRX.003.134 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] when associated Claim Type is CRX (RX Claim) | 1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] |
| 2023-06-14 | CIP.002.132 | Definition | UPDATE | The field denotes whether the payment amount was determined at the claim header or line/detail level. | The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2023-06-14 | CLT.002.082 | Definition | UPDATE | The field denotes whether the payment amount was determined at the claim header or line/detail level. | The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2023-06-14 | COT.002.068 | Definition | UPDATE | The field denotes whether the payment amount was determined at the claim header or line/detail level. | The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2023-06-14 | CRX.002.058 | Definition | UPDATE | The field denotes whether the payment amount was determined at the claim header or line/detail level. | The field denotes whether the payment amount was determined at the claim header or line/detail level.For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
| 2023-06-14 | PRV.009.120 | Definition | UPDATE | A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. If Affiliated Program Type = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in which a provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the value in Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in Affiliated Program ID is an identifier for something other than a health plan, waiver, or health home entity. | A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. |
| 2023-06-21 | ELG.003.034 | Definition | UPDATE | A code to classify eligible individual's marital/domestic-relationship status. An eligible individual who is younger than 12 years should have a marital status of never married or unknown. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). | A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 2023-06-23 | PRV120 | Data Dictionary | UPDATE | DE NO||DATA ELEMENT NAME COMPUTING|||DEFINITIONPRV120|AFFILIATED-PROGRAM-ID|||A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.If Affiliated Program Type = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in which a provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal Waiver ID in which a provider isallowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the value in Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in Affiliated Program ID is an identifier for something other than a health plan, waiver, or health home entity. | DE NO||DATA ELEMENT NAME COMPUTING|||DEFINITIONPRV120|AFFILIATED-PROGRAM-ID|||A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. |
| 2023-07-12 | CIP.002.194 | Coding requirement | UPDATE | Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
| 2023-07-12 | CIP.002.194 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional | Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
| 2023-07-12 | CIP.002.194 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must not be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
| 2023-07-12 | CIP.002.202 | Definition | UPDATE | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 2023-07-12 | CIP.002.202 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory | 1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 2023-07-12 | CLT.002.144 | Definition | UPDATE | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 2023-07-12 | CLT.002.144 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory | 1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 2023-07-12 | COT.002.126 | Definition | UPDATE | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 2023-07-12 | COT.002.126 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory | 1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 2023-07-12 | CRX.002.081 | Definition | UPDATE | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. | The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
| 2023-07-12 | CRX.002.081 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory | 1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 2023-07-12 | ELG.003.040 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory | 1. Value must be 1 character2. Value must be in [0, 1, 2] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
| 2023-07-12 | ELG.005.097 | Coding requirement | UPDATE | Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) | 1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 2023-07-12 | ELG.005.097 | Coding requirement | UPDATE | 1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25" | Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 2023-07-12 | ELG.009.270 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Conditional | 1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service valid value list |
| 2023-07-13 | CIP.002.022 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)6. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' | 1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 2023-07-13 | CIP.003.234 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' | 1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
| 2023-07-13 | CLT.002.022 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)6. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date | 1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 2023-07-13 | CLT.003.187 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' | 1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 2023-07-13 | COT.002.022 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)6. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) | 1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 2023-07-13 | COT.003.157 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' | 1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 2023-07-13 | CRX.002.022 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) | 1. Mandatory2. Value must be 20 characters or less3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
| 2023-07-13 | CRX.003.111 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' | 1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
| 2023-07-13 | ELG.002.019 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.003.033 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN3. Value must be 20 characters or less |
| 2023-07-13 | ELG.004.064 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.005.082 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.006.106 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.007.117 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.008.129 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.010.149 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.011.162 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.012.171 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.013.181 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.014.191 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.015.203 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.016.212 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.017.223 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.018.232 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.020.241 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.021.251 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | ELG.022.260 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | TPL.002.019 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | TPL.003.032 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-13 | TPL.005.066 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-14 | CIP022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CIP022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CIP022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CIP022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CIP022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CIP022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CIP194 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|CIP194|DRG-OUTLIER-AMT|Value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'| | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|CIP194|DRG-OUTLIER-AMT|Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'| |
| 2023-07-14 | CIP202 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|CIP202|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|CIP202|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2023-07-14 | CIP234 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CIP234|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CIP234|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CIP234 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CIP234|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CIP234|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CLT022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CLT022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CLT022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CLT022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CLT022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CLT022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CLT144 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|CLT144|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detaile dexplanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|CLT144|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2023-07-14 | CLT187 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CLT187|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CLT187|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CLT187 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CLT187|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CLT187|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | COT022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|COT022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|COT022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | COT022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|COT022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|COT022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | COT126 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|COT126|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|COT126|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2023-07-14 | COT157 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|COT157|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|COT157|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | COT157 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|COT157|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|COT157|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CRX022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CRX022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CRX022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CRX022 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CRX022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CRX022|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CRX081 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|CRX081|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))"| | DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|CRX081|REMITTANCE-NUM|The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.|| |
| 2023-07-14 | CRX111 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CRX111|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CRX111|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | CRX111 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|CRX111|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|CRX111|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG.003.038 | Definition | UPDATE | A code indicating the family income level. | A code indicating the federal poverty level range in which the family income falls.If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 2023-07-14 | ELG.003.269 | Definition | UPDATE | This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group. | This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 2023-07-14 | ELG.009.139 | Coding requirement | UPDATE | 1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less | 1. Mandatory2. Value must be 20 characters or less |
| 2023-07-14 | ELG019 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG019|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG019|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG019 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG019|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG019|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG033 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG033|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG033|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG038 | Data Dictionary | UPDATE | DE No|DE Name|Definition|ELG038|INCOME-CODE|A code indicating the family income level. | DE No|DE Name|Definition|ELG038|INCOME-CODE|A code indicating the federal poverty level range in which the family income falls.If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 2023-07-14 | ELG040 | Data Dictionary | UPDATE | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG040|CITIZENSHIP-IND|Value must be in [0, 1] or not populated| | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG040|CITIZENSHIP-IND|Value must be in [0, 1, 2] or not populated| |
| 2023-07-14 | ELG064 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG064|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG064|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG064 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG064|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG064|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG082 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG082|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG082|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG082 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG082|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG082|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG097 | Data Dictionary | ADD | N/A | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG097|RESTRICTED-BENEFITS-CODE|(Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’)| |
| 2023-07-14 | ELG106 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG016|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG106|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG106 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG016|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG106|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG117 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG117|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG117|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG117 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG117|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG117|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG129 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG129|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG129|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG129 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG129|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG129|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG139 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG139|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG139|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG139 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG139|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG139|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG149 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG149|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG149|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG149 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG149|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG149|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG162 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG162|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG162|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG162 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG162|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG162|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG171 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG171|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG171|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG171 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG171|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG171|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG181 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG181|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG181|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG181 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG181|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG181|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG191 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG191|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG191|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG191 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG191|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG191|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG203 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG203|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG203|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG203 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG203|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG203|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG212 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG212|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG212|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG212 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG212|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG212|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG223 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG223|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG223|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG223 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG223|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG223|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG232 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG232|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG232|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG232 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG232|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG232|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG241 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG241|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG241|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG241 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG241|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG241|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG251 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG251|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG251|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG251 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG251|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG251|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG260 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG260|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG260|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG260 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|ELG260|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|ELG260|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | ELG269 | Data Dictionary | UPDATE | DE No|DE Name|Definition|ELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed usingmultiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group. | DE No|DE Name|Definition|ELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 2023-07-14 | ELG270 | Data Dictionary | ADD | N/A | DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|ELG270|LOCKED-IN-SRVCS|Must be a 3 digit value from the Type-of-Service valid value list| |
| 2023-07-14 | TPL019 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|TPL019|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|TPL019|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | TPL019 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|TPL019|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|TPL019|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | TPL032 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|TLP032|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|TPL032|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | TPL032 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|TLP032|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|TPL032|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | TPL066 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|TLP066|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|TPL066|MSIS-IDENTIFICATION-NUM|| |
| 2023-07-14 | TPL066 | Data Dictionary | UPDATE | DE No|DE Name|Coding Requirement|TLP066|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| | DE No|DE Name|Coding Requirement|TPL066|MSIS-IDENTIFICATION-NUM|| |
| 2023-08-01 | CIP.002.025 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 2023-08-01 | CIP.002.121 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 2023-08-01 | CIP.002.125 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 2023-08-01 | CIP.002.128 | Coding requirement | UPDATE | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 2023-08-01 | CIP.002.138 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 2023-08-01 | CIP.002.139 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 2023-08-01 | CIP.002.204 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 2023-08-01 | CLT.002.024 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 2023-08-01 | CLT.002.071 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 2023-08-01 | CLT.002.075 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 2023-08-01 | CLT.002.078 | Coding requirement | UPDATE | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 2023-08-01 | CLT.002.090 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 2023-08-01 | CLT.002.091 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 2023-08-01 | CLT.002.151 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 2023-08-01 | COT.002.024 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 2023-08-01 | COT.002.057 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 2023-08-01 | COT.002.061 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 2023-08-01 | COT.002.064 | Coding requirement | UPDATE | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 2023-08-01 | COT.002.072 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 2023-08-01 | COT.002.073 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 2023-08-01 | COT.002.128 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 2023-08-01 | CRX.002.024 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 2023-08-01 | CRX.002.048 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 2023-08-01 | CRX.002.052 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 2023-08-01 | CRX.002.061 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 2023-08-01 | CRX.002.082 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 2023-08-01 | CRX.002.160 | Coding requirement | UPDATE | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional | 1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 2023-08-01 | ELG.003.049 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Pregnancy Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Pregnancy Indicator List (VVL)4. Conditional |
| 2023-08-01 | ELG.005.086 | Coding requirement | UPDATE | 1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. Mandatory | 1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory |
| 2023-08-01 | ELG.016.215 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
| 2023-08-01 | ELG.018.233 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
| 2023-08-07 | CIP.002.026 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 2023-08-07 | CIP.002.212 | Coding requirement | UPDATE | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 2023-08-07 | CIP.003.239 | Coding requirement | UPDATE | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 2023-08-07 | CLT.002.025 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 2023-08-07 | CLT.002.159 | Coding requirement | UPDATE | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 2023-08-07 | CLT.003.192 | Coding requirement | UPDATE | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 2023-08-07 | COT.002.025 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 2023-08-07 | COT.002.136 | Coding requirement | UPDATE | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 2023-08-07 | COT.003.162 | Coding requirement | UPDATE | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 2023-08-07 | CRX.002.025 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 2023-08-07 | CRX.002.094 | Coding requirement | UPDATE | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory | 1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 2023-08-07 | CRX.003.116 | Coding requirement | UPDATE | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated | 1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 2023-08-09 | CIP.002.100 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.002.100 | Definition | UPDATE | A code to indicate what type of payment is covered in this claim. | A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2023-08-09 | CIP.002.104 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.002.104 | Definition | UPDATE | The field denotes the claims payment system from which the claim was extracted. | The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 2023-08-09 | CIP.002.112 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.002.112 | Definition | UPDATE | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CIP.002.112 | Definition | UPDATE | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. |
| 2023-08-09 | CIP.002.113 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.002.113 | Definition | UPDATE | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CIP.002.114 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.002.114 | Definition | UPDATE | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CIP.003.251 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.003.251 | Definition | UPDATE | The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. | The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CIP.003.252 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.003.252 | Definition | UPDATE | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CIP.003.254 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CIP.003.254 | Definition | UPDATE | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CLT.002.052 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.002.052 | Definition | UPDATE | A code to indicate what type of payment is covered in this claim. | A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2023-08-09 | CLT.002.056 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.002.056 | Definition | UPDATE | The field denotes the claims payment system from which the claim was extracted. | The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 2023-08-09 | CLT.002.063 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.002.063 | Definition | UPDATE | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CLT.002.064 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.002.064 | Definition | UPDATE | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CLT.002.065 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.002.065 | Definition | UPDATE | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CLT.003.204 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.003.204 | Definition | UPDATE | The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. | The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CLT.003.205 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.003.205 | Definition | UPDATE | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CLT.003.208 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CLT.003.208 | Definition | UPDATE | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | COT.002.033 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.033 | Definition | UPDATE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 2023-08-09 | COT.002.034 | Definition | UPDATE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 2023-08-09 | COT.002.037 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.037 | Definition | UPDATE | A code to indicate what type of payment is covered in this claim. | A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2023-08-09 | COT.002.041 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.041 | Definition | UPDATE | The field denotes the claims payment system from which the claim was extracted. | The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
| 2023-08-09 | COT.002.048 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.048 | Definition | UPDATE | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | COT.002.049 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.049 | Definition | UPDATE | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | COT.002.050 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.050 | Definition | UPDATE | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
| 2023-08-09 | COT.002.066 | Definition | UPDATE | A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. | A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | COT.002.112 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.112 | Definition | UPDATE | A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. | A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
| 2023-08-09 | COT.002.113 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.002.113 | Definition | UPDATE | The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. | The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |
| 2023-08-09 | COT.003.166 | Last update date | UPDATE | 8/6/2023 | 8/9/2023 |
| 2023-08-09 | COT.003.166 | Last update date | UPDATE | 12/08/2022 | 8/6/2023 |
| 2023-08-09 | COT.003.166 | Definition | UPDATE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 2023-08-09 | COT.003.167 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.003.167 | Definition | UPDATE | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. | For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 2023-08-09 | COT.003.174 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.003.174 | Definition | UPDATE | The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. | The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | COT.003.175 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.003.175 | Definition | UPDATE | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | COT.003.178 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | COT.003.178 | Definition | UPDATE | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CRX.002.029 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.002.029 | Definition | UPDATE | A code to indicate what type of payment is covered in this claim. | A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |
| 2023-08-09 | CRX.002.032 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.002.032 | Definition | UPDATE | The field denotes the claims payment system from which the claim was extracted. | The field denotes the claims payment system from which the claim was extracted.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
| 2023-08-09 | CRX.002.039 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.002.039 | Definition | UPDATE | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. | The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CRX.002.040 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.002.040 | Definition | UPDATE | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. | The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CRX.002.041 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.002.041 | Definition | UPDATE | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. | The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. |
| 2023-08-09 | CRX.003.121 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.003.121 | Definition | UPDATE | The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. | The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CRX.003.122 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.003.122 | Definition | UPDATE | The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. | The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | CRX.003.125 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | CRX.003.125 | Definition | UPDATE | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. | The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider.For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
| 2023-08-09 | ELG.004.074 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | ELG.004.074 | Definition | UPDATE | A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid value lists. | A free-form text field to describe the type of living arrangement used for the eligibility determination process. |
| 2023-08-09 | ELG.005.095 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | ELG.005.095 | Definition | UPDATE | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
| 2023-08-09 | ELG.005.095 | Definition | UPDATE | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual, there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. | The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
| 2023-08-09 | MCR.002.020 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | MCR.002.020 | Definition | UPDATE | The first calendar day on which all of the other data elements in the same segment were effective. | The start date of the managed care contract period with the state. |
| 2023-08-09 | PRV.002.024 | Last update date | UPDATE | 12/08/2022 | 8/9/2023 |
| 2023-08-09 | PRV.002.024 | Definition | UPDATE | The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. | The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. Provider Organization Name should be same as provider last name when provider is an individual. |
| 2023-08-10 | CIP.002.293 | Last update date | UPDATE | 12/08/2022 | 8/10/23 |
| 2023-08-10 | CIP.002.293 | Definition | UPDATE | The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 2023-08-10 | CIP.002.294 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | CIP.002.294 | Definition | UPDATE | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible. | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 2023-08-10 | CLT.002.240 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | CLT.002.240 | Definition | UPDATE | The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 2023-08-10 | CLT.002.241 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | CLT.002.241 | Definition | UPDATE | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible. | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 2023-08-10 | COT.002.231 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | COT.002.231 | Definition | UPDATE | The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 2023-08-10 | COT.002.232 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | COT.002.232 | Definition | UPDATE | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible. | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 2023-08-10 | CRX - CLAIM PHARMACY | Title | UPDATE | CRX - CLAIM PRESCRIPTION | CRX - CLAIM PHARMACY |
| 2023-08-10 | CRX.002.164 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | CRX.002.164 | Definition | UPDATE | The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the copayment. | The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
| 2023-08-10 | CRX.002.165 | Last update date | UPDATE | 12/08/2022 | 8/10/2023 |
| 2023-08-10 | CRX.002.165 | Definition | UPDATE | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability for covered services on the claim. Do not subtract out any payments made toward the deductible. | The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
| 2023-08-11 | COT.002.037 | Last update date | UPDATE | 8/9/2023 | 8/11/2023 |
| 2023-08-11 | COT.002.037 | Definition | UPDATE | A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. | A code to indicate what type of payment is covered in this claim.For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
| 2023-08-11 | CRX - CLAIM PHARMACY | File name | UPDATE | CRX - CLAIM PRESCRIPTION | CRX - CLAIM PHARMACY |
| 2023-08-14 | CIP.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | CIP.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | CIP.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | CIP.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | CIP.002.094 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date (CE) value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth (CE) value.5. Value must be less than or equal to associated eligible Date of Death (CE) value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
| 2023-08-14 | CIP.002.096 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date (CE) value.4. Value must be greater than or equal to associated Admission Date (CE) value.5. Value must be greater than or equal to associated eligible Date of Birth (CE) value.6. Value must be less than or equal to associated eligible Date of Death (CE) value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
| 2023-08-14 | CIP.002.137 | Coding requirement | UPDATE | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 2023-08-14 | CIP.002.160 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.161 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.162 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.163 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.164 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.165 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.166 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.168 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.002.169 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CIP.003.233 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | CLT.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | CLT.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | CLT.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | CLT.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | CLT.002.044 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date (CE) value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth (CE) value.5. Value must be less than or equal to associated eligible Date of Death (CE) value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
| 2023-08-14 | CLT.002.046 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date (CE) value.4. Value must be greater than or equal to associated Admission Date (CE) value.5. Value must be greater than or equal to associated eligible Date of Birth (CE) value.6. Value must be less than or equal to associated eligible Date of Death (CE) value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
| 2023-08-14 | CLT.002.087 | Coding requirement | UPDATE | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 2023-08-14 | CLT.002.112 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.113 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.114 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.115 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.116 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.117 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.118 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.119 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.120 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.002.121 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | CLT.003.186 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | CLT.003.209 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 2023-08-14 | COT.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | COT.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | COT.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | COT.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | COT.002.070 | Coding requirement | UPDATE | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 2023-08-14 | COT.002.094 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.095 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.096 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.098 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.099 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.100 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.101 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.102 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.002.103 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 2023-08-14 | COT.003.156 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | COT.003.179 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 2023-08-14 | COT.003.199 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
| 2023-08-14 | COT.003.200 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | COT.003.204 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
| 2023-08-14 | COT.003.205 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | CRX.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | CRX.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | CRX.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | CRX.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | CRX.002.060 | Coding requirement | UPDATE | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory | 1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 2023-08-14 | CRX.003.110 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | CRX.003.126 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 2023-08-14 | ELG.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | ELG.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | ELG.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | ELG.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.002.024 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period (CE) value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
| 2023-08-14 | ELG.003.032 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.004.063 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.004.066 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 2023-08-14 | ELG.004.067 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | ELG.004.068 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | ELG.005.081 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.006.105 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.007.116 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.008.128 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.009.138 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.010.148 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.011.161 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.012.170 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.013.180 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.014.190 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.015.202 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.016.211 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.017.222 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.018.231 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.020.240 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.021.250 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | ELG.022.259 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | MCR.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | MCR.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | MCR.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | MCR.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | MCR.003.036 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | MCR.003.042 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 2023-08-14 | MCR.003.043 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | MCR.004.056 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | MCR.005.065 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | MCR.006.075 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | MCR.007.084 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | PRV.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | PRV.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | PRV.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.003.041 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.003.047 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 2023-08-14 | PRV.003.048 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | PRV.003.049 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | PRV.004.062 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.005.074 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.006.086 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.007.096 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | PRV.008.108 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | TPL.001.008 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 2023-08-14 | TPL.001.009 | Coding requirement | UPDATE | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory | 1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 2023-08-14 | TPL.001.010 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory | 1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 2023-08-14 | TPL.002.018 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-14 | TPL.006.077 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Optional5. When populated, the associated Address Type is required | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Optional5. When populated, the associated Address Type is required |
| 2023-08-14 | TPL.006.078 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-14 | TPL.006.079 | Coding requirement | UPDATE | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional | 1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 2023-08-15 | CIP.002.026 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-08-15 | CIP.002.031 | Coding requirement | UPDATE | 1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character | 1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character3. Conditional |
| 2023-08-15 | CIP.002.118 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 2023-08-15 | CIP.002.178 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 2023-08-15 | CIP.002.184 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Conditional3. Value must have an associated Provider Identifier Type equal to '2' | 1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to '2'4. Value must exist in the NPPES NPI File |
| 2023-08-15 | CIP.003.245 | Coding requirement | UPDATE | 1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Mandatory | 1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 2023-08-15 | CIP.003.251 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount (CE) value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
| 2023-08-15 | CLT.002.025 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-08-15 | CLT.002.028 | Coding requirement | UPDATE | 1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character | 1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character3. Conditional |
| 2023-08-15 | CLT.002.069 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 2023-08-15 | CLT.002.129 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 2023-08-15 | CLT.002.174 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES data file |
| 2023-08-15 | CLT.003.198 | Coding requirement | UPDATE | 1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Mandatory | 1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 2023-08-15 | CLT.003.204 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount (CE) value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
| 2023-08-15 | COT.002.025 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-08-15 | COT.002.054 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 2023-08-15 | COT.002.111 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 2023-08-15 | COT.002.229 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 2023-08-15 | COT.003.168 | Coding requirement | UPDATE | 1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Conditional | 1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional |
| 2023-08-15 | COT.003.175 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
| 2023-08-15 | CRX.002.025 | Coding requirement | UPDATE | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-08-15 | CRX.002.045 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 2023-08-15 | CRX.002.069 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 2023-08-15 | ELG.009.270 | Coding requirement | UPDATE | 1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service valid value list | 1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service (VVL) |
| 2023-08-15 | ELG.012.172 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
| 2023-08-15 | PRV.003.053 | Coding requirement | UPDATE | 1. Value must be 10-digit number2. Optional | 1. Value must be 10-digit number2. Situational |
| 2023-08-15 | PRV.003.054 | Coding requirement | UPDATE | 1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Optional | 1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 2023-08-15 | PRV.009.117 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-15 | PRV.010.127 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-15 | TPL.003.031 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-15 | TPL.004.054 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-15 | TPL.005.065 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-15 | TPL.006.074 | Coding requirement | UPDATE | 1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory | 1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 2023-08-16 | CIP.002.179 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 2023-08-16 | CIP.002.180 | Coding requirement | UPDATE | Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file 4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) | 1.Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 2023-08-16 | CIP.002.180 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' | Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file 4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 2023-08-16 | CIP.003.269 | Coding requirement | UPDATE | 1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’, ‘A’], value must be populated | 1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’,‘A’], value must be populated |
| 2023-08-16 | CIP.003.269 | Coding requirement | UPDATE | Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported.8. When Type of Claim is in [‘1’, ‘A’], value must be populated | 1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
| 2023-08-16 | CIP.003.269 | Coding requirement | UPDATE | 1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. | Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported.8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
| 2023-08-16 | CLT.002.130 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 2023-08-16 | CLT.002.131 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W'), then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 2023-08-16 | COT.002.112 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
| 2023-08-16 | COT.002.112 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. When Type of Service (COT.003.186) is not in ['119', '120', '122'], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
| 2023-08-16 | COT.003.176 | Coding requirement | UPDATE | 1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) | 1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
| 2023-08-16 | COT.003.176 | Coding requirement | UPDATE | 1. Conditional2. Value must be 11 digits or less left of the decimal i.e. 99999999999.99 | 1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) |
| 2023-08-16 | CRX.002.070 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 2023-08-16 | CRX.002.071 | Coding requirement | UPDATE | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 2023-08-16 | CRX.002.071 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) | 1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 2023-08-16 | ELG.003.040 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1, 2] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory | 1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'5. Mandatory |
| 2023-08-16 | ELG.005.094 | Coding requirement | UPDATE | 1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Value must be 1 character8. Conditional | 1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
| 2023-08-21 | CIP.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CIP.002.229 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CIP.003.273 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CLT.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CLT.002.173 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CLT.003.226 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | COT.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | COT.002.152 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | COT.003.214 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CRX.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CRX.002.106 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | CRX.003.153 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.002.028 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.003.059 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.004.077 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.005.101 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.006.112 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.007.124 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.008.134 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.009.144 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.010.157 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.011.166 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.012.176 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.013.186 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.014.198 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.015.207 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.016.218 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.017.227 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.018.236 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.020.245 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.021.255 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | ELG.022.267 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.002.032 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.003.052 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.004.061 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.005.071 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.006.080 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | MCR.007.089 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.002.037 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.003.058 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.004.070 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.005.082 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.006.092 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.007.104 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.008.113 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.009.123 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | PRV.010.136 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | TPL.001.014 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | TPL.002.027 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | TPL.003.050 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | TPL.004.061 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | TPL.005.070 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-21 | TPL.006.086 | Coding requirement | UPDATE | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-22 | ELG.016.215 | Definition | UPDATE | "American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the `Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? | "American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
| 2023-08-23 | CIP.002.216 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | CIP.002.217 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 2023-08-23 | CIP.002.218 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | CIP.002.219 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 2023-08-23 | CIP.002.219 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational |
| 2023-08-23 | CLT.002.163 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | CLT.002.164 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 2023-08-23 | CLT.002.165 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | CLT.002.166 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 2023-08-23 | CLT.002.166 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational |
| 2023-08-23 | COT.002.140 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | COT.002.141 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 2023-08-23 | COT.002.142 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | COT.002.143 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 2023-08-23 | CRX.002.098 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | CRX.002.099 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 2023-08-23 | CRX.002.100 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 2023-08-23 | CRX.002.101 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 2023-08-28 | CIP.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | CIP.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CIP.002.020 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | CIP.002.023 | Coding requirement | UPDATE | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported6. Conditional |
| 2023-08-28 | CIP.002.112 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X]6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
| 2023-08-28 | CIP.002.114 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (CIP.002.113) | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [‘5’, ‘E’]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 2023-08-28 | CIP.002.176 | Coding requirement | UPDATE | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 2023-08-28 | CIP.002.178 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 2023-08-28 | CIP.002.190 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 2023-08-28 | CIP.002.213 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CIP.002.213 | Coding requirement | UPDATE | 1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional | 1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Situational |
| 2023-08-28 | CIP.002.220 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['4', 'D', 'X'], value must not be populated |
| 2023-08-28 | CIP.002.221 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file4. Conditional |
| 2023-08-28 | CIP.002.229 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CIP.003.236 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | CIP.003.270 | Coding requirement | UPDATE | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 2023-08-28 | CIP.003.271 | Coding requirement | UPDATE | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 2023-08-28 | CIP.003.273 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CIP.003.296 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] | 1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 2023-08-28 | CLT.001.002 | Coding requirement | UPDATE | Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | CLT.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | CLT.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CLT.002.020 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | CLT.002.023 | Coding requirement | UPDATE | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 2023-08-28 | CLT.002.063 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X]6. Value should not be populated when associated Type of Claim (CIP.002.100) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated 6. Value should not be populated when associated Type of Claim (CLT.002.052) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
| 2023-08-28 | CLT.002.065 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount11. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
| 2023-08-28 | CLT.002.065 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
| 2023-08-28 | CLT.002.067 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 2023-08-28 | CLT.002.127 | Coding requirement | UPDATE | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 2023-08-28 | CLT.002.129 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 2023-08-28 | CLT.002.136 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 2023-08-28 | CLT.002.160 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CLT.002.160 | Coding requirement | UPDATE | 1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional | 1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 2023-08-28 | CLT.002.167 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 2023-08-28 | CLT.002.173 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CLT.003.189 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | CLT.003.224 | Coding requirement | UPDATE | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 2023-08-28 | CLT.003.225 | Coding requirement | UPDATE | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 2023-08-28 | CLT.003.226 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CLT.003.243 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] | 1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 2023-08-28 | COT.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | COT.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | COT.002.020 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | COT.002.023 | Coding requirement | UPDATE | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 2023-08-28 | COT.002.048 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
| 2023-08-28 | COT.002.050 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049)8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
| 2023-08-28 | COT.002.050 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049) | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049)8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
| 2023-08-28 | COT.002.052 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 2023-08-28 | COT.002.109 | Coding requirement | UPDATE | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 2023-08-28 | COT.002.111 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 2023-08-28 | COT.002.118 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must be in the NPPES NPI data file4. Conditional |
| 2023-08-28 | COT.002.137 | Definition | UPDATE | Not Applicable | An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 2023-08-28 | COT.002.137 | Necessity | UPDATE | Not Applicable | Situational |
| 2023-08-28 | COT.002.137 | Coding requirement | UPDATE | Optional | 1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Situational |
| 2023-08-28 | COT.002.138 | Coding requirement | UPDATE | 1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional | 1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals ‘138’ (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals ‘45’ (health homes for substance use services) |
| 2023-08-28 | COT.002.146 | Coding requirement | UPDATE | Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
| 2023-08-28 | COT.002.146 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated | Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
| 2023-08-28 | COT.002.152 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | COT.003.159 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | COT.003.211 | Coding requirement | UPDATE | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 2023-08-28 | COT.003.212 | Coding requirement | UPDATE | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 2023-08-28 | COT.003.214 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | COT.003.234 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] | 1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 2023-08-28 | CRX.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | CRX.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CRX.002.020 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | CRX.002.023 | Coding requirement | UPDATE | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional | 1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 2023-08-28 | CRX.002.039 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
| 2023-08-28 | CRX.002.041 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] |
| 2023-08-28 | CRX.002.043 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 2023-08-28 | CRX.002.067 | Coding requirement | UPDATE | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional | 1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 2023-08-28 | CRX.002.069 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 2023-08-28 | CRX.002.095 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CRX.002.095 | Coding requirement | UPDATE | 1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional | 1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 2023-08-28 | CRX.002.102 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. Nppes Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 2023-08-28 | CRX.002.104 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 2023-08-28 | CRX.002.106 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CRX.003.113 | Coding requirement | UPDATE | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional | 1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 2023-08-28 | CRX.003.123 | Necessity | UPDATE | Conditional | Situational |
| 2023-08-28 | CRX.003.123 | Coding requirement | UPDATE | 1. Conditional2. Value must be 5 digits or less left of the decimal i.e. 99999.99 | 1. Situational2. Value must be 5 digits or less left of the decimal i.e. 99999.99 |
| 2023-08-28 | CRX.003.150 | Coding requirement | UPDATE | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated | 1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 2023-08-28 | CRX.003.151 | Coding requirement | UPDATE | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less | 1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 2023-08-28 | CRX.003.153 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | CRX.003.172 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] | 1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 2023-08-28 | ELG.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | ELG.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.002.028 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.003.039 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
| 2023-08-28 | ELG.003.059 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.004.073 | Coding requirement | UPDATE | 1. Value must be 10-digit number2. Conditional | 1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) = ''01', then value is mandatory and must be provided |
| 2023-08-28 | ELG.004.077 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.005.087 | Coding requirement | UPDATE | 1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05" | Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
| 2023-08-28 | ELG.005.101 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.006.112 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.007.124 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.008.134 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.009.140 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Mandatory | 1. Value must be 30 characters or less2. Mandatory3. Value must match a corresponding Provider Identifier (PRV.005.081) |
| 2023-08-28 | ELG.009.144 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.010.157 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.011.166 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.012.172 | Coding requirement | UPDATE | 1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory | 1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Mandatory |
| 2023-08-28 | ELG.012.172 | Coding requirement | UPDATE | Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory | 1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
| 2023-08-28 | ELG.012.172 | Coding requirement | UPDATE | 1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory | Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
| 2023-08-28 | ELG.012.172 | Coding requirement | UPDATE | 1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory | 1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
| 2023-08-28 | ELG.012.176 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.013.183 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Mandatory | 1. Value must be 30 characters or less2. Mandatory3. Value must match a corresponding Provider Identifier (PRV.005.081) |
| 2023-08-28 | ELG.013.186 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.014.198 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.015.207 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.015.271 | Coding requirement | UPDATE | 1. Value must be 25 characters or less2. Value is required when Ethnicity Code (ELG.015.204) equals '4' (Other)3. Conditional | 1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated. 3. Conditional |
| 2023-08-28 | ELG.016.218 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.017.227 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.018.236 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.020.245 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.021.255 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | ELG.022.265 | Coding requirement | UPDATE | 1. Value must be 20 characters or less2. Mandatory3. Must not contain a pipe symbol | 1. Value must be 20 characters or less2. Mandatory3. Must not contain a pipe or asterisk symbol |
| 2023-08-28 | ELG.022.267 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | MCR.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | MCR.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | MCR.002.032 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | MCR.003.049 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | MCR.003.049 | Coding requirement | UPDATE | 1. Value must be 10-digit number2. Optional | 1. Value must be 10-digit number2. Situational |
| 2023-08-28 | MCR.003.050 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | MCR.003.050 | Coding requirement | UPDATE | Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational | 1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 2023-08-28 | MCR.003.050 | Coding requirement | UPDATE | 1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Optional | Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 2023-08-28 | MCR.003.051 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | MCR.003.051 | Coding requirement | UPDATE | Optional | 1. Value must be a 10-digit number2. Situational |
| 2023-08-28 | PRV.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | PRV.002.026 | Coding requirement | UPDATE | 1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated | 1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals '03', then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to ‘2’ (NPI) |
| 2023-08-28 | PRV.002.035 | Coding requirement | UPDATE | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Conditional4. If populated, value must be on or after individual's Date of Birth5. Value must be less than or equal to associated End of Time Period (PRV.001.010)6. There can only be one value on all records when the value is populated7. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Conditional4. When populated, value must be on or after individual's Date of Birth5. Value must be less than or equal to associated End of Time Period (PRV.001.010)6. There can only be one value on all records when the value is populated7. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater |
| 2023-08-28 | TPL.001.002 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory | 1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 2023-08-28 | TPL.002.020 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Value must be 1 character5. Mandatory6. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
| 2023-08-28 | TPL.006.080 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | TPL.006.080 | Coding requirement | UPDATE | 1. Value must be 28 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 28 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-28 | TPL.006.081 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | TPL.006.081 | Coding requirement | UPDATE | 1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Optional | 1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Situational |
| 2023-08-28 | TPL.006.082 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | TPL.006.082 | Coding requirement | UPDATE | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Optional | 1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational |
| 2023-08-28 | TPL.006.083 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | TPL.006.083 | Coding requirement | UPDATE | 1. Value must be 10-digit number2. Optional | 1. Value must be 10-digit number2. Situational |
| 2023-08-28 | TPL.006.090 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | TPL.006.090 | Coding requirement | UPDATE | 1. Value must be 10 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 10 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-28 | TPL.006.091 | Necessity | UPDATE | Optional | Situational |
| 2023-08-28 | TPL.006.091 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional | 1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 2023-08-29 | CIP.002.216 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CIP.002.218 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CIP.002.219 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CLT.002.163 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CLT.002.165 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CLT.002.166 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | COT.002.140 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | COT.002.142 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | COT.002.143 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CRX.002.098 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CRX.002.100 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CRX.002.101 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | CRX.002.101 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 2023-08-29 | MCR.003.052 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | MCR.004.061 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | MCR.005.071 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | MCR.006.080 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | MCR.007.089 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.002.037 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.003.058 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.004.070 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.005.082 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.006.092 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.007.104 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.008.113 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.009.123 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | PRV.010.136 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | TPL.001.014 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | TPL.002.027 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | TPL.003.050 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | TPL.004.061 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | TPL.005.070 | Necessity | UPDATE | Optional | Situational |
| 2023-08-29 | TPL.006.086 | Necessity | UPDATE | Optional | Situational |
| 2023-09-01 | CIP.002.228 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 2023-09-01 | CIP.003.254 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 2023-09-01 | CIP.003.255 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 2023-09-01 | CLT.002.179 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 2023-09-01 | CLT.003.208 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 2023-09-01 | COT.003.178 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 2023-09-01 | COT.003.182 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 2023-09-01 | CRX.003.120 | Coding requirement | UPDATE | 1. Value must be 12 digits or less2. Value must be a valid National Drug Code3. Mandatory4. Value must have an associated Metric Decimal Quantity (CRX.003.144)5. Value must have an associated Unit of Measure (CRX.003.133) | 1. Value must be 12 digits or less2. Value must be a valid National Drug Code3. Mandatory4. Value must have an associated Dtl Metric Decimal Quantity (CRX.003.144)5. Value must have an associated Unit of Measure (CRX.003.133) |
| 2023-09-01 | CRX.003.127 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated if associated Crossover Indicator value is '0' (not a crossover claim)5. If value is greater than '0,' then Crossover Indicator must be '1' | Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. If associated Crossover Indicator value is '0' (not a crossover claim), value should not be populated5. If value is greater than '0,' then Crossover Indicator must be '1' |
| 2023-09-01 | CRX.003.129 | Coding requirement | UPDATE | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" | 1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 2023-09-06 | CLT.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-06 | COT.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-06 | COT.003.205 | Definition | UPDATE | The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. | The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. |
| 2023-09-06 | CRX.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-06 | ELG.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-06 | MCR.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-06 | PRV.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-06 | TPL.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-07 | CIP.002.206 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CIP.002.208 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CIP.002.210 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CLT.002.153 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CLT.002.155 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary.. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CLT.002.157 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | COT.002.130 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | COT.002.132 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | COT.002.134 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | COT.003.183 | Definition | UPDATE | The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. | The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. This field is only applicable when the service being billed can be quantified in discrete units, e.g. a number of visits or the number of units of a prescription/refill that were filled. |
| 2023-09-07 | COT.003.184 | Definition | UPDATE | The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. | The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
| 2023-09-07 | COT.003.184 | Definition | UPDATE | The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use theRevenue center -quantity Allowedfield. NOTE: One prescription for 100 250 milligram tablets results inPrescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value inPrescription Quantity allowedmust correspond with the value in Unit of measure. | The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
| 2023-09-07 | COT.003.186 | Definition | UPDATE | A code to categorize the services provided to a Medicaid or CHIP enrollee. | A code to categorize the services provided to a Medicaid or CHIP enrollee. For sub-capitation payments, report a TYPE-OF-SERVICE value 119, 120, or 122. |
| 2023-09-07 | CRX.002.087 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CRX.002.089 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-07 | CRX.002.092 | Definition | UPDATE | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. | The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary. |
| 2023-09-25 | CIP.002.219 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 2023-09-25 | CLT.002.166 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 2023-09-25 | COT.002.143 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 2023-09-25 | CRX.002.101 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 2023-11-02 | CIP.001.012 | Coding requirement | UPDATE | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 2023-11-02 | CIP.002.203 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional |
| 2023-11-02 | CIP.003.260 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) |
| 2023-11-02 | CIP.003.261 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file5. When Type of Claim is in ['1','3','A','C'], then value must be populated |
| 2023-11-02 | CIP.003.265 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 2023-11-02 | CLT.001.012 | Coding requirement | UPDATE | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 2023-11-02 | CLT.002.150 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional |
| 2023-11-02 | CLT.003.212 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) |
| 2023-11-02 | CLT.003.213 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file |
| 2023-11-02 | COT.001.012 | Coding requirement | UPDATE | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 2023-11-02 | COT.003.189 | Coding requirement | UPDATE | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID | 1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ["1","3","A","C"] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in "01", "02", "03", "04", "05", "06"] (active) |
| 2023-11-02 | COT.003.190 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file |
| 2023-11-02 | CRX.001.012 | Coding requirement | UPDATE | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 2023-11-02 | CRX.002.075 | Coding requirement | UPDATE | 1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Mandatory | 1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Mandatory4. Value must exist in the NPPES NPI data file5. NPPES Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 2023-11-02 | ELG.005.089 | Coding requirement | UPDATE | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSDI Indicator List (VVL)4. Value must be 1 character5. Conditional | 1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSDI Indicator List (VVL)4. Conditional |
| 2023-11-02 | ELG.005.091 | Coding requirement | UPDATE | 1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be '1'5. Value must not be populated or must be '000' when SSI Status (ELG.005.092) is not populated or is '000' | 1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1"5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" |
| 2023-11-02 | TPL.001.012 | Coding requirement | UPDATE | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory | 1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 2023-11-07 | CIP.002.026 | Segment key field identifier | UPDATE | Not Applicable | 4 |
| 2023-11-07 | CIP.002.026 | Coding requirement | UPDATE | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-11-07 | CLT.002.025 | Segment key field identifier | UPDATE | Not Applicable | 4 |
| 2023-11-07 | CLT.002.025 | Coding requirement | UPDATE | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-11-07 | COT.002.025 | Segment key field identifier | UPDATE | Not Applicable | 4 |
| 2023-11-07 | COT.002.025 | Coding requirement | UPDATE | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-11-07 | CRX.002.025 | Segment key field identifier | UPDATE | Not Applicable | 4 |
| 2023-11-07 | CRX.002.025 | Coding requirement | UPDATE | Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ | 1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 2023-11-09 | CIP.002.217 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 2023-11-09 | CLT.002.164 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 2023-11-09 | COT.002.141 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 2023-11-09 | CRX.002.099 | Coding requirement | UPDATE | Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional | 1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 2024-02-08 | CIP.001.002 | Definition | UPDATE | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". | A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 2023-09-28 | ADMITTING-DIAGNOSIS-CODE/CIP.002.030 | All Data Element Attributes | DELETE | CIP030|CIP.002.030|ADMITTING-DIAGNOSIS-CODE|Admitting Diagnosis Code|Conditional|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.|CIP030 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|183|189|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional |
N/A |
| 2023-09-28 | ADMITTING-DIAGNOSIS-CODE-FLAG/CIP.002.031 | All Data Element Attributes | DELETE | CIP031|CIP.002.031|ADMITTING-DIAGNOSIS-CODE-FLAG|Admitting Diagnosis Code Flag|Conditional|A flag that identifies the coding system used for the Admitting Diagnosis Code.|CIP031 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|190|190|1. Value must be in Diagnosis Code Flag List(VVL) 2. Value must be 1 character |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-1/CIP.002.032 | All Data Element Attributes | DELETE | CIP032|CIP.002.032|DIAGNOSIS-CODE-1|Diagnosis Code 1|Conditional|The primary/principal ICD-9/10-CM diagnosis code as reported on the claim.|CIP032 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|191|197|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. If Type of Claim (CIP.002.100) in ("1", "3", "A", "C", "U", "W") then value must be populated. |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-1/CIP.002.033 | All Data Element Attributes | DELETE | CIP033|CIP.002.033|DIAGNOSIS-CODE-FLAG-1|Diagnosis Code Flag 1|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP033 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|198|198|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-1/CIP.002.034 | All Data Element Attributes | DELETE | CIP034|CIP.002.034|DIAGNOSIS-POA-FLAG-1|Diagnosis POA Flag 1|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP034 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|199|199|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-2/CIP.002.035 | All Data Element Attributes | DELETE | CIP035|CIP.002.035|DIAGNOSIS-CODE-2|Diagnosis Code 2|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP035 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|200|206|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 1 (CIP.002.032) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-2/CIP.002.036 | All Data Element Attributes | DELETE | CIP036|CIP.002.036|DIAGNOSIS-CODE-FLAG-2|Diagnosis Code Flag 2|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP036 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|207|207|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-2/CIP.002.037 | All Data Element Attributes | DELETE | CIP037|CIP.002.037|DIAGNOSIS-POA-FLAG-2|Diagnosis POA Flag 2|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP037 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|208|208|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-3/CIP.002.038 | All Data Element Attributes | DELETE | CIP038|CIP.002.038|DIAGNOSIS-CODE-3|Diagnosis Code 3|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP038 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|209|215|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 2 (CIP.002.035) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-3/CIP.002.039 | All Data Element Attributes | DELETE | CIP039|CIP.002.039|DIAGNOSIS-CODE-FLAG-3|Diagnosis Code Flag 3|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP039 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|216|216|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-3/CIP.002.040 | All Data Element Attributes | DELETE | CIP040|CIP.002.040|DIAGNOSIS-POA-FLAG-3|Diagnosis POA Flag 3|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP040 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|217|217|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-4/CIP.002.041 | All Data Element Attributes | DELETE | CIP041|CIP.002.041|DIAGNOSIS-CODE-4|Diagnosis Code 4|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP041 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|218|224|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 3 (CIP.002.038) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-4/CIP.002.042 | All Data Element Attributes | DELETE | CIP042|CIP.002.042|DIAGNOSIS-CODE-FLAG-4|Diagnosis Code Flag 4|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP042 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|225|225|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-4/CIP.002.043 | All Data Element Attributes | DELETE | CIP043|CIP.002.043|DIAGNOSIS-POA-FLAG-4|Diagnosis POA Flag 4|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP043 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|226|226|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-5/CIP.002.044 | All Data Element Attributes | DELETE | CIP044|CIP.002.044|DIAGNOSIS-CODE-5|Diagnosis Code 5|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP044 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|227|233|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 4 (CIP.002.041) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-5/CIP.002.045 | All Data Element Attributes | DELETE | CIP045|CIP.002.045|DIAGNOSIS-CODE-FLAG-5|Diagnosis Code Flag 5|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP045 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|234|234|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-5/CIP.002.046 | All Data Element Attributes | DELETE | CIP046|CIP.002.046|DIAGNOSIS-POA-FLAG-5|Diagnosis POA Flag 5|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP046 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|235|235|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-6/CIP.002.047 | All Data Element Attributes | DELETE | CIP047|CIP.002.047|DIAGNOSIS-CODE-6|Diagnosis Code 6|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP047 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|236|242|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 5 (CIP.002.044) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-6/CIP.002.048 | All Data Element Attributes | DELETE | CIP048|CIP.002.048|DIAGNOSIS-CODE-FLAG-6|Diagnosis Code Flag 6|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP048 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|243|243|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-6/CIP.002.049 | All Data Element Attributes | DELETE | CIP049|CIP.002.049|DIAGNOSIS-POA-FLAG-6|Diagnosis POA Flag 6|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP049 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|244|244|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-7/CIP.002.050 | All Data Element Attributes | DELETE | CIP050|CIP.002.050|DIAGNOSIS-CODE-7|Diagnosis Code 7|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP050 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|245|251|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 6 (CIP.002.047) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-7/CIP.002.051 | All Data Element Attributes | DELETE | CIP051|CIP.002.051|DIAGNOSIS-CODE-FLAG-7|Diagnosis Code Flag 7|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP051 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|252|252|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-7/CIP.002.052 | All Data Element Attributes | DELETE | CIP052|CIP.002.052|DIAGNOSIS-POA-FLAG-7|Diagnosis POA Flag 7|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP052 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|253|253|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-8/CIP.002.053 | All Data Element Attributes | DELETE | CIP053|CIP.002.053|DIAGNOSIS-CODE-8|Diagnosis Code 8|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP053 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|254|260|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 7 (CIP.002.050) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-8/CIP.002.054 | All Data Element Attributes | DELETE | CIP054|CIP.002.054|DIAGNOSIS-CODE-FLAG-8|Diagnosis Code Flag 8|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP054 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|261|261|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-8/CIP.002.055 | All Data Element Attributes | DELETE | CIP055|CIP.002.055|DIAGNOSIS-POA-FLAG-8|Diagnosis POA Flag 8|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP055 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|262|262|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-9/CIP.002.056 | All Data Element Attributes | DELETE | CIP056|CIP.002.056|DIAGNOSIS-CODE-9|Diagnosis Code 9|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP056 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|263|269|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 8 (CIP.002.053) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-9/CIP.002.057 | All Data Element Attributes | DELETE | CIP057|CIP.002.057|DIAGNOSIS-CODE-FLAG-9|Diagnosis Code Flag 9|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP057 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|270|270|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-9/CIP.002.058 | All Data Element Attributes | DELETE | CIP058|CIP.002.058|DIAGNOSIS-POA-FLAG-9|Diagnosis POA Flag 9|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP058 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|271|271|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-10/CIP.002.059 | All Data Element Attributes | DELETE | CIP059|CIP.002.059|DIAGNOSIS-CODE-10|Diagnosis Code 10|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP059 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|272|278|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 9 (CIP.002.056) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-10/CIP.002.060 | All Data Element Attributes | DELETE | CIP060|CIP.002.060|DIAGNOSIS-CODE-FLAG-10|Diagnosis Code Flag 10|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP060 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|279|279|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-10/CIP.002.061 | All Data Element Attributes | DELETE | CIP061|CIP.002.061|DIAGNOSIS-POA-FLAG-10|Diagnosis POA Flag 10|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP061 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|280|280|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-11/CIP.002.062 | All Data Element Attributes | DELETE | CIP062|CIP.002.062|DIAGNOSIS-CODE-11|Diagnosis Code 11|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP062 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|281|287|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 10 (CIP.002.059) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-11/CIP.002.063 | All Data Element Attributes | DELETE | CIP063|CIP.002.063|DIAGNOSIS-CODE-FLAG-11|Diagnosis Code Flag 11|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP063 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|288|288|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-11/CIP.002.064 | All Data Element Attributes | DELETE | CIP064|CIP.002.064|DIAGNOSIS-POA-FLAG-11|Diagnosis POA Flag 11|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP064 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|289|289|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-12/CIP.002.065 | All Data Element Attributes | DELETE | CIP065|CIP.002.065|DIAGNOSIS-CODE-12|Diagnosis Code 12|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CIP065 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(7)|N/A|290|296|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 11 (CIP.002.062) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-12/CIP.002.066 | All Data Element Attributes | DELETE | CIP066|CIP.002.066|DIAGNOSIS-CODE-FLAG-12|Diagnosis Code Flag 12|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP066 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|297|297|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-12/CIP.002.067 | All Data Element Attributes | DELETE | CIP067|CIP.002.067|DIAGNOSIS-POA-FLAG-12|Diagnosis POA Flag 12|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CIP067 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|N/A|298|298|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-TYPE/CIP.002.123 | All Data Element Attributes | DELETE | CIP123|CIP.002.123|SERVICE-TRACKING-TYPE|Service Tracking Type|Conditional|A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee.|CIP123 Values|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|N/A|602|603|1. Value must be in Service Tracking Type List (VVL) 2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported 3. Value must be 2 characters 4. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-PAYMENT-AMT/CIP.002.124 | All Data Element Attributes | DELETE | CIP124|CIP.002.124|SERVICE-TRACKING-PAYMENT-AMT|Service Tracking Payment Amount|Conditional|On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(11)V99|N/A|604|616|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided 4. Conditional 5. When populated, Service Tracking Type must be populated 6. When populated, Total Medicaid Amount must not be populated |
N/A |
| 2023-09-28 | IMMUNIZATION-TYPE/CIP.003.248 | All Data Element Attributes | DELETE | CIP248|CIP.003.248|IMMUNIZATION-TYPE|Immunization Type|Conditional|This field identifies the type of immunization provided in order to track additional detail not currently contained in Current Procedural Terminology (CPT) codes.|CIP248 Values|CIP00003|CLAIM-LINE-RECORD-IP|X(2)|N/A|187|188|1. Value must be in Immunization Type List (VVL) 2. Value must be 2 characters 3. Conditional |
N/A |
| 2023-09-28 | BENEFIT-TYPE/CIP.003.268 | All Data Element Attributes | DELETE | CIP268|CIP.003.268|BENEFIT-TYPE|Benefit Type|Mandatory|The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types|CIP268 Values|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|N/A|330|332|1. Value must be in Benefit Type Code List (VVL) 2. Value must be 3 characters 3. Mandatory |
N/A |
| 2023-09-28 | XIX-MBESCBES-CATEGORY-OF-SERVICE/CIP.003.270 | All Data Element Attributes | DELETE | CIP270|CIP.003.270|XIX-MBESCBES-CATEGORY-OF-SERVICE|XIX MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation.|CIP270 Values|CIP00003|CLAIM-LINE-RECORD-IP|X(5)|N/A|335|339|1. Value must be in XIX MBESCBES Category of Service List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported 5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' 6. If XXI MBESCBES Category of Service is populated then must not be populated |
N/A |
| 2023-09-28 | XXI-MBESCBES-CATEGORY-OF-SERVICE/CIP.003.271 | All Data Element Attributes | DELETE | CIP271|CIP.003.271|XXI-MBESCBES-CATEGORY-OF-SERVICE|XXI MBESCBES Category of Service|Conditional|A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation.|CIP271 Values|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|N/A|340|342|1. Value must be in XXI MBESCBES Category of Service List (VVL) 2. Conditional 3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported 4. If XIX MBESCBES Category of Service is populated then value must not be populated 5. Value must be 3 characters or less |
N/A |
| 2023-09-28 | HCPCS-RATE/CIP.003.279 | All Data Element Attributes | DELETE | CIP279|CIP.003.279|HCPCS-RATE|HCPCS Rate|Conditional|This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44.|CIP279 Values|CIP00003|CLAIM-LINE-RECORD-IP|X(14)|N/A|856|869|1. Value must be 14 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Value must be in HCPCS Rate List (VVL) 4. Conditional |
N/A |
| 2023-09-28 | ADMITTING-DIAGNOSIS-CODE/CLT.002.027 | All Data Element Attributes | DELETE | CLT027|CLT.002.027|ADMITTING-DIAGNOSIS-CODE|Admitting Diagnosis Code|Conditional|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician.|CLT027 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(7)|N/A|160|166|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional |
N/A |
| 2023-09-28 | ADMITTING-DIAGNOSIS-CODE-FLAG/CLT.002.028 | All Data Element Attributes | DELETE | CLT028|CLT.002.028|ADMITTING-DIAGNOSIS-CODE-FLAG|Admitting Diagnosis Code Flag|Conditional|A flag that identifies the coding system used for the Admitting Diagnosis Code.|CLT028 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|167|167|1. Value must be in Diagnosis Code Flag List(VVL) 2. Value must be 1 character |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-1/CLT.002.029 | All Data Element Attributes | DELETE | CLT029|CLT.002.029|DIAGNOSIS-CODE-1|Diagnosis Code 1|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CLT029 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(7)|N/A|168|174|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. If Type of Claim (CLT.002.052) in ("1", "3", "A", "C", "U", "W") then value must be populated. |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-1/CLT.002.030 | All Data Element Attributes | DELETE | CLT030|CLT.002.030|DIAGNOSIS-CODE-FLAG-1|Diagnosis Code Flag 1|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT030 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|175|175|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-1/CLT.002.031 | All Data Element Attributes | DELETE | CLT031|CLT.002.031|DIAGNOSIS-POA-FLAG-1|Diagnosis POA Flag 1|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT031 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|176|176|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-2/CLT.002.032 | All Data Element Attributes | DELETE | CLT032|CLT.002.032|DIAGNOSIS-CODE-2|Diagnosis Code 2|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CLT032 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(7)|N/A|177|183|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 1 (CLT.002.029) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-2/CLT.002.033 | All Data Element Attributes | DELETE | CLT033|CLT.002.033|DIAGNOSIS-CODE-FLAG-2|Diagnosis Code Flag 2|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT033 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|184|184|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-2/CLT.002.034 | All Data Element Attributes | DELETE | CLT034|CLT.002.034|DIAGNOSIS-POA-FLAG-2|Diagnosis POA Flag 2|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT034 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|185|185|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-3/CLT.002.035 | All Data Element Attributes | DELETE | CLT035|CLT.002.035|DIAGNOSIS-CODE-3|Diagnosis Code 3|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CLT035 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(7)|N/A|186|192|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 2 (CLT.002.032) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-3/CLT.002.036 | All Data Element Attributes | DELETE | CLT036|CLT.002.036|DIAGNOSIS-CODE-FLAG-3|Diagnosis Code Flag 3|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT036 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|193|193|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-3/CLT.002.037 | All Data Element Attributes | DELETE | CLT037|CLT.002.037|DIAGNOSIS-POA-FLAG-3|Diagnosis POA Flag 3|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT037 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|194|194|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-4/CLT.002.038 | All Data Element Attributes | DELETE | CLT038|CLT.002.038|DIAGNOSIS-CODE-4|Diagnosis Code 4|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CLT038 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(7)|N/A|195|201|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 3 (CLT.002.035) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-4/CLT.002.039 | All Data Element Attributes | DELETE | CLT039|CLT.002.039|DIAGNOSIS-CODE-FLAG-4|Diagnosis Code Flag 4|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT039 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|202|202|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-4/CLT.002.040 | All Data Element Attributes | DELETE | CLT040|CLT.002.040|DIAGNOSIS-POA-FLAG-4|Diagnosis POA Flag 4|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT040 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|203|203|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-5/CLT.002.041 | All Data Element Attributes | DELETE | CLT041|CLT.002.041|DIAGNOSIS-CODE-5|Diagnosis Code 5|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|CLT041 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(7)|N/A|204|210|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. Value must not be populated when Diagnosis Code 4 (CLT.002.038) is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-5/CLT.002.042 | All Data Element Attributes | DELETE | CLT042|CLT.002.042|DIAGNOSIS-CODE-FLAG-5|Diagnosis Code Flag 5|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT042 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|211|211|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-5/CLT.002.043 | All Data Element Attributes | DELETE | CLT043|CLT.002.043|DIAGNOSIS-POA-FLAG-5|Diagnosis POA Flag 5|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|CLT043 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|N/A|212|212|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-TYPE/CLT.002.073 | All Data Element Attributes | DELETE | CLT073|CLT.002.073|SERVICE-TRACKING-TYPE|Service Tracking Type|Conditional|A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee.|CLT073 Values|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|N/A|416|417|1. Value must be in Service Tracking Type List (VVL) 2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported 3. Value must be 2 characters 4. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-PAYMENT-AMT/CLT.002.074 | All Data Element Attributes | DELETE | CLT074|CLT.002.074|SERVICE-TRACKING-PAYMENT-AMT|Service Tracking Payment Amount|Conditional|On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|S9(11)V99|N/A|418|430|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided 4. Conditional 5. When populated, Service Tracking Type must be populated 6. When populated, Total Medicaid Amount must not be populated |
N/A |
| 2023-09-28 | DAILY-RATE/CLT.002.146 | All Data Element Attributes | DELETE | CLT146|CLT.002.146|DAILY-RATE|Daily Rate|Conditional|The amount a policy will pay per day for a covered service.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|S9(5)V99|N/A|928|934|1. Value must be between 0.00 and 99999.99 2. Conditional 3. Value must be expressed as a number with 2-digit precision (e.g. 100.50) |
N/A |
| 2023-09-28 | IMMUNIZATION-TYPE/CLT.003.201 | All Data Element Attributes | DELETE | CLT201|CLT.003.201|IMMUNIZATION-TYPE|Immunization Type|Not Applicable|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|CLT201 Values|CLT00003|CLAIM-LINE-RECORD-LT|X(2)|N/A|187|188|Not Applicable | N/A |
| 2023-09-28 | BENEFIT-TYPE/CLT.003.218 | All Data Element Attributes | DELETE | CLT218|CLT.003.218|BENEFIT-TYPE|Benefit Type|Mandatory|The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types|CLT218 Values|CLT00003|CLAIM-LINE-RECORD-LT|X(3)|N/A|337|339|1. Value must be in Benefit Type Code List (VVL) 2. Value must be 3 characters 3. Mandatory |
N/A |
| 2023-09-28 | XIX-MBESCBES-CATEGORY-OF-SERVICE/CLT.003.224 | All Data Element Attributes | DELETE | CLT224|CLT.003.224|XIX-MBESCBES-CATEGORY-OF-SERVICE|XIX MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation.|CLT224 Values|CLT00003|CLAIM-LINE-RECORD-LT|X(5)|N/A|351|355|1. Value must be in XIX MBESCBES Category of Service List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported 5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' 6. If XXI MBESCBES Category of Service is populated then must not be populated |
N/A |
| 2023-09-28 | XXI-MBESCBES-CATEGORY-OF-SERVICE/CLT.003.225 | All Data Element Attributes | DELETE | CLT225|CLT.003.225|XXI-MBESCBES-CATEGORY-OF-SERVICE|XXI MBESCBES Category of Service|Conditional|A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation.|CLT225 Values|CLT00003|CLAIM-LINE-RECORD-LT|X(3)|N/A|356|358|1. Value must be in XXI MBESCBES Category of Service List (VVL) 2. Conditional 3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported 4. If XIX MBESCBES Category of Service is populated then value must not be populated 5. Value must be 3 characters or less |
N/A |
| 2023-09-28 | HCPCS-RATE/CLT.003.231 | All Data Element Attributes | DELETE | CLT231|CLT.003.231|HCPCS-RATE|HCPCS Rate|Conditional|This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44.|CLT231 Values|CLT00003|CLAIM-LINE-RECORD-LT|X(14)|N/A|884|897|1. Value must be 14 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Value must be in HCPCS Rate List (VVL) 4. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-1/COT.002.027 | All Data Element Attributes | DELETE | COT027|COT.002.027|DIAGNOSIS-CODE-1|Diagnosis Code 1|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|COT027 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(7)|N/A|160|166|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. If Type of Claim (COT.002.037) is in ("1", "3", "A", "C", "U", "W") then Diagnosis Code 1 (COT.002.027) must be populated. |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-1/COT.002.028 | All Data Element Attributes | DELETE | COT028|COT.002.028|DIAGNOSIS-CODE-FLAG-1|Diagnosis Code Flag 1|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|COT028 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|N/A|167|167|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-1/COT.002.029 | All Data Element Attributes | DELETE | COT029|COT.002.029|DIAGNOSIS-POA-FLAG-1|Diagnosis POA Flag 1|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|COT029 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|N/A|168|168|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-2/COT.002.030 | All Data Element Attributes | DELETE | COT030|COT.002.030|DIAGNOSIS-CODE-2|Diagnosis Code 2|Conditional|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".|COT030 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(7)|N/A|169|175|1. When populated, a Diagnosis Code Flag is required 2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 4. Value must be a minimum of 3 characters 5. Value must not contain a decimal point 6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters 7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters 8. When there is more than one diagnosis code on a claim, each value must be unique 9. Conditional 10. When populated, value cannot equal Diagnosis Code 1 (COT.002.027) 11. When Diagnosis Code 1 (COT.002.027) is not populated, value should not be populated |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG-2/COT.002.031 | All Data Element Attributes | DELETE | COT031|COT.002.031|DIAGNOSIS-CODE-FLAG-2|Diagnosis Code Flag 2|Conditional|Flag used to identify if associated Diagnosis Code field is reported with ICD-9 or ICD-10 code. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|COT031 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|N/A|176|176|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Conditional 4. Value should not be populated, if the associated diagnosis code is not populated |
N/A |
| 2023-09-28 | DIAGNOSIS-POA-FLAG-2/COT.002.032 | All Data Element Attributes | DELETE | COT032|COT.002.032|DIAGNOSIS-POA-FLAG-2|Diagnosis POA Flag 2|Conditional|A code to identify conditions that are present at the time the order for inpatient admission occurs; conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery. POA indicator is used to identify certain preventable conditions that are: (a) high cost or high volume or both, (b) result in the assignment of a case to a Diagnosis Related Group (DRG)* that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. *States that do not use the grouper methodology may use CMS-approved methodology that is prospective in nature. Each Diagnosis Code Flag is associated with one, and only one, Diagnosis Code in a given file segment record. For example, Diagnosis Code n is associated with Diagnosis Code Flag n, where n can be any integer greater than or equal to 1.|COT032 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|N/A|177|177|1. Value must be in Diagnosis POA Flag List (VVL) 2. Value must be 1 character 3. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-TYPE/COT.002.059 | All Data Element Attributes | DELETE | COT059|COT.002.059|SERVICE-TRACKING-TYPE|Service Tracking Type|Conditional|A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee.|COT059 Values|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|N/A|361|362|1. Value must be in Service Tracking Type List (VVL) 2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported 3. Value must be 2 characters 4. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-PAYMENT-AMT/COT.002.060 | All Data Element Attributes | DELETE | COT060|COT.002.060|SERVICE-TRACKING-PAYMENT-AMT|Service Tracking Payment Amount|Conditional|On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|S9(11)V99|N/A|363|375|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided 4. Conditional 5. When populated, Service Tracking Type must be populated 6. When populated, Total Medicaid Amount must not be populated |
N/A |
| 2023-09-28 | UNDER-SUPERVISION-OF-PROV-NPI/COT.002.150 | All Data Element Attributes | DELETE | COT150|COT.002.150|UNDER-SUPERVISION-OF-PROV-NPI|Under Supervision of Provider NPI|Not Applicable|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|N/A|1024|1033|Not Applicable | N/A |
| 2023-09-28 | ORDERING-PROV-NUM/COT.002.228 | All Data Element Attributes | DELETE | COT228|COT.002.228|ORDERING-PROV-NUM|Ordering Provider Number|Conditional|The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. [Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(30)|N/A|1539|1568|1. Value must be 30 characters or less 2. Conditional |
N/A |
| 2023-09-28 | ORDERING-PROV-NPI-NUM/COT.002.229 | All Data Element Attributes | DELETE | COT229|COT.002.229|ORDERING-PROV-NPI-NUM|Ordering Provider NPI Number|Conditional|The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. [Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|N/A|1569|1578|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
N/A |
| 2023-09-28 | IMMUNIZATION-TYPE/COT.003.173 | All Data Element Attributes | DELETE | COT173|COT.003.173|IMMUNIZATION-TYPE|Immunization Type|Not Applicable|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|COT173 Values|COT00003|CLAIM-LINE-RECORD-OT|X(2)|N/A|207|208|Not Applicable | N/A |
| 2023-09-28 | BENEFIT-TYPE/COT.003.209 | All Data Element Attributes | DELETE | COT209|COT.003.209|BENEFIT-TYPE|Benefit Type|Mandatory|The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types|COT209 Values|COT00003|CLAIM-LINE-RECORD-OT|X(3)|N/A|715|717|1. Value must be in Benefit Type Code List (VVL) 2. Value must be 3 characters 3. Mandatory |
N/A |
| 2023-09-28 | XIX-MBESCBES-CATEGORY-OF-SERVICE/COT.003.211 | All Data Element Attributes | DELETE | COT211|COT.003.211|XIX-MBESCBES-CATEGORY-OF-SERVICE|XIX MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation.|COT211 Values|COT00003|CLAIM-LINE-RECORD-OT|X(5)|N/A|720|724|1. Value must be in XIX MBESCBES Category of Service List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported 5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' 6. If XXI MBESCBES Category of Service is populated then must not be populated |
N/A |
| 2023-09-28 | XXI-MBESCBES-CATEGORY-OF-SERVICE/COT.003.212 | All Data Element Attributes | DELETE | COT212|COT.003.212|XXI-MBESCBES-CATEGORY-OF-SERVICE|XXI MBESCBES Category of Service|Conditional|A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation.|COT212 Values|COT00003|CLAIM-LINE-RECORD-OT|X(3)|N/A|725|727|1. Value must be in XXI MBESCBES Category of Service List (VVL) 2. Conditional 3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported 4. If XIX MBESCBES Category of Service is populated then value must not be populated 5. Value must be 3 characters or less |
N/A |
| 2023-09-28 | DIAGNOSIS-CODE/COT.004.284 | Entire New Data Element | ADD | N/A | COT284|COT.004.284|DIAGNOSIS-CODE|Diagnosis Code|Mandatory|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'.|DIAGNOSIS-CODE|COT00004|CLAIM-DX-OT|X(7)|11|135|141|1. If associated Diagnosis Code Flag value is '1' (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 2. If associated Diagnosis Code Flag value is '2' (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 3. Value must be a minimum of 3 characters 4. Value must not contain a decimal point 5. Mandatory |
| 2023-09-28 | STATE-NOTATION/COT.004.285 | Entire New Data Element | ADD | N/A | COT285|COT.004.285|STATE-NOTATION|State Notation|Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|COT00004|CLAIM-DX-OT|X(500)|12|142|641|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/CRX.002.022 | Definition; Coding Requirement |
UPDATE | CRX022|CRX.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(20)|N/A|134|153|1. Mandatory 2. Value must be 20 characters or less 3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
CRX022|CRX.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(20)|7|134|153|1. Mandatory 2. Value must be 20 characters or less 3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
| 2023-09-28 | CROSSOVER-INDICATOR/CRX.002.023 | Definition; Coding Requirement |
UPDATE | CRX023|CRX.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Conditional|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CRX023 Values|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|N/A|154|154|1. Value must be in Crossover Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) 5. Value must be 1 character 6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported. 7. Conditional |
CRX023|CRX.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|8|154|154|1. Value must be in Crossover Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) 5. Value must be 1 character 6. Mandatory |
| 2023-09-28 | ADJUSTMENT-IND/CRX.002.025 | Coding Requirement | UPDATE | CRX025|CRX.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record. |CRX025 Values|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|N/A|156|156|1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory |
CRX025|CRX.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record. |ADJUSTMENT-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|10|156|156|1. Value must be in Adjustment Indicator List (VVL). 2. Value must be in [0, 1, 4]. 3. Value must be 1 character. 4. Mandatory |
| 2023-09-28 | TOT-BILLED-AMT/CRX.002.039 | Definition; Coding Requirement |
UPDATE | CRX039|CRX.002.039|TOT-BILLED-AMT|Total Billed Amount|Conditional|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|S9(11)V99|N/A|228|240|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Value must equal the sum of all Billed Amount instances for the associated claim 4. Conditional 5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] |
CRX039|CRX.002.039|TOT-BILLED-AMT|Total Billed Amount|Conditional|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|S9(11)V99|24|228|240|1. Value must be between -99999999999.99 and 99999999999.99. 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ). 3. Value must equal the sum of all Billed Amount instances for the associated claim. 4. Conditional |
| 2023-09-28 | SERVICE-TRACKING-TYPE/CRX.002.050 | All Data Element Attributes | DELETE | CRX050|CRX.002.050|SERVICE-TRACKING-TYPE|Service Tracking Type|Conditional|A code to categorize service tracking claims. A "service tracking claim" is used to report lump sum payments that cannot be attributed to a single enrollee.|CRX050 Values|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|N/A|323|324|1. Value must be in Service Tracking Type List (VVL) 2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported 3. Value must be 2 characters 4. Conditional |
N/A |
| 2023-09-28 | SERVICE-TRACKING-PAYMENT-AMT/CRX.002.051 | All Data Element Attributes | DELETE | CRX051|CRX.002.051|SERVICE-TRACKING-PAYMENT-AMT|Service Tracking Payment Amount|Conditional|On service tracking claims, the payment amount is the lump sum that cannot be attributed to any one beneficiary paid to the provider.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|S9(11)V99|N/A|325|337|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided 4. Conditional 5. When populated, Service Tracking Type must be populated 6. When populated, Total Medicaid Amount must not be populated |
N/A |
| 2023-09-28 | PLAN-ID-NUMBER/CRX.002.056 | Coding Requirement | UPDATE | CRX056|CRX.002.056|PLAN-ID-NUMBER|Plan ID Number|Conditional|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(12)|N/A|345|356|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. Value should be populated when Type of Claim (CRX.002.029) is in [3, C, W, 2, B, V] 7. When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) 8. When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
CRX056|CRX.002.056|PLAN-ID-NUMBER|Plan ID Number|Conditional|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(12)|37|330|341|1. Value must be 12 characters or less. 2. Value must not contain a pipe or asterisk symbols. 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192). 5. Value must match State Plan ID Number (MCR.002.019). 6. Value should be populated when Type of Claim (CRX.002.029) is in [3, C, W]. 7. When Type of Claim in [3, C, W] value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198). 8. When Type of Claim in [3, C, W] value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021). |
| 2023-09-28 | BILLING-PROV-NUM/CRX.002.070 | Definition; Coding Requirement |
UPDATE | CRX070|CRX.002.070|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(30)|N/A|477|506|1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier 5. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
CRX070|CRX.002.070|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(30)|50|462|491|1. Value must be 30 characters or less. 2. Conditional 3. When Type of Claim not in ('3','C','W') then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in ('3','C','W') then value may match (PRV.005.081) Provider Identifier where the Provider Identifier. 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080). |
| 2023-09-28 | PRESCRIPTION-FILL-DATE/CRX.002.085 | Definition; Coding Requirement |
UPDATE | CRX085|CRX.002.085|PRESCRIPTION-FILL-DATE|Prescription Fill Date|Mandatory|Date the drug, device, or supply was dispensed by the provider. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|9(8)|N/A|622|629|1. Value must be 8 characters in the form 'CCYYMMDD' 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be on or before associated End of Time Period (CRX.001.010) 4. Value must be on or after associated Start of Time Period (CRX.001.009) 5. Value must be on or after associated Date Prescribed (CRX.002.084) 6. Value must be on or after associated eligible party's Date of Birth (ELG.002.024) 7. Value must be on or before associated eligible party's Date of Death (ELG.002.025) 8. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal '1' and Type of Claim (CRX.002.029) does not equal 'Z' 9. Mandatory |
CRX085|CRX.002.085|PRESCRIPTION-FILL-DATE|Prescription Fill Date|Mandatory|Date the drug, device, or supply was dispensed by the provider. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|9(8)|60|607|614|1. Value must be 8 characters in the form 'CCYYMMDD'. 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st). 3. Value must be on or before associated End of Time Period (CRX.001.010). 4. Value must be on or after associated Start of Time Period (CRX.001.009). 5. Value must be on or after associated Date Prescribed (CRX.002.084). 6. Value must be on or after associated eligible party's Date of Birth (ELG.002.024). 7. Value must be on or before associated eligible party's Date of Death (ELG.002.025). 8. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal '1'. 9. Mandatory |
| 2023-09-28 | DISPENSING-PRESCRIPTION-DRUG-PROV-NUM/CRX.002.156 | Definition; Coding Requirement |
UPDATE | CRX156|CRX.002.156|DISPENSING-PRESCRIPTION-DRUG-PROV-NUM|Dispensing Prescription Drug Provider Number|Mandatory|The state-specific provider id of the provider who actually dispensed the prescription medication.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(30)|N/A|1320|1349|1. Value must be 30 characters or less 2. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Submitting State Provider ID (PRV.002.019) or 3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) = '1' 4. Mandatory |
CRX156|CRX.002.156|DISPENSING-PRESCRIPTION-DRUG-PROV-NUM|Dispensing Prescription Drug Provider Number|Mandatory|The state-specific provider id of the provider who actually dispensed the prescription medication.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(30)|78|805|834|1. Value must be 30 characters or less. 2. When Type of Claim not in ('3','C','W') then value may match Submitting State Provider ID (PRV.002.019) or 3. When Type of Claim not in ('3','C','W') then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) = '1'. 4. Mandatory |
| 2023-09-28 | LTC-RCP-LIAB-AMT/CRX.002.173 | Entire New Data Element | ADD | N/A | CRX173|CRX.002.173|LTC-RCP-LIAB-AMT|LTC RCP Liability Amount|Conditional|The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|S9(11)V99|86|894|906|1. Value must be between -99999999999.99 and 99999999999.99 . 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ). 3. Conditional |
| 2023-09-28 | PROVIDER-CLAIM-FORM-CODE/CRX.002.174 | Entire New Data Element | ADD | N/A | CRX174|CRX.002.174|PROVIDER-CLAIM-FORM-CODE|Provider Claim Form Code|Mandatory|A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other".|PROVIDER-CLAIM-FORM-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|87|907|908|1. Value must not be more than 2 characters 2. Value must be in Provider Claim Form Code List (VVL) 3. Mandatory |
| 2023-09-28 | PROVIDER-CLAIM-FORM-OTHER-TEXT/CRX.002.175 | Entire New Data Element | ADD | N/A | CRX175|CRX.002.175|PROVIDER-CLAIM-FORM-OTHER-TEXT|Provider Claim Form Other Text|Conditional|A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(50)|88|909|958|1. Value must not be more than 50 characters long. 2. Conditional 3. Value is mandatory when corresponding Provider Claim Form Code is 'Other' |
| 2023-09-28 | TOT-GME-AMOUNT-PAID/CRX.002.176 | Entire New Data Element | ADD | N/A | CRX176|CRX.002.176|TOT-GME-AMOUNT-PAID|Total GME Amount Paid|Conditional|The amount included in the Total Medicaid Amount (CRX.002.041) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.|N/A|CRX00002|CLAIM-HEADER-RECORD-IP|S9(11)V99|89|959|971|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
| 2023-09-28 | TOT-SDP-ALLOWED-AMT/CRX.002.177 | Entire New Data Element | ADD | N/A | CRX177|CRX.002.177|TOT-SDP-ALLOWED-AMT|Total State Directed Payment Allowed Amount|Conditional|The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii).|N/A|CRX00002|CLAIM-HEADER-RECORD-IP|S9(11)V99|90|972|984|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
| 2023-09-28 | TOT-SDP-PAID-AMT/CRX.002.178 | Entire New Data Element | ADD | N/A | CRX178|CRX.002.178|TOT-SDP-PAID-AMT|Total State Directed Payment Paid Amount|Conditional|The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii).|N/A|CRX00002|CLAIM-HEADER-RECORD-IP|S9(11)V99|91|985|997|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/CRX.003.111 | Definition; Coding Requirement |
UPDATE | CRX111|CRX.003.111|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less 3. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
CRX111|CRX.003.111|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less. |
| 2023-09-28 | LINE-ADJUSTMENT-IND/CRX.003.116 | Coding Requirement | UPDATE | CRX116|CRX.003.116|LINE-ADJUSTMENT-IND|Line Adjustment Indicator|Conditional|A code to indicate the type of adjustment record claim/encounter represents at claim detail level. |CRX116 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|N/A|148|148|1. Value must be in Line Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6] 4. Value must be 1 character 5. Conditional 6. If associated Line Adjustment Number is populated, then value must be populated |
CRX116|CRX.003.116|LINE-ADJUSTMENT-IND|Line Adjustment Indicator|Conditional|A code to indicate the type of adjustment record claim/encounter represents at claim detail level. |LINE-ADJUSTMENT-IND|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|9|148|148|1. Value must be in Line Adjustment Indicator List (VVL) 2. Value must be in [0, 1, 4] 3. Value must be 1 character 4. Conditional 5. If associated Line Adjustment Number is populated, then value must be populated |
| 2023-09-28 | PRESCRIPTION-QUANTITY-ALLOWED/CRX.003.131 | Coding Requirement | UPDATE | CRX131|CRX.003.131|PRESCRIPTION-QUANTITY-ALLOWED|Prescription Quantity Allowed|Conditional|The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(8)V999|N/A|290|300|1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. When populated, corresponding Unit of Measure must be populated 3. Conditional |
CRX131|CRX.003.131|PRESCRIPTION-QUANTITY-ALLOWED|Prescription Quantity Allowed|Conditional|The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|23|290|307|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. When populated, corresponding Unit of Measure must be populated 3. Conditional |
| 2023-09-28 | PRESCRIPTION-QUANTITY-ACTUAL/CRX.003.132 | Size; Coding Requirement |
UPDATE | CRX132|CRX.003.132|PRESCRIPTION-QUANTITY-ACTUAL|Prescription Quantity Actual|Conditional|The quantity of a drug that is dispensed for a prescription as reported ny National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(8)V999|N/A|301|311|1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Conditional 3. If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported. 4. When populated, corresponding Unit of Measure must be populated |
CRX132|CRX.003.132|PRESCRIPTION-QUANTITY-ACTUAL|Prescription Quantity Actual|Mandatory|The quantity of a drug that is dispensed for a prescription as reported ny National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|24|308|325|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Mandatory 3. When populated, corresponding Unit of Measure must be populated |
| 2023-09-28 | IMMUNIZATION-TYPE/CRX.003.147 | All Data Element Attributes | DELETE | CRX147|CRX.003.147|IMMUNIZATION-TYPE|Immunization Type|Not Applicable|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|CRX147 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|N/A|373|374|Not Applicable | N/A |
| 2023-09-28 | BENEFIT-TYPE/CRX.003.148 | All Data Element Attributes | DELETE | CRX148|CRX.003.148|BENEFIT-TYPE|Benefit Type|Mandatory|The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types|CRX148 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|N/A|375|377|1. Value must be in Benefit Type Code List (VVL) 2. Value must be 3 characters 3. Mandatory |
N/A |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/CRX.003.149 | Definition; Coding Requirement |
UPDATE | CRX149|CRX.003.149|CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT|CMS 64 Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CRX149 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|N/A|378|379|1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL) 2. Value must be 2 characters 3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3'] 4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1' 5. Conditional 6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. 7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
CRX149|CRX.003.149|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|39|387|388|1. Value must be in Category for Federal Reimbursement List (VVL). 2. Value must be 2 characters. 3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']. 4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'. 5. Conditional 6. If Type of Claim is in ['1','A','U'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. |
| 2023-09-28 | XIX-MBESCBES-CATEGORY-OF-SERVICE/CRX.003.150 | All Data Element Attributes | DELETE | CRX150|CRX.003.150|XIX-MBESCBES-CATEGORY-OF-SERVICE|XIX MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation.|CRX150 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(5)|N/A|380|384|1. Value must be in XIX MBESCBES Category of Service List (VVL) 2. Value must be 5 characters or less 3. Conditional 4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported 5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M' 6. If XXI MBESCBES Category of Service is populated then must not be populated |
N/A |
| 2023-09-28 | XXI-MBESCBES-CATEGORY-OF-SERVICE/CRX.003.151 | All Data Element Attributes | DELETE | CRX151|CRX.003.151|XXI-MBESCBES-CATEGORY-OF-SERVICE|XXI MBESCBES Category of Service|Conditional|A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation.|CRX151 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|N/A|385|387|1. Value must be in XXI MBESCBES Category of Service List (VVL) 2. Conditional 3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported 4. If XIX MBESCBES Category of Service is populated then value must not be populated 5. Value must be 3 characters or less |
N/A |
| 2023-09-28 | IHS-SERVICE-IND/CRX.003.172 | Coding Requirement | UPDATE | CRX172|CRX.003.172|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |CRX172 Values|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|N/A|995|995|1. Value must be 1 character 2. Value must be in [0, 1] |
CRX172|CRX.003.172|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |IHS-SERVICE-IND|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|49|496|496|1. Value must be 1 character 2. Value must be in [0, 1] 3. Mandatory |
| 2023-09-28 | UNIQUE-DEVICE-IDENTIFIER/CRX.003.179 | Entire New Data Element | ADD | N/A | CRX179|CRX.003.179|UNIQUE-DEVICE-IDENTIFIER|Unique Device Identifier|Conditional|An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(76)|50|497|572|1. Value must not be more than 76 characters long. 2. Conditional |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/CRX.003.180 | Entire New Data Element | ADD | N/A | CRX180|CRX.003.180|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|CRX00003|CLAIM-LINE-RECORD-RX|X(5)|51|573|577|1. Value must not be more than 5 characters 2. Value must be in MBES or CBES Category of Service Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
| 2023-09-28 | MBESCBES-FORM/CRX.003.181 | Entire New Data Element | ADD | N/A | CRX181|CRX.003.181|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CRX00003|CLAIM-LINE-RECORD-RX|X(50)|52|578|627|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
| 2023-09-28 | PROCEDURE-CODE/CRX.003.182 | Entire New Data Element | ADD | N/A | CRX182|CRX.003.182|PROCEDURE-CODE|Procedure Code|Conditional|The procedure code (e.g., CPT, HCPCS, or other procedure code that is not an NDC or UDI) reported by a pharmacy on their NDPCP transaction.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(6)|53|628|633|1. Value must not be more than 6 characters. 2. Value must be in Procedure Code List (VVL) 3. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-1/CRX.003.183 | Entire New Data Element | ADD | N/A | CRX183|CRX.003.183|PROCEDURE-CODE-MODIFIER-1|Procedure Code Modifier 1|Conditional|The first modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|54|634|635|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-2/CRX.003.184 | Entire New Data Element | ADD | N/A | CRX184|CRX.003.184|PROCEDURE-CODE-MODIFIER-2|Procedure Code Modifier 2|Conditional|The second modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|55|636|637|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-3/CRX.003.185 | Entire New Data Element | ADD | N/A | CRX185|CRX.003.185|PROCEDURE-CODE-MODIFIER-3|Procedure Code Modifier 3|Conditional|The third modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|56|638|639|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-4/CRX.003.186 | Entire New Data Element | ADD | N/A | CRX186|CRX.003.186|PROCEDURE-CODE-MODIFIER-4|Procedure Code Modifier 4|Conditional|The fourth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|57|640|641|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-5/CRX.003.187 | Entire New Data Element | ADD | N/A | CRX187|CRX.003.187|PROCEDURE-CODE-MODIFIER-5|Procedure Code Modifier 5|Conditional|The fifth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|58|642|643|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-6/CRX.003.188 | Entire New Data Element | ADD | N/A | CRX188|CRX.003.188|PROCEDURE-CODE-MODIFIER-6|Procedure Code Modifier 6|Conditional|The sixth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|59|644|645|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-7/CRX.003.189 | Entire New Data Element | ADD | N/A | CRX189|CRX.003.189|PROCEDURE-CODE-MODIFIER-7|Procedure Code Modifier 7|Conditional|The seventh modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|60|646|647|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-8/CRX.003.190 | Entire New Data Element | ADD | N/A | CRX190|CRX.003.190|PROCEDURE-CODE-MODIFIER-8|Procedure Code Modifier 8|Conditional|The eighth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|61|648|649|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-9/CRX.003.191 | Entire New Data Element | ADD | N/A | CRX191|CRX.003.191|PROCEDURE-CODE-MODIFIER-9|Procedure Code Modifier 9|Conditional|The ninth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|62|650|651|1. Value must be 2 characters 2. Conditional |
| 2023-09-28 | PROCEDURE-CODE-MODIFIER-10/CRX.003.192 | Entire New Data Element | ADD | N/A | CRX192|CRX.003.192|PROCEDURE-CODE-MODIFIER-10|Procedure Code Modifier 10|Conditional|The tenth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|63|652|653|1. Value must be 2 characters. 2. Conditional |
| 2023-09-28 | GME-AMOUNT-PAID/CRX.003.193 | Entire New Data Element | ADD | N/A | CRX193|CRX.003.193|GME-AMOUNT-PAID|GME Amount Paid|Conditional|The amount included in the Medicaid Amount (CRX.003.125) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(11)V99|64|654|666|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
| 2023-09-28 | SDP-ALLOWED-AMT/CRX.003.194 | Entire New Data Element | ADD | N/A | CRX194|CRX.003.194|SDP-ALLOWED-AMT|State Directed Payment Allowed Amount|Conditional|The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii).|N/A|CRX00003|CLAIM-LINE-RECORD-IP|S9(11)V99|65|667|679|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
| 2023-09-28 | SDP-PAID-AMT/CRX.003.195 | Entire New Data Element | ADD | N/A | CRX195|CRX.003.195|SDP-PAID-AMT|State Directed Payment Paid Amount|Conditional|The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii).|N/A|CRX00003|CLAIM-LINE-RECORD-IP|S9(11)V99|66|680|692|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
| 2023-09-28 | RECORD-ID/CRX.004.196 | Entire New Data Element | ADD | N/A | CRX196|CRX.004.196|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|CRX00004|CLAIM-DX-RX|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
| 2023-09-28 | SUBMITTING-STATE/CRX.004.197 | Entire New Data Element | ADD | N/A | CRX197|CRX.004.197|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|CRX00004|CLAIM-DX-RX|X(2)|2|9|10|1. Value must be in State Code List (VVL) 2. Value must be 2 characters 3. Mandatory 4. Value must be the same as Submitting State (CRX.001.007) |
| 2023-09-28 | RECORD-NUMBER/CRX.004.198 | Entire New Data Element | ADD | N/A | CRX198|CRX.004.198|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|CRX00004|CLAIM-DX-RX|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID (CE) 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/CRX.004.199 | Entire New Data Element | ADD | N/A | CRX199|CRX.004.199|ICN-ORIG|Original ICN|Mandatory|A unique number assigned by the state's payment system that identifies an original or adjustment claim.|N/A|CRX00004|CLAIM-DX-RX|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2023-09-28 | ICN-ADJ/CRX.004.200 | Entire New Data Element | ADD | N/A | CRX200|CRX.004.200|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00004|CLAIM-DX-RX|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/CRX.004.201 | Entire New Data Element | ADD | N/A | CRX201|CRX.004.201|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|LINE-ADJUSTMENT-IND|CRX00004|CLAIM-DX-RX|X(1)|6|122|122|1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory |
| 2023-09-28 | ADJUDICATION-DATE/CRX.004.202 | Entire New Data Element | ADD | N/A | CRX202|CRX.004.202|ADJUDICATION-DATE|Adjudication Date|Mandatory|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.|N/A|CRX00004|CLAIM-DX-RX|9(8)|7|123|130|1. Value must be 8 characters in the form 'CCYYMMDD' 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value should be on or before End of Time Period value found in associated T-MSIS File Header Record 4. Mandatory |
| 2023-09-28 | DIAGNOSIS-TYPE/CRX.004.203 | Entire New Data Element | ADD | N/A | CRX203|CRX.004.203|DIAGNOSIS-TYPE|Diagnosis Type|Mandatory|Indicates the context of the diagnosis code from the provider's claim (i.e., an NCPDP claim can have up to 5 diagnosis codes). The type of diagnosis code (e.g., principal, admitting, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number.|DIAGNOSIS-TYPE|CRX00004|CLAIM-DX-RX|X(1)|8|131|131|1. Value must be 1 character 2. Value must be in Diagnosis Type Code List (VVL) 3. Value must be in [D] 4. Mandatory |
| 2023-09-28 | DIAGNOSIS-SEQUENCE-NUMBER/CRX.004.204 | Entire New Data Element | ADD | N/A | CRX204|CRX.004.204|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an NCPDP claim can have up to 5 diagnosis codes).|N/A|CRX00004|CLAIM-DX-RX|9(2)|9|132|133|1. Value must be between 1 and 24 2. Mandatory |
| 2023-09-28 | DIAGNOSIS-CODE-FLAG/CRX.004.205 | Entire New Data Element | ADD | N/A | CRX205|CRX.004.205|DIAGNOSIS-CODE-FLAG|Diagnosis Code Flag|Mandatory|Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code.|DIAGNOSIS-CODE-FLAG|CRX00004|CLAIM-DX-RX|X(1)|10|134|134|1. Value must be in Diagnosis Code Flag List (VVL) 2. Value must be 1 character 3. Mandatory |
| 2023-09-28 | DIAGNOSIS-CODE/CRX.004.206 | Entire New Data Element | ADD | N/A | CRX206|CRX.004.206|DIAGNOSIS-CODE|Diagnosis Code|Mandatory|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'.|DIAGNOSIS-CODE|CRX00004|CLAIM-DX-RX|X(7)|11|135|141|1. If associated Diagnosis Code Flag value is '1' (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL) 2. If associated Diagnosis Code Flag value is '2' (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL) 3. Value must be a minimum of 3 characters 4. Value must not contain a decimal point 5. Mandatory |
| 2023-09-28 | STATE-NOTATION/CRX.004.207 | Entire New Data Element | ADD | N/A | CRX207|CRX.004.207|STATE-NOTATION|State Notation|Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|CRX00004|CLAIM-DX-RX|X(500)|12|142|641|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | FILE-SUBMISSION-METHOD/ELG.001.272 | Entire New Data Element | ADD | N/A | ELG272|ELG.001.272|FILE-SUBMISSION-METHOD|File Submission Method|Mandatory|The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period.|FILE-SUBMISSION-METHOD|ELG00001|FILE-SUBMISSION-METHOD|X(2)|14|79|80|1. Value must be in File Submission Method List (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.002.019 | Definition | UPDATE | ELG019|ELG.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00002|PRIMARY-DEMOGRAPHICS-ELIGIBILITY|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG019|ELG.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00002|PRIMARY-DEMOGRAPHICS-ELIGIBILITY|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.003.033 | Definition; Coding Requirement |
UPDATE | ELG033|ELG.003.033|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(20)|N/A|22|41|1. Mandatory 2. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN 3. Value must be 20 characters or less |
ELG033|ELG.003.033|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(20)|4|22|41|1. Mandatory 2. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN 3. Value must be 20 characters or less |
| 2023-09-28 | PREFERRED-LANGUAGE-CODE/ELG.003.046 | Definition; Coding Requirement |
UPDATE | ELG046|ELG.003.046|PRIMARY-LANGUAGE-CODE|Primary Language Code|Conditional|A code indicating the language that is the individuals' preferred spoken or written language.|ELG046 Values|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(3)|N/A|120|122|1. Value must be in Primary Language Code List (VVL) 2. Value must be 3 characters 3. Conditional |
ELG046|ELG.003.046|PREFERRED-LANGUAGE-CODE|Primary Language Code|Conditional|A code indicating the language that is the individuals' preferred spoken or written language.|PREFERRED-LANGUAGE-CODE|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(3)|17|120|122|1. Value must be in Primary Language Code List (VVL) 2. Value must be 3 characters 3. Conditional |
| 2023-09-28 | APPLICATION-SIGNATURE-DATE/ELG.003.273 | Entire New Data Element | ADD | N/A | ELG273|ELG.003.273|APPLICATION-SIGNATURE-DATE|Application Signature Date|Conditional|The date that a beneficiary signed their Medicaid or CHIP application. If the beneficiary was deemed eligible via an administrative determination then a signature may not be applicable/available. |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(8)|26|170|177|1. Value must be a valid date 2. Conditional 3. Value must be less than the VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.004.064 | Definition | UPDATE | ELG064|ELG.004.064|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG064|ELG.004.064|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.005.082 | Definition; Coding Requirement |
UPDATE | ELG082|ELG.005.082|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG082|ELG.005.082|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MEDICAID-BASIS-OF-ELIGIBILITY/ELG.005.084 | All Data Element Attributes | DELETE | ELG084|ELG.005.084|MEDICAID-BASIS-OF-ELIGIBILITY|Medicaid Basis Of Eligibility|Not Applicable|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|ELG084 Values|ELG00005|ELIGIBILITY-DETERMINANTS|X(2)|N/A|54|55|Not Applicable | N/A |
| 2023-09-28 | ELIGIBILITY-TERMINATION-REASON/ELG.005.095 | Definition; Coding Requirement |
UPDATE | ELG095|ELG.005.095|ELIGIBILITY-CHANGE-REASON|Eligibility Change Reason|Conditional|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |ELG095 Values|ELG00005|ELIGIBILITY-DETERMINANTS|X(2)|N/A|79|80|1. Value must be in Eligibility Change Reason List (VVL) 2. Value must be 2 characters 3. Conditional |
ELG095|ELG.005.095|ELIGIBILITY-TERMINATION-REASON|Eligibility Termination Reason|Conditional|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21'; (Other) '22'; (Unknown), then the state should not report the co-occurring value '21'; and/or '22'; to T-MSIS. If there are multiple co-occurring distinct values between '01'; and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01'; throug '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |ELIGIBILITY-TERMINATION-REASON|ELG00005|ELIGIBILITY-DETERMINANTS|X(2)|16|77|78|1. Value must be in Eligibility Change Reason List (VVL) 2. Value must be 2 characters 3. Conditional |
| 2023-09-28 | MAINTENANCE-ASSISTANCE-STATUS/ELG.005.096 | All Data Element Attributes | DELETE | ELG096|ELG.005.096|MAINTENANCE-ASSISTANCE-STATUS|Maintenance Assistance Status|Not Applicable|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|ELG096 Values|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|N/A|81|81|Not Applicable | N/A |
| 2023-09-28 | ELIGIBILITY-REDETERMINTATION-DATE/ELG.005.274 | Entire New Data Element | ADD | N/A | ELG274|ELG.005.274|ELIGIBILITY-REDETERMINTATION-DATE|Eligibility Redetermination Date|Conditional|The date by which a person's Medicaid or CHIP eligiblity must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligiblity characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|21|97|104|1. Value must be a valid date 2. Conditional 3. Value must be greater than the ELIGIBLITY-DETERMINANTS-EFF-DATE |
| 2023-09-28 | ELIGIBILITY-EXTENSION-CODE/ELG.005.275 | Entire New Data Element | ADD | N/A | ELG275|ELG.005.275|ELIGIBILITY-EXTENSION-CODE|Eligibility Extension Code|Conditional|A code to identify the authority used to extend eligibility during the period of coverage. This code should correspond to the eligibility characteristics, including eligibility redetermination date, with which the code is being reported.|ELIGIBILITY-EXTENSION-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(3)|22|105|107|1. Value must not be more than 3 characters 2. Value must be in Eligibility Extension Code List (VVL) 3. Conditional |
| 2023-09-28 | ELIGIBILITY-EXTENSION-OTHER-TEXT /ELG.005.276 | Entire New Data Element | ADD | N/A | ELG276|ELG.005.276|ELIGIBILITY-EXTENSION-OTHER-TEXT |Eligibility Extension Other Text|Conditional|A free-form text field where a state can identify the “other” authority used to extend eligibility; required when 995 is used.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(50)|23|108|157|1. Value must not be more than 50 characters long 2. Conditional 3. Value is mandatory when corresponding Eligibility Extension Code is 'Other' |
| 2023-09-28 | CONTINUOUS-ELIGIBILITY-CODE/ELG.005.277 | Entire New Data Element | ADD | N/A | ELG277|ELG.005.277|CONTINUOUS-ELIGIBILITY-CODE|Continuous Eligibility Code|Conditional|A code to identify the authority used to provide continuous eligibility during the period of coverage|CONTINUOUS-ELIGIBILITY-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(3)|24|158|160|1. Value must not be more than 3 characters 2. Value must be in Continuous Eligibility Code List (VVL) 3. Conditional |
| 2023-09-28 | CONTINUOUS-ELIGIBILITY-OTHER-TEXT/ELG.005.278 | Entire New Data Element | ADD | N/A | ELG278|ELG.005.278|CONTINUOUS-ELIGIBILITY-OTHER-TEXT|Continuous Eligibility Other Text|Conditional|A free-form text field where a state can identify the "other" authority used to provide continuous eligibility. |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(50)|25|161|210|1. Value must not be more than 50 characters long 2. Conditional 3. Value is mandatory when corresponding Continuous Eligibility Code is 'Other' |
| 2023-09-28 | INCOME-STANDARD-CODE/ELG.005.279 | Entire New Data Element | ADD | N/A | ELG279|ELG.005.279|INCOME-STANDARD-CODE|Income Standard Code|Conditional|An indicator that identifies the income standard used by the state to assign the corresponding primary eligibility group.|INCOME-STANDARD-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(2)|26|211|212|1. Value must not be more than 2 characters 2. Value must be in Income Standard Code List (VVL) 3. Conditional |
| 2023-09-28 | INCOME-STANDARD-OTHER-TEXT/ELG.005.280 | Entire New Data Element | ADD | N/A | ELG280|ELG.005.280|INCOME-STANDARD-OTHER-TEXT|Income Standard Other Text|Conditional|A free-form text field where a state can identify the "other" income standard used to assign the corresponding primary eligibility group. Required when "Other" is reported to Income Standard Code.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(50)|27|213|262|1. Value must not be more than 50 characters long. 2. Conditional 3. Value is mandatory when corresponding Income Standard Code is 'Other' |
| 2023-09-28 | ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT/ELG.005.281 | Entire New Data Element | ADD | N/A | ELG281|ELG.005.281|ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT|Eligibility Termination Reason Other Type Text|Conditional|Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(100)|28|263|362|1. Value must be 100 characters or less 2. Value must not be populated when Eligibility Termination Reason = 22 (Other) 3. Value must be populated when Eligibility Termination Reason <> 22 (Other) 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.006.106 | Definition | UPDATE | ELG106|ELG.006.106|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00006|HEALTH-HOME-SPA-PARTICIPATION-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG106|ELG.006.106|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00006|HEALTH-HOME-SPA-PARTICIPATION-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.007.117 | Definition | UPDATE | ELG117|ELG.007.117|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG117|ELG.007.117|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.008.129 | Definition | UPDATE | ELG129|ELG.008.129|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00008|HEALTH-HOME-CHRONIC-CONDITIONS|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG129|ELG.008.129|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00008|HEALTH-HOME-CHRONIC-CONDITIONS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.009.139 | Definition | UPDATE | ELG139|ELG.009.139|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00009|LOCK-IN-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG139|ELG.009.139|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00009|LOCK-IN-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.010.149 | Definition | UPDATE | ELG149|ELG.010.149|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00010|MFP-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG149|ELG.010.149|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00010|MFP-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.011.162 | Definition | UPDATE | ELG162|ELG.011.162|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00011|STATE-PLAN-OPTION-PARTICIPATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG162|ELG.011.162|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00011|STATE-PLAN-OPTION-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.012.171 | Definition | UPDATE | ELG171|ELG.012.171|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00012|WAIVER-PARTICIPATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG171|ELG.012.171|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00012|WAIVER-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.013.181 | Definition | UPDATE | ELG181|ELG.013.181|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00013|LTSS-PARTICIPATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG181|ELG.013.181|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00013|LTSS-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.014.191 | Definition | UPDATE | ELG191|ELG.014.191|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00014|MANAGED-CARE-PARTICIPATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG191|ELG.014.191|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00014|MANAGED-CARE-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.015.203 | Definition | UPDATE | ELG203|ELG.015.203|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00015|ETHNICITY-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG203|ELG.015.203|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00015|ETHNICITY-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.016.212 | Definition | UPDATE | ELG212|ELG.016.212|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00016|RACE-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG212|ELG.016.212|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00016|RACE-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.017.223 | Definition | UPDATE | ELG223|ELG.017.223|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00017|DISABILITY-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG223|ELG.017.223|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00017|DISABILITY-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.018.232 | Definition | UPDATE | ELG232|ELG.018.232|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00018|1115A-DEMONSTRATION-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG232|ELG.018.232|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00018|1115A-DEMONSTRATION-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.020.241 | Definition | UPDATE | ELG241|ELG.020.241|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00020|HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG241|ELG.020.241|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00020|HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.021.251 | Definition | UPDATE | ELG251|ELG.021.251|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00021|ENROLLMENT-TIME-SPAN-SEGMENT|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG251|ELG.021.251|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00021|ENROLLMENT-TIME-SPAN-SEGMENT|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/ELG.022.260 | Definition | UPDATE | ELG260|ELG.022.260|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00022|ELG-IDENTIFIERS|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG260|ELG.022.260|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00022|ELG-IDENTIFIERS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | RECORD-ID/FTX.001.001 | Entire New Data Element | ADD | N/A | FTX001|FTX.001.001|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00001|FILE-HEADER-RECORD-FTX|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00001" 4. Mandatory |
| 2023-09-28 | DATA-DICTIONARY-VERSION/FTX.001.002 | Entire New Data Element | ADD | N/A | FTX002|FTX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
| 2023-09-28 | SUBMISSION-TRANSACTION-TYPE/FTX.001.003 | Entire New Data Element | ADD | N/A | FTX003|FTX.001.003|SUBMISSION-TRANSACTION-TYPE|Submission Transaction Type|Mandatory|A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects.|SUBMISSION-TRANSACTION-TYPE|FTX00001|FILE-HEADER-RECORD-FTX|X(1)|3|19|19|1. Value must be in SUBMISSION-TRANSACTION-TYPE list (VVL) 2. Value must be 1 character 3. Mandatory |
| 2023-09-28 | FILE-ENCODING-SPECIFICATION/FTX.001.004 | Entire New Data Element | ADD | N/A | FTX004|FTX.001.004|FILE-ENCODING-SPECIFICATION|File Encoding Specification|Mandatory|Denotes which supported file encoding standard was used to create the file.|FILE-ENCODING-SPECIFICATION|FTX00001|FILE-HEADER-RECORD-FTX|X(3)|4|20|22|1. Value must be in FILE-ENCODING-SPECIFICATION list (VVL) 2. Value must be 3 characters 3. Mandatory |
| 2023-09-28 | DATA-MAPPING-DOCUMENT-VERSION/FTX.001.005 | Entire New Data Element | ADD | N/A | FTX005|FTX.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2023-09-28 | FILE-NAME/FTX.001.006 | Entire New Data Element | ADD | N/A | FTX006|FTX.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|FTX00001|FILE-HEADER-RECORD-FTX|X(8)|6|32|39|1. Value must equal 'FINTRANS' 2. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.001.007 | Entire New Data Element | ADD | N/A | FTX007|FTX.001.007|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00001|FILE-HEADER-RECORD-FTX|X(2)|7|40|41|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | DATE-FILE-CREATED/FTX.001.008 | Entire New Data Element | ADD | N/A | FTX008|FTX.001.008|DATE-FILE-CREATED|Date File Created|Mandatory|The date on which the file was created.|N/A|FTX00001|FILE-HEADER-RECORD-FTX|9(8)|8|42|49|1. Value of the CC component must be "20" 2. Value must be 8 characters in the form "CCYYMMDD" 3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 4. Value must be less than current date 5. Mandatory |
| 2023-09-28 | START-OF-TIME-PERIOD/FTX.001.009 | Entire New Data Element | ADD | N/A | FTX009|FTX.001.009|START-OF-TIME-PERIOD|Start of Time Period|Mandatory|newly acquired SSN for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS Identification Number and the social security number.|N/A|FTX00001|FILE-HEADER-RECORD-FTX|9(8)|9|50|57|1. Value of the CC component must be "20" 2. Value must be 8 characters in the form "CCYYMMDD" 3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 4. Value must be equal to or earlier than associated Date File Created 5. Value must be before associated END-OF-TIME-PERIOD 6. Mandatory |
| 2023-09-28 | END-OF-TIME-PERIOD/FTX.001.010 | Entire New Data Element | ADD | N/A | FTX010|FTX.001.010|END-OF-TIME-PERIOD|End of Time Period|Mandatory|This value must be the last day of the reporting month, regardless of the actual date span.|N/A|FTX00001|FILE-HEADER-RECORD-FTX|9(8)|10|58|65|1. Value must be 8 characters in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 4. Value must be equal to or earlier than associated Date File Created 5. Value must be equal to or after associated START-OF-TIME-PERIOD 6. Mandatory |
| 2023-09-28 | FILE-STATUS-INDICATOR/FTX.001.011 | Entire New Data Element | ADD | N/A | FTX011|FTX.001.011|FILE-STATUS-INDICATOR|File Status Indicator|Mandatory|A code to indicate whether the records in the file are test or production records.|FILE-STATUS-INDICATOR|FTX00001|FILE-HEADER-RECORD-FTX|X(1)|11|66|66|1. For production files, value must be equal to 'P' 2. Value must be in File Status Indicator list (VVL) 3. Value must be 1 character 4. Mandatory |
| 2023-09-28 | SSN-INDICATOR/FTX.001.012 | Entire New Data Element | ADD | N/A | FTX012|FTX.001.012|SSN-INDICATOR|SSN Indicator|Mandatory|with the temporary MSIS Identification Number and the SSN field should be space-filled, or blank. When the SSN becomes known, the MSIS Identification Number field should continue to be populated with the temporary MSIS Identification Number and the SSN field should be populated with the |SSN-INDICATOR|FTX00001|FILE-HEADER-RECORD-FTX|X(1)|12|67|67|1. Value must be in SSN-INDICATOR list (VVL) 2. Value must be 1 character 3. Mandatory |
| 2023-09-28 | TOT-REC-CNT/FTX.001.013 | Entire New Data Element | ADD | N/A | FTX013|FTX.001.013|TOT-REC-CNT|Total Record Count|Mandatory|A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission.|N/A|FTX00001|FILE-HEADER-RECORD-FTX|9(11)|13|68|78|1. Value must be a positive integer 2. Value must be between 0:99999999999 (inclusive) 3. Value must be 11 digits or less 4. Value must equal the number of records included in the file submission except for the file header record. 5. Mandatory |
| 2023-09-28 | SEQUENCE-NUMBER/FTX.001.014 | Entire New Data Element | ADD | N/A | FTX014|FTX.001.014|SEQUENCE-NUMBER|Sequence Number|Mandatory|To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area).|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(4)|14|79|82|1. Value must between 1 and 9999 2. Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1) 3. Value must not contain a pipe symbol 4. Value must be 4 characters or less 5. Mandatory |
| 2023-09-28 | STATE-NOTATION /FTX.001.015 | Entire New Data Element | ADD | N/A | FTX015|FTX.001.015|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(500)|15|83|582|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.002.017 | Entire New Data Element | ADD | N/A | FTX017|FTX.002.017|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00002" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.002.018 | Entire New Data Element | ADD | N/A | FTX018|FTX.002.018|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.002.019 | Entire New Data Element | ADD | N/A | FTX019|FTX.002.019|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.002.020 | Entire New Data Element | ADD | N/A | FTX020|FTX.002.020|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.002.021 | Entire New Data Element | ADD | N/A | FTX021|FTX.002.021|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.002.022 | Entire New Data Element | ADD | N/A | FTX022|FTX.002.022|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.002.023 | Entire New Data Element | ADD | N/A | FTX023|FTX.002.023|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.002.024 | Entire New Data Element | ADD | N/A | FTX024|FTX.002.024|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.002.025 | Entire New Data Element | ADD | N/A | FTX025|FTX.002.025|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.002.026 | Entire New Data Element | ADD | N/A | FTX026|FTX.002.026|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.002.027 | Entire New Data Element | ADD | N/A | FTX027|FTX.002.027|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.002.028 | Entire New Data Element | ADD | N/A | FTX028|FTX.002.028|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.002.029 | Entire New Data Element | ADD | N/A | FTX029|FTX.002.029|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.002.030 | Entire New Data Element | ADD | N/A | FTX030|FTX.002.030|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYER-MCR-PLAN-TYPE/FTX.002.031 | Entire New Data Element | ADD | N/A | FTX031|FTX.002.031|PAYER-MCR-PLAN-TYPE|Payer MCR Plan Type|Conditional|This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|15|349|350|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYER-ID-TYPE is '02' then PAYER-MCR-PLAN-TYPE must be populated 4. If PAYER-ID-TYPE is not '02' then PAYER-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYER-MCR-PLAN-TYPE-OTHER-TEXT/FTX.002.032 | Entire New Data Element | ADD | N/A | FTX032|FTX.002.032|PAYER-MCR-PLAN-TYPE-OTHER-TEXT|Payer MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|16|351|450|1. Value must be 100 characters or less 2. PAYER-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.002.033 | Entire New Data Element | ADD | N/A | FTX033|FTX.002.033|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|17|451|480|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.002.034 | Entire New Data Element | ADD | N/A | FTX034|FTX.002.034|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.002.035 | Entire New Data Element | ADD | N/A | FTX035|FTX.002.035|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.002.036 | Entire New Data Element | ADD | N/A | FTX036|FTX.002.036|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|20|583|584|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.002.037 | Entire New Data Element | ADD | N/A | FTX037|FTX.002.037|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|21|585|684|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.002.038 | Entire New Data Element | ADD | N/A | FTX038|FTX.002.038|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|22|685|714|1. Value must be 12 characters or less 2. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.002.039 | Entire New Data Element | ADD | N/A | FTX039|FTX.002.039|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|23|715|716|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.002.040 | Entire New Data Element | ADD | N/A | FTX040|FTX.002.040|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|24|717|816|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | CONTRACT-ID/FTX.002.041 | Entire New Data Element | ADD | N/A | FTX041|FTX.002.041|CONTRACT-ID|Contract ID|Conditional| Managed care plan contract ID|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|25|817|916|1. Value must be 100 characters or less 2. Value must be populated if SUBCAPITATION-IND = '01' 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/FTX.002.042 | Entire New Data Element | ADD | N/A | FTX042|FTX.002.042|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(20)|26|917|936|1. Value must be 20 characters or less 2. Mandatory |
| 2023-09-28 | CAPITATION-PERIOD-START-DATE/FTX.002.043 | Entire New Data Element | ADD | N/A | FTX043|FTX.002.043|CAPITATION-PERIOD-START-DATE|Capitation Period Start Date|Mandatory|The date representing the beginning of the period covered by the capitation or sub-capitation payment or recoupment; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|27|937|944|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated CAPITATION-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CAPITATION-PERIOD-END-DATE/FTX.002.044 | Entire New Data Element | ADD | N/A | FTX044|FTX.002.044|CAPITATION-PERIOD-END-DATE|Capitation Period End Date|Mandatory|The date representing the end of the period covered by the capitation or sub-capitation payment or recoupment; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|28|945|952|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated CAPITATION-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.002.045 | Entire New Data Element | ADD | N/A | FTX045|FTX.002.045|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|29|953|954|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.002.046 | Entire New Data Element | ADD | N/A | FTX046|FTX.002.046|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(5)|30|955|959|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
| 2023-09-28 | MBESCBES-FORM/FTX.002.047 | Entire New Data Element | ADD | N/A | FTX047|FTX.002.047|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|31|960|1009|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.002.048 | Entire New Data Element | ADD | N/A | FTX048|FTX.002.048|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|32|1010|1010|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
| 2023-09-28 | WAIVER-ID/FTX.002.049 | Entire New Data Element | ADD | N/A | FTX049|FTX.002.049|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(20)|33|1011|1030|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must match Eligible Waiver ID (ELG.012.172) for the enrollee for the same time period 6. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.002.050 | Entire New Data Element | ADD | N/A | FTX050|FTX.002.050|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|34|1031|1032|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Value must match ELIGIBLE-WAIVER-TYPE (ELG.012.173) for the enrollee for the same time period 5. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.002.051 | Entire New Data Element | ADD | N/A | FTX051|FTX.002.051|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|35|1033|1034|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.002.052 | Entire New Data Element | ADD | N/A | FTX052|FTX.002.052|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|36|1035|1036|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Mandatory |
| 2023-09-28 | SDP-IND/FTX.002.053 | Entire New Data Element | ADD | N/A | FTX053|FTX.002.053|SDP-IND|State Directed Payment Indicator|Mandatory|Indicates whether the financial transaction from an MC plan plan to a provider or other entity is a type of State Directed Payment.|SDP-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|37|1037|1037|1. Value must be 1 character 2. Value must be in SPD-IND list (VVL) 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.002.054 | Entire New Data Element | ADD | N/A | FTX054|FTX.002.054|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|38|1038|1039|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.002.055 | Entire New Data Element | ADD | N/A | FTX055|FTX.002.055|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(15)|39|1040|1054|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | SUBCAPITATION-IND/FTX.002.056 | Entire New Data Element | ADD | N/A | FTX056|FTX.002.056|SUBCAPITATION-IND|Subcapitation Ind|Mandatory|Indicates whethe the transaction represents a sub-capitation payment between a managed care plan and a sub-capitated entity or sub-capitated network provider or not. A sub-capitation payment could also be between a sub-capitated entity and another sub-capitated entity or sub-capitated network provider. |SUBCAPITATION-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|40|1055|1055|1. Value must be 1 characters 2. Value must be in SUBCAPITATION-IND list (VVL) 3. Mandatory |
| 2023-09-28 | PAYMENT-CAT-XREF/FTX.002.057 | Entire New Data Element | ADD | N/A | FTX057|FTX.002.057|PAYMENT-CAT-XREF|Payment Cat Xref|Conditional|Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|41|1056|1105|1. Value must be 50 characters or less 2. Value must be populated if SUBCAPITATION-IND = '01' 3. Conditional |
| 2023-09-28 | RATE-CELL-DESCRIPTION-TEXT/FTX.002.058 | Entire New Data Element | ADD | N/A | FTX058|FTX.002.058|RATE-CELL-DESCRIPTION-TEXT|Rate Cell Description Text|Conditional|This is the description of the rate cell from the rate setting process that applies to the capitation payment. For example, a rate cell may represent the monthly capitation rate paid for adults with chronic conditions who live in a rural area. If the rate paid for this capitation payment is based on the rate cell for adults with chronic conditions who live in a rural area, then the rate cell description could be "Adults with chronic conditions living in a rural area."|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|42|1106|1205|1. Value must be 100 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.002.059 | Entire New Data Element | ADD | N/A | FTX059|FTX.002.059|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Conditional|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|43|1206|1207|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.002.060 | Entire New Data Element | ADD | N/A | FTX060|FTX.002.060|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|44|1208|1307|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.002.061 | Entire New Data Element | ADD | N/A | FTX061|FTX.002.061|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(500)|45|1308|1807|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION/FTX.002.062 | Entire New Data Element | ADD | N/A | FTX062|FTX.002.062|STATE-NOTATION|State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(500)|46|1808|2307|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.003.064 | Entire New Data Element | ADD | N/A | FTX064|FTX.003.064|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00003" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.003.065 | Entire New Data Element | ADD | N/A | FTX065|FTX.003.065|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.003.066 | Entire New Data Element | ADD | N/A | FTX066|FTX.003.066|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.003.067 | Entire New Data Element | ADD | N/A | FTX067|FTX.003.067|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.003.068 | Entire New Data Element | ADD | N/A | FTX068|FTX.003.068|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.003.069 | Entire New Data Element | ADD | N/A | FTX069|FTX.003.069|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.003.070 | Entire New Data Element | ADD | N/A | FTX070|FTX.003.070|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.003.071 | Entire New Data Element | ADD | N/A | FTX071|FTX.003.071|PAYMENT-OR-RECOUPMENT-DATE|Payment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-AMOUNT/FTX.003.072 | Entire New Data Element | ADD | N/A | FTX072|FTX.003.072|PAYMENT-AMOUNT|Payment Amount|Mandatory|The dollar amount being paid to the payee.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.003.073 | Entire New Data Element | ADD | N/A | FTX073|FTX.003.073|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.003.074 | Entire New Data Element | ADD | N/A | FTX074|FTX.003.074|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.003.075 | Entire New Data Element | ADD | N/A | FTX075|FTX.003.075|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.003.076 | Entire New Data Element | ADD | N/A | FTX076|FTX.003.076|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.003.077 | Entire New Data Element | ADD | N/A | FTX077|FTX.003.077|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.003.078 | Entire New Data Element | ADD | N/A | FTX078|FTX.003.078|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.003.079 | Entire New Data Element | ADD | N/A | FTX079|FTX.003.079|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.003.080 | Entire New Data Element | ADD | N/A | FTX080|FTX.003.080|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.003.081 | Entire New Data Element | ADD | N/A | FTX081|FTX.003.081|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|18|481|510|1. Value must be 12 characters or less 2. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.003.082 | Entire New Data Element | ADD | N/A | FTX082|FTX.003.082|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|19|511|512|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.003.083 | Entire New Data Element | ADD | N/A | FTX083|FTX.003.083|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(100)|20|513|612|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | INSURANCE-CARRIER-ID-NUM/FTX.003.084 | Entire New Data Element | ADD | N/A | FTX084|FTX.003.084|INSURANCE-CARRIER-ID-NUM|Insurance Carrier ID Num|Mandatory| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(12)|21|613|624|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2023-09-28 | INSURANCE-PLAN-ID/FTX.003.085 | Entire New Data Element | ADD | N/A | FTX085|FTX.003.085|INSURANCE-PLAN-ID|Insurance Plan ID|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|22|625|644|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/FTX.003.086 | Entire New Data Element | ADD | N/A | FTX086|FTX.003.086|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|23|645|664|1. Value must be 20 characters or less 2. Mandatory |
| 2023-09-28 | MEMBER-ID/FTX.003.087 | Entire New Data Element | ADD | N/A | FTX087|FTX.003.087|MEMBER-ID|Member ID|Conditional|Member identification number as it appears on the card issued by the TPL insurance carrier.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|24|665|684|1. Value must be 20 characters or less 2. Conditional |
| 2023-09-28 | PREMIUM-PERIOD-START-DATE/FTX.003.088 | Entire New Data Element | ADD | N/A | FTX088|FTX.003.088|PREMIUM-PERIOD-START-DATE|Premium Period Start Date|Mandatory|The date representing the beginning of the period covered by the premium payment or recoupment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|9(8)|25|685|692|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated PREMIUM-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PREMIUM-PERIOD-END-DATE/FTX.003.089 | Entire New Data Element | ADD | N/A | FTX089|FTX.003.089|PREMIUM-PERIOD-END-DATE|Premium Period End Date|Mandatory|The date representing the end of the period covered by the premium payment or recoupment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|9(8)|26|693|700|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated PREMIUM-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.003.090 | Entire New Data Element | ADD | N/A | FTX090|FTX.003.090|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|27|701|702|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.003.091 | Entire New Data Element | ADD | N/A | FTX091|FTX.003.091|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(5)|28|703|707|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.003.092 | Entire New Data Element | ADD | N/A | FTX092|FTX.003.092|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|29|708|757|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.003.093 | Entire New Data Element | ADD | N/A | FTX093|FTX.003.093|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(1)|30|758|758|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.003.094 | Entire New Data Element | ADD | N/A | FTX094|FTX.003.094|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|31|759|778|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must match Eligible Waiver ID (ELG.012.172) for the enrollee for the same time period 6. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.003.095 | Entire New Data Element | ADD | N/A | FTX095|FTX.003.095|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|32|779|780|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Value must match ELIGIBLE-WAIVER-TYPE (ELG.012.173) for the enrollee for the same time period 5. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.003.096 | Entire New Data Element | ADD | N/A | FTX096|FTX.003.096|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|33|781|782|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.003.097 | Entire New Data Element | ADD | N/A | FTX097|FTX.003.097|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|34|783|784|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.003.098 | Entire New Data Element | ADD | N/A | FTX098|FTX.003.098|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|35|785|786|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.003.099 | Entire New Data Element | ADD | N/A | FTX099|FTX.003.099|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(15)|36|787|801|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.003.100 | Entire New Data Element | ADD | N/A | FTX100|FTX.003.100|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|37|802|803|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.003.101 | Entire New Data Element | ADD | N/A | FTX101|FTX.003.101|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(100)|38|804|903|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.003.102 | Entire New Data Element | ADD | N/A | FTX102|FTX.003.102|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(500)|39|904|1403|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.003.103 | Entire New Data Element | ADD | N/A | FTX103|FTX.003.103|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(500)|40|1404|1903|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.004.105 | Entire New Data Element | ADD | N/A | FTX105|FTX.004.105|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00004" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.004.106 | Entire New Data Element | ADD | N/A | FTX106|FTX.004.106|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.004.107 | Entire New Data Element | ADD | N/A | FTX107|FTX.004.107|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.004.108 | Entire New Data Element | ADD | N/A | FTX108|FTX.004.108|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.004.109 | Entire New Data Element | ADD | N/A | FTX109|FTX.004.109|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.004.110 | Entire New Data Element | ADD | N/A | FTX110|FTX.004.110|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.004.111 | Entire New Data Element | ADD | N/A | FTX111|FTX.004.111|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-DATE/FTX.004.112 | Entire New Data Element | ADD | N/A | FTX112|FTX.004.112|PAYMENT-DATE|Payment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-AMOUNT/FTX.004.113 | Entire New Data Element | ADD | N/A | FTX113|FTX.004.113|PAYMENT-AMOUNT|Payment Amount|Mandatory|The dollar amount being paid to the payee.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.004.114 | Entire New Data Element | ADD | N/A | FTX114|FTX.004.114|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.004.115 | Entire New Data Element | ADD | N/A | FTX115|FTX.004.115|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.004.116 | Entire New Data Element | ADD | N/A | FTX116|FTX.004.116|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.004.117 | Entire New Data Element | ADD | N/A | FTX117|FTX.004.117|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.004.118 | Entire New Data Element | ADD | N/A | FTX118|FTX.004.118|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.004.119 | Entire New Data Element | ADD | N/A | FTX119|FTX.004.119|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.004.120 | Entire New Data Element | ADD | N/A | FTX120|FTX.004.120|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.004.121 | Entire New Data Element | ADD | N/A | FTX121|FTX.004.121|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.004.122 | Entire New Data Element | ADD | N/A | FTX122|FTX.004.122|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|18|481|510|1. Value must be 12 characters or less 2. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.004.123 | Entire New Data Element | ADD | N/A | FTX123|FTX.004.123|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|19|511|512|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.004.124 | Entire New Data Element | ADD | N/A | FTX124|FTX.004.124|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(100)|20|513|612|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | INSURANCE-CARRIER-ID-NUM/FTX.004.125 | Entire New Data Element | ADD | N/A | FTX125|FTX.004.125|INSURANCE-CARRIER-ID-NUM|Insurance Carrier ID Num|Mandatory| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(12)|21|613|624|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2023-09-28 | INSURANCE-PLAN-ID/FTX.004.126 | Entire New Data Element | ADD | N/A | FTX126|FTX.004.126|INSURANCE-PLAN-ID|Insurance Plan ID|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|22|625|644|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/FTX.004.127 | Entire New Data Element | ADD | N/A | FTX127|FTX.004.127|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|23|645|664|1. Value must be 20 characters or less 2. Conditional 3. If value is not populated, then SSN must be populated. |
| 2023-09-28 | SSN/FTX.004.128 | Entire New Data Element | ADD | N/A | FTX128|FTX.004.128|SSN|SSN|Conditional|The eligible individual's social security number. For newborns when value is unknown it is not required. For SSN states, in instances where the social security number is not known and a temporary MSIS Identification Number is used, the MSIS Identification Number field should be populated |N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(9)|24|665|673|1. Value must be 9-digit number 2. For any individual, the value must be the same over all segment effective and end dates 3. (SSN State) if associated SSN Indicator (ELG.001.012) value is coded as "1", then value must equal MSIS Identification Number (ELG.002.019) value 4. Value can only be reported with one MSIS Identification Number (ELG.002.019) 5. Conditional 6. (Non-SSN State) if associated SSN Indicator (ELG.001.012) value is coded as "0", then value must not equal MSIS Identification Number (ELG.002.019) |
| 2023-09-28 | MEMBER-ID/FTX.004.129 | Entire New Data Element | ADD | N/A | FTX129|FTX.004.129|MEMBER-ID|Member ID|Conditional|Member identification number as it appears on the card issued by the TPL insurance carrier.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|25|674|693|1. Value must be 20 characters or less 2. Conditional |
| 2023-09-28 | GROUP-NUM/FTX.004.130 | Entire New Data Element | ADD | N/A | FTX130|FTX.004.130|GROUP-NUM|Group Num|Conditional|The group number of the TPL health insurance policy.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(16)|26|694|709|1. Value must not contain a pipe symbol 2. Value must be 16 characters or less 3. Conditional |
| 2023-09-28 | POLICY-OWNER-CODE/FTX.004.131 | Entire New Data Element | ADD | N/A | FTX131|FTX.004.131|POLICY-OWNER-CODE|Policy Owner Code|Conditional|This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary.|POLICY-OWNER-CODE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|27|710|711|1. Value must be 2 characters 2. Value must be in VVL 3. Conditional |
| 2023-09-28 | PREMIUM-PERIOD-START-DATE/FTX.004.132 | Entire New Data Element | ADD | N/A | FTX132|FTX.004.132|PREMIUM-PERIOD-START-DATE|Premium Period Start Date|Mandatory|The date representing the beginning of the period covered by the premium payment or recoupment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|9(8)|28|712|719|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated PREMIUM-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PREMIUM-PERIOD-END-DATE/FTX.004.133 | Entire New Data Element | ADD | N/A | FTX133|FTX.004.133|PREMIUM-PERIOD-END-DATE|Premium Period End Date|Mandatory|The date representing the end of the period covered by the premium payment or recoupment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|9(8)|29|720|727|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated PREMIUM-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.004.134 | Entire New Data Element | ADD | N/A | FTX134|FTX.004.134|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|30|728|729|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.004.135 | Entire New Data Element | ADD | N/A | FTX135|FTX.004.135|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(5)|31|730|734|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
| 2023-09-28 | MBESCBES-FORM/FTX.004.136 | Entire New Data Element | ADD | N/A | FTX136|FTX.004.136|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|32|735|784|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.004.137 | Entire New Data Element | ADD | N/A | FTX137|FTX.004.137|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(1)|33|785|785|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
| 2023-09-28 | WAIVER-ID/FTX.004.138 | Entire New Data Element | ADD | N/A | FTX138|FTX.004.138|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|34|786|805|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must match Eligible Waiver ID (ELG.012.172) for the enrollee for the same time period 6. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.004.139 | Entire New Data Element | ADD | N/A | FTX139|FTX.004.139|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|35|806|807|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Value must match ELIGIBLE-WAIVER-TYPE (ELG.012.173) for the enrollee for the same time period 5. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.004.140 | Entire New Data Element | ADD | N/A | FTX140|FTX.004.140|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|36|808|809|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. If FTX0004, then conditionally mandatory if the POLICY-OWNER-CODE = '01' 4. Conditional |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.004.141 | Entire New Data Element | ADD | N/A | FTX141|FTX.004.141|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|37|810|811|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.004.142 | Entire New Data Element | ADD | N/A | FTX142|FTX.004.142|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|38|812|813|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.004.143 | Entire New Data Element | ADD | N/A | FTX143|FTX.004.143|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(15)|39|814|828|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.004.144 | Entire New Data Element | ADD | N/A | FTX144|FTX.004.144|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Conditional|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|40|829|830|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.004.145 | Entire New Data Element | ADD | N/A | FTX145|FTX.004.145|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(100)|41|831|930|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.004.146 | Entire New Data Element | ADD | N/A | FTX146|FTX.004.146|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(500)|42|931|1430|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.004.147 | Entire New Data Element | ADD | N/A | FTX147|FTX.004.147|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(500)|43|1431|1930|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.005.149 | Entire New Data Element | ADD | N/A | FTX149|FTX.005.149|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00005|COST-SHARING-OFFSET|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00005" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.005.150 | Entire New Data Element | ADD | N/A | FTX150|FTX.005.150|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00005|COST-SHARING-OFFSET|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.005.151 | Entire New Data Element | ADD | N/A | FTX151|FTX.005.151|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00005|COST-SHARING-OFFSET|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.005.152 | Entire New Data Element | ADD | N/A | FTX152|FTX.005.152|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.005.153 | Entire New Data Element | ADD | N/A | FTX153|FTX.005.153|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.005.154 | Entire New Data Element | ADD | N/A | FTX154|FTX.005.154|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.005.155 | Entire New Data Element | ADD | N/A | FTX155|FTX.005.155|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00005|COST-SHARING-OFFSET|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.005.156 | Entire New Data Element | ADD | N/A | FTX156|FTX.005.156|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00005|COST-SHARING-OFFSET|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.005.157 | Entire New Data Element | ADD | N/A | FTX157|FTX.005.157|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00005|COST-SHARING-OFFSET|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.005.158 | Entire New Data Element | ADD | N/A | FTX158|FTX.005.158|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00005|COST-SHARING-OFFSET|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.005.159 | Entire New Data Element | ADD | N/A | FTX159|FTX.005.159|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00005|COST-SHARING-OFFSET|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.005.160 | Entire New Data Element | ADD | N/A | FTX160|FTX.005.160|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. For beneficiary Cost Sharing Offset, the payee is always the state and the payee is always a beneficiary.|N/A|FTX00005|COST-SHARING-OFFSET|X(30)|12|217|246|1. Value must be 30 characters or less 2. Value must equal SUBMITTING-STATE (FTX00001) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.005.161 | Entire New Data Element | ADD | N/A | FTX161|FTX.005.161|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.005.162 | Entire New Data Element | ADD | N/A | FTX162|FTX.005.162|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.005.163 | Entire New Data Element | ADD | N/A | FTX163|FTX.005.163|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. For beneficiary Cost Sharing Offset, the beneficiary is always the payee. |N/A|FTX00005|COST-SHARING-OFFSET|X(30)|15|349|378|1. Value must be 30 characters or less 2. Value must equal MSIS-IDENTIFICATION-NUM (ELG00002) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.005.164 | Entire New Data Element | ADD | N/A | FTX164|FTX.005.164|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00005|COST-SHARING-OFFSET|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.005.165 | Entire New Data Element | ADD | N/A | FTX165|FTX.005.165|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.005.166 | Entire New Data Element | ADD | N/A | FTX166|FTX.005.166|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.005.167 | Entire New Data Element | ADD | N/A | FTX167|FTX.005.167|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.005.168 | Entire New Data Element | ADD | N/A | FTX168|FTX.005.168|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00005|COST-SHARING-OFFSET|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.005.169 | Entire New Data Element | ADD | N/A | FTX169|FTX.005.169|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|21|613|614|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.005.170 | Entire New Data Element | ADD | N/A | FTX170|FTX.005.170|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | CONTRACT-ID/FTX.005.171 | Entire New Data Element | ADD | N/A | FTX171|FTX.005.171|CONTRACT-ID|Contract ID|Conditional| Managed care plan contract ID|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|23|715|814|1. Value must be 100 characters or less 2. Value must be populated if OFFSET-TRANS-TYPE = '1' 3. Conditional |
| 2023-09-28 | INSURANCE-PLAN-ID/FTX.005.172 | Entire New Data Element | ADD | N/A | FTX172|FTX.005.172|INSURANCE-PLAN-ID|Insurance Plan ID|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00005|COST-SHARING-OFFSET|X(20)|24|815|834|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/FTX.005.173 | Entire New Data Element | ADD | N/A | FTX173|FTX.005.173|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00005|COST-SHARING-OFFSET|X(20)|25|835|854|1. Value must be 20 characters or less 2. Mandatory |
| 2023-09-28 | COVERAGE-PERIOD-START-DATE/FTX.005.174 | Entire New Data Element | ADD | N/A | FTX174|FTX.005.174|COVERAGE-PERIOD-START-DATE|Coverage Period Start Date|Mandatory|The date representing the beginning of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the beginning of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them.|N/A|FTX00005|COST-SHARING-OFFSET|9(8)|26|855|862|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated COVERAGE-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | COVERAGE-PERIOD-END-DATE/FTX.005.175 | Entire New Data Element | ADD | N/A | FTX175|FTX.005.175|COVERAGE-PERIOD-END-DATE|Coverage Period End Date|Mandatory|The date representing the end of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the end of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them.|N/A|FTX00005|COST-SHARING-OFFSET|9(8)|27|863|870|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated COVERAGE-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.005.176 | Entire New Data Element | ADD | N/A | FTX176|FTX.005.176|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00005|COST-SHARING-OFFSET|X(2)|28|871|872|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.005.177 | Entire New Data Element | ADD | N/A | FTX177|FTX.005.177|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00005|COST-SHARING-OFFSET|X(5)|29|873|877|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.005.178 | Entire New Data Element | ADD | N/A | FTX178|FTX.005.178|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00005|COST-SHARING-OFFSET|X(50)|30|878|927|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.005.179 | Entire New Data Element | ADD | N/A | FTX179|FTX.005.179|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00005|COST-SHARING-OFFSET|X(1)|31|928|928|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.005.180 | Entire New Data Element | ADD | N/A | FTX180|FTX.005.180|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00005|COST-SHARING-OFFSET|X(20)|32|929|948|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.005.181 | Entire New Data Element | ADD | N/A | FTX181|FTX.005.181|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|33|949|950|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.005.182 | Entire New Data Element | ADD | N/A | FTX182|FTX.005.182|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00005|COST-SHARING-OFFSET|X(2)|34|951|952|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.005.183 | Entire New Data Element | ADD | N/A | FTX183|FTX.005.183|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00005|COST-SHARING-OFFSET|X(2)|35|953|954|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | OFFSET-TRANS-TYPE/FTX.005.184 | Entire New Data Element | ADD | N/A | FTX184|FTX.005.184|OFFSET-TRANS-TYPE|Offset Trans Type|Conditional|This indicates the type of payment that the beneficiary cost-sharing is/was offsetting.|OFFSET-TRANS-TYPE|FTX00005|COST-SHARING-OFFSET|X(1)|36|955|955|1. Value must be one character 2. Value must be in OFFSET-TRANS-TYPE list (VVL) 3. Conditional |
| 2023-09-28 | SOURCE-LOCATION/FTX.005.185 | Entire New Data Element | ADD | N/A | FTX185|FTX.005.185|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00005|COST-SHARING-OFFSET|X(2)|37|956|957|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.005.186 | Entire New Data Element | ADD | N/A | FTX186|FTX.005.186|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00005|COST-SHARING-OFFSET|X(15)|38|958|972|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.005.187 | Entire New Data Element | ADD | N/A | FTX187|FTX.005.187|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|39|973|974|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.005.188 | Entire New Data Element | ADD | N/A | FTX188|FTX.005.188|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|40|975|1074|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.005.189 | Entire New Data Element | ADD | N/A | FTX189|FTX.005.189|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00005|COST-SHARING-OFFSET|X(500)|41|1075|1574|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.005.190 | Entire New Data Element | ADD | N/A | FTX190|FTX.005.190|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00005|COST-SHARING-OFFSET|X(500)|42|1575|2074|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.006.192 | Entire New Data Element | ADD | N/A | FTX192|FTX.006.192|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00006|VALUE-BASED-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00006" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.006.193 | Entire New Data Element | ADD | N/A | FTX193|FTX.006.193|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00006|VALUE-BASED-PAYMENT|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.006.194 | Entire New Data Element | ADD | N/A | FTX194|FTX.006.194|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00006|VALUE-BASED-PAYMENT|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.006.195 | Entire New Data Element | ADD | N/A | FTX195|FTX.006.195|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.006.196 | Entire New Data Element | ADD | N/A | FTX196|FTX.006.196|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.006.197 | Entire New Data Element | ADD | N/A | FTX197|FTX.006.197|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.006.198 | Entire New Data Element | ADD | N/A | FTX198|FTX.006.198|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00006|VALUE-BASED-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.006.199 | Entire New Data Element | ADD | N/A | FTX199|FTX.006.199|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00006|VALUE-BASED-PAYMENT|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.006.200 | Entire New Data Element | ADD | N/A | FTX200|FTX.006.200|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00006|VALUE-BASED-PAYMENT|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.006.201 | Entire New Data Element | ADD | N/A | FTX201|FTX.006.201|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00006|VALUE-BASED-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.006.202 | Entire New Data Element | ADD | N/A | FTX202|FTX.006.202|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.006.203 | Entire New Data Element | ADD | N/A | FTX203|FTX.006.203|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.006.204 | Entire New Data Element | ADD | N/A | FTX204|FTX.006.204|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.006.205 | Entire New Data Element | ADD | N/A | FTX205|FTX.006.205|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00006|VALUE-BASED-PAYMENT|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.006.206 | Entire New Data Element | ADD | N/A | FTX206|FTX.006.206|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.006.207 | Entire New Data Element | ADD | N/A | FTX207|FTX.006.207|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00006|VALUE-BASED-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.006.208 | Entire New Data Element | ADD | N/A | FTX208|FTX.006.208|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00006|VALUE-BASED-PAYMENT|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.006.209 | Entire New Data Element | ADD | N/A | FTX209|FTX.006.209|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.006.210 | Entire New Data Element | ADD | N/A | FTX210|FTX.006.210|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00006|VALUE-BASED-PAYMENT|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.006.211 | Entire New Data Element | ADD | N/A | FTX211|FTX.006.211|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.006.212 | Entire New Data Element | ADD | N/A | FTX212|FTX.006.212|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|21|613|614|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.006.213 | Entire New Data Element | ADD | N/A | FTX213|FTX.006.213|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00006|VALUE-BASED-PAYMENT|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | CONTRACT-ID/FTX.006.214 | Entire New Data Element | ADD | N/A | FTX214|FTX.006.214|CONTRACT-ID|Contract ID|Conditional| Managed care plan contract ID|N/A|FTX00006|VALUE-BASED-PAYMENT|X(100)|23|715|814|1. Value must be 100 characters or less 2. Value must be populated if either PAYEE-ID-TYPE = '02' or PAYER-ID-TYPE = '02' 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/FTX.006.215 | Entire New Data Element | ADD | N/A | FTX215|FTX.006.215|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00006|VALUE-BASED-PAYMENT|X(20)|24|815|834|1. Value must be 20 characters or less 2. Conditional |
| 2023-09-28 | PERFORMANCE-PERIOD-START-DATE/FTX.006.216 | Entire New Data Element | ADD | N/A | FTX216|FTX.006.216|PERFORMANCE-PERIOD-START-DATE|Performance Period Start Date|Mandatory|The date representing the beginning of the performance period that the value-based dollar amount is rewarding or penalizing.|N/A|FTX00006|VALUE-BASED-PAYMENT|9(8)|25|835|842|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated PERFORMANCE-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PERFORMANCE-PERIOD-END-DATE/FTX.006.217 | Entire New Data Element | ADD | N/A | FTX217|FTX.006.217|PERFORMANCE-PERIOD-END-DATE|Performance Period End Date|Mandatory|The date representing the end of the performance period that the value-based dollar amount is rewarding or penalizing.|N/A|FTX00006|VALUE-BASED-PAYMENT|9(8)|26|843|850|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated PERFORMANCE-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.006.218 | Entire New Data Element | ADD | N/A | FTX218|FTX.006.218|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00006|VALUE-BASED-PAYMENT|X(2)|27|851|852|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.006.219 | Entire New Data Element | ADD | N/A | FTX219|FTX.006.219|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00006|VALUE-BASED-PAYMENT|X(5)|28|853|857|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.006.220 | Entire New Data Element | ADD | N/A | FTX220|FTX.006.220|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00006|VALUE-BASED-PAYMENT|X(50)|29|858|907|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.006.221 | Entire New Data Element | ADD | N/A | FTX221|FTX.006.221|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00006|VALUE-BASED-PAYMENT|X(1)|30|908|908|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.006.222 | Entire New Data Element | ADD | N/A | FTX222|FTX.006.222|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(20)|31|909|928|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.006.223 | Entire New Data Element | ADD | N/A | FTX223|FTX.006.223|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|32|929|930|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.006.224 | Entire New Data Element | ADD | N/A | FTX224|FTX.006.224|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00006|VALUE-BASED-PAYMENT|X(2)|33|931|932|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.006.225 | Entire New Data Element | ADD | N/A | FTX225|FTX.006.225|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00006|VALUE-BASED-PAYMENT|X(2)|34|933|934|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SDP-IND/FTX.006.226 | Entire New Data Element | ADD | N/A | FTX226|FTX.006.226|SDP-IND|State Directed Payment Indicator|Mandatory|Indicates whether the financial transaction from an MC plan plan to a provider or other entity is a type of State Directed Payment.|SDP-IND|FTX00006|VALUE-BASED-PAYMENT|X(1)|35|935|935|1. Value must be 1 character 2. Value must be in SPD-IND list (VVL) 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.006.227 | Entire New Data Element | ADD | N/A | FTX227|FTX.006.227|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00006|VALUE-BASED-PAYMENT|X(2)|36|936|937|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.006.228 | Entire New Data Element | ADD | N/A | FTX228|FTX.006.228|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00006|VALUE-BASED-PAYMENT|X(15)|37|938|952|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | VALUE-BASED-PAYMENT-MODEL-TYPE/FTX.006.229 | Entire New Data Element | ADD | N/A | FTX229|FTX.006.229|VALUE-BASED-PAYMENT-MODEL-TYPE|Value Based Payment Model Type|Conditional|This is the type of value-based payment model to which the financial transaction applies. These values come from the “Alternative Payment Model (APM) Framework Final White Paper”. Produced by the Healthcare Learning and Action Network. https://hcp-lan.org/workproducts/apm-whitepaper.pdf |VALUE-BASED-PAYMENT-MODEL-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|38|953|954|1. Value must be 2 characters 2. Value must be in VALUE-BASED-PAYMENT-MODEL-TYPE list (VVL) 3. Conditional |
| 2023-09-28 | PAYMENT-CAT-XREF/FTX.006.230 | Entire New Data Element | ADD | N/A | FTX230|FTX.006.230|PAYMENT-CAT-XREF|Payment Cat Xref|Conditional|Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|39|955|1004|1. Value must be 50 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.006.231 | Entire New Data Element | ADD | N/A | FTX231|FTX.006.231|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|40|1005|1006|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.006.232 | Entire New Data Element | ADD | N/A | FTX232|FTX.006.232|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(100)|41|1007|1106|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.006.233 | Entire New Data Element | ADD | N/A | FTX233|FTX.006.233|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(500)|42|1107|1606|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.006.234 | Entire New Data Element | ADD | N/A | FTX234|FTX.006.234|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(500)|43|1607|2106|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.007.236 | Entire New Data Element | ADD | N/A | FTX236|FTX.007.236|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00007" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.007.237 | Entire New Data Element | ADD | N/A | FTX237|FTX.007.237|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.007.238 | Entire New Data Element | ADD | N/A | FTX238|FTX.007.238|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.007.239 | Entire New Data Element | ADD | N/A | FTX239|FTX.007.239|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.007.240 | Entire New Data Element | ADD | N/A | FTX240|FTX.007.240|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.007.241 | Entire New Data Element | ADD | N/A | FTX241|FTX.007.241|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.007.242 | Entire New Data Element | ADD | N/A | FTX242|FTX.007.242|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.007.243 | Entire New Data Element | ADD | N/A | FTX243|FTX.007.243|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.007.244 | Entire New Data Element | ADD | N/A | FTX244|FTX.007.244|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.007.245 | Entire New Data Element | ADD | N/A | FTX245|FTX.007.245|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.007.246 | Entire New Data Element | ADD | N/A | FTX246|FTX.007.246|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.007.247 | Entire New Data Element | ADD | N/A | FTX247|FTX.007.247|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.007.248 | Entire New Data Element | ADD | N/A | FTX248|FTX.007.248|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.007.249 | Entire New Data Element | ADD | N/A | FTX249|FTX.007.249|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.007.250 | Entire New Data Element | ADD | N/A | FTX250|FTX.007.250|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.007.251 | Entire New Data Element | ADD | N/A | FTX251|FTX.007.251|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.007.252 | Entire New Data Element | ADD | N/A | FTX252|FTX.007.252|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.007.253 | Entire New Data Element | ADD | N/A | FTX253|FTX.007.253|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.007.254 | Entire New Data Element | ADD | N/A | FTX254|FTX.007.254|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.007.255 | Entire New Data Element | ADD | N/A | FTX255|FTX.007.255|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.007.256 | Entire New Data Element | ADD | N/A | FTX256|FTX.007.256|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|21|613|614|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.007.257 | Entire New Data Element | ADD | N/A | FTX257|FTX.007.257|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | CONTRACT-ID/FTX.007.258 | Entire New Data Element | ADD | N/A | FTX258|FTX.007.258|CONTRACT-ID|Contract ID|Mandatory| Managed care plan contract ID|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|23|715|814|1. Value must be 100 characters or less 2. Mandatory |
| 2023-09-28 | PAYMENT-PERIOD-BEGIN-DATE/FTX.007.259 | Entire New Data Element | ADD | N/A | FTX259|FTX.007.259|PAYMENT-PERIOD-BEGIN-DATE|Payment Period Begin Date|Mandatory|The date representing the beginning of the time period that the payment is expected to be used by the provider. |N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|24|815|822|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated PAYMENT-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PAYMENT-PERIOD-END-DATE/FTX.007.260 | Entire New Data Element | ADD | N/A | FTX260|FTX.007.260|PAYMENT-PERIOD-END-DATE|Payment Period End Date|Mandatory|The date representing the end of the time period that the payment is expected to be used by the provider.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|25|823|830|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated PAYMENT-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PAYMENT-PERIOD-TYPE/FTX.007.261 | Entire New Data Element | ADD | N/A | FTX261|FTX.007.261|PAYMENT-PERIOD-TYPE|Payment Period Type|Conditional|A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an dend dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment.|PAYMENT-PERIOD-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|26|831|832|1. Value must be 2 characters 2. Value must be in PAYMENT-PERIOD-TYPE list 3. Conditional |
| 2023-09-28 | PAYMENT-PERIOD-TYPE-OTHER-TEXT/FTX.007.262 | Entire New Data Element | ADD | N/A | FTX262|FTX.007.262|PAYMENT-PERIOD-TYPE-OTHER-TEXT|Payment Period Type Other Text|Conditional|This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|27|833|932|1. Value must be 100 characters or less 2. PAYMENT-PERIOD-TYPE must = '95' 3. Conditional |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.007.263 | Entire New Data Element | ADD | N/A | FTX263|FTX.007.263|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|28|933|934|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.007.264 | Entire New Data Element | ADD | N/A | FTX264|FTX.007.264|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(5)|29|935|939|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.007.265 | Entire New Data Element | ADD | N/A | FTX265|FTX.007.265|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|30|940|989|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.007.266 | Entire New Data Element | ADD | N/A | FTX266|FTX.007.266|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(1)|31|990|990|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.007.267 | Entire New Data Element | ADD | N/A | FTX267|FTX.007.267|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(20)|32|991|1010|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.007.268 | Entire New Data Element | ADD | N/A | FTX268|FTX.007.268|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|33|1011|1012|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.007.269 | Entire New Data Element | ADD | N/A | FTX269|FTX.007.269|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|34|1013|1014|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.007.270 | Entire New Data Element | ADD | N/A | FTX270|FTX.007.270|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|35|1015|1016|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.007.271 | Entire New Data Element | ADD | N/A | FTX271|FTX.007.271|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|36|1017|1018|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.007.272 | Entire New Data Element | ADD | N/A | FTX272|FTX.007.272|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(15)|37|1019|1033|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | PAYMENT-CAT-XREF/FTX.007.273 | Entire New Data Element | ADD | N/A | FTX273|FTX.007.273|PAYMENT-CAT-XREF|Payment Cat Xref|Conditional|Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|38|1034|1083|1. Value must be 50 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.007.274 | Entire New Data Element | ADD | N/A | FTX274|FTX.007.274|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|39|1084|1085|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.007.275 | Entire New Data Element | ADD | N/A | FTX275|FTX.007.275|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|40|1086|1185|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.007.276 | Entire New Data Element | ADD | N/A | FTX276|FTX.007.276|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(500)|41|1186|1685|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.007.277 | Entire New Data Element | ADD | N/A | FTX277|FTX.007.277|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(500)|42|1686|2185|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.008.279 | Entire New Data Element | ADD | N/A | FTX279|FTX.008.279|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00008|COST-SETTLEMENT-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00008" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.008.280 | Entire New Data Element | ADD | N/A | FTX280|FTX.008.280|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.008.281 | Entire New Data Element | ADD | N/A | FTX281|FTX.008.281|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.008.282 | Entire New Data Element | ADD | N/A | FTX282|FTX.008.282|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.008.283 | Entire New Data Element | ADD | N/A | FTX283|FTX.008.283|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.008.284 | Entire New Data Element | ADD | N/A | FTX284|FTX.008.284|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.008.285 | Entire New Data Element | ADD | N/A | FTX285|FTX.008.285|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00008|COST-SETTLEMENT-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.008.286 | Entire New Data Element | ADD | N/A | FTX286|FTX.008.286|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.008.287 | Entire New Data Element | ADD | N/A | FTX287|FTX.008.287|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.008.288 | Entire New Data Element | ADD | N/A | FTX288|FTX.008.288|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.008.289 | Entire New Data Element | ADD | N/A | FTX289|FTX.008.289|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.008.290 | Entire New Data Element | ADD | N/A | FTX290|FTX.008.290|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.008.291 | Entire New Data Element | ADD | N/A | FTX291|FTX.008.291|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.008.292 | Entire New Data Element | ADD | N/A | FTX292|FTX.008.292|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.008.293 | Entire New Data Element | ADD | N/A | FTX293|FTX.008.293|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.008.294 | Entire New Data Element | ADD | N/A | FTX294|FTX.008.294|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.008.295 | Entire New Data Element | ADD | N/A | FTX295|FTX.008.295|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.008.296 | Entire New Data Element | ADD | N/A | FTX296|FTX.008.296|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.008.297 | Entire New Data Element | ADD | N/A | FTX297|FTX.008.297|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.008.298 | Entire New Data Element | ADD | N/A | FTX298|FTX.008.298|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.008.299 | Entire New Data Element | ADD | N/A | FTX299|FTX.008.299|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|21|613|614|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.008.300 | Entire New Data Element | ADD | N/A | FTX300|FTX.008.300|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | COST-SETTLEMENT-PERIOD-START-DATE/FTX.008.301 | Entire New Data Element | ADD | N/A | FTX301|FTX.008.301|COST-SETTLEMENT-PERIOD-START-DATE|Cost Settlement Period Start Date|Mandatory|The date representing the beginning of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement begin date would be March 1 of that year. |N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|23|715|722|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated COST-SETTLEMENT-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | COST-SETTLEMENT-PERIOD-END-DATE/FTX.008.302 | Entire New Data Element | ADD | N/A | FTX302|FTX.008.302|COST-SETTLEMENT-PERIOD-END-DATE|Cost Settlement Period End Date|Mandatory|The date representing the end of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement end date would be March 31 of that year. |N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|24|723|730|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated COST-SETTLEMENT-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.008.303 | Entire New Data Element | ADD | N/A | FTX303|FTX.008.303|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|25|731|732|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.008.304 | Entire New Data Element | ADD | N/A | FTX304|FTX.008.304|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00008|COST-SETTLEMENT-PAYMENT|X(5)|26|733|737|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.008.305 | Entire New Data Element | ADD | N/A | FTX305|FTX.008.305|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|27|738|787|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.008.306 | Entire New Data Element | ADD | N/A | FTX306|FTX.008.306|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00008|COST-SETTLEMENT-PAYMENT|X(1)|28|788|788|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.008.307 | Entire New Data Element | ADD | N/A | FTX307|FTX.008.307|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(20)|29|789|808|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.008.308 | Entire New Data Element | ADD | N/A | FTX308|FTX.008.308|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|30|809|810|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.008.309 | Entire New Data Element | ADD | N/A | FTX309|FTX.008.309|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|31|811|812|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.008.310 | Entire New Data Element | ADD | N/A | FTX310|FTX.008.310|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|32|813|814|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.008.311 | Entire New Data Element | ADD | N/A | FTX311|FTX.008.311|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|33|815|816|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.008.312 | Entire New Data Element | ADD | N/A | FTX312|FTX.008.312|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(15)|34|817|831|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.008.313 | Entire New Data Element | ADD | N/A | FTX313|FTX.008.313|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|35|832|833|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.008.314 | Entire New Data Element | ADD | N/A | FTX314|FTX.008.314|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|36|834|933|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.008.315 | Entire New Data Element | ADD | N/A | FTX315|FTX.008.315|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(500)|37|934|1433|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.008.316 | Entire New Data Element | ADD | N/A | FTX316|FTX.008.316|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(500)|38|1434|1933|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.009.318 | Entire New Data Element | ADD | N/A | FTX318|FTX.009.318|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00009| FQHC-WRAP-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00009" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.009.319 | Entire New Data Element | ADD | N/A | FTX319|FTX.009.319|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.009.320 | Entire New Data Element | ADD | N/A | FTX320|FTX.009.320|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00009| FQHC-WRAP-PAYMENT|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.009.321 | Entire New Data Element | ADD | N/A | FTX321|FTX.009.321|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.009.322 | Entire New Data Element | ADD | N/A | FTX322|FTX.009.322|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.009.323 | Entire New Data Element | ADD | N/A | FTX323|FTX.009.323|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.009.324 | Entire New Data Element | ADD | N/A | FTX324|FTX.009.324|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00009| FQHC-WRAP-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.009.325 | Entire New Data Element | ADD | N/A | FTX325|FTX.009.325|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00009| FQHC-WRAP-PAYMENT|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.009.326 | Entire New Data Element | ADD | N/A | FTX326|FTX.009.326|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00009| FQHC-WRAP-PAYMENT|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.009.327 | Entire New Data Element | ADD | N/A | FTX327|FTX.009.327|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00009| FQHC-WRAP-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.009.328 | Entire New Data Element | ADD | N/A | FTX328|FTX.009.328|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.009.329 | Entire New Data Element | ADD | N/A | FTX329|FTX.009.329|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.009.330 | Entire New Data Element | ADD | N/A | FTX330|FTX.009.330|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.009.331 | Entire New Data Element | ADD | N/A | FTX331|FTX.009.331|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.009.332 | Entire New Data Element | ADD | N/A | FTX332|FTX.009.332|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.009.333 | Entire New Data Element | ADD | N/A | FTX333|FTX.009.333|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00009| FQHC-WRAP-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.009.334 | Entire New Data Element | ADD | N/A | FTX334|FTX.009.334|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(100)|17|381|480|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.009.335 | Entire New Data Element | ADD | N/A | FTX335|FTX.009.335|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.009.336 | Entire New Data Element | ADD | N/A | FTX336|FTX.009.336|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.009.337 | Entire New Data Element | ADD | N/A | FTX337|FTX.009.337|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.009.338 | Entire New Data Element | ADD | N/A | FTX338|FTX.009.338|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|21|613|614|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.009.339 | Entire New Data Element | ADD | N/A | FTX339|FTX.009.339|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | WRAP-PERIOD-START-DATE/FTX.009.340 | Entire New Data Element | ADD | N/A | FTX340|FTX.009.340|WRAP-PERIOD-START-DATE|Wrap Period Start Date|Mandatory|The date representing the beginning of the FQHC wrap payment or recoupment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment begin date would be March 1 of that year.|N/A|FTX00009| FQHC-WRAP-PAYMENT|9(8)|23|715|722|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated WRAP-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | WRAP-PERIOD-END-DATE/FTX.009.341 | Entire New Data Element | ADD | N/A | FTX341|FTX.009.341|WRAP-PERIOD-END-DATE|Wrap Period End Date|Mandatory|The date representing the end of the FQHC wrap payment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment end date would be March 31 of that year.|N/A|FTX00009| FQHC-WRAP-PAYMENT|9(8)|24|723|730|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated WRAP-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.009.342 | Entire New Data Element | ADD | N/A | FTX342|FTX.009.342|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00009| FQHC-WRAP-PAYMENT|X(2)|25|731|732|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.009.343 | Entire New Data Element | ADD | N/A | FTX343|FTX.009.343|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00009| FQHC-WRAP-PAYMENT|X(5)|26|733|737|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.009.344 | Entire New Data Element | ADD | N/A | FTX344|FTX.009.344|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00009| FQHC-WRAP-PAYMENT|X(50)|27|738|787|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.009.345 | Entire New Data Element | ADD | N/A | FTX345|FTX.009.345|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00009| FQHC-WRAP-PAYMENT|X(1)|28|788|788|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.009.346 | Entire New Data Element | ADD | N/A | FTX346|FTX.009.346|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(20)|29|789|808|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.009.347 | Entire New Data Element | ADD | N/A | FTX347|FTX.009.347|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|30|809|810|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.009.348 | Entire New Data Element | ADD | N/A | FTX348|FTX.009.348|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|31|811|812|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.009.349 | Entire New Data Element | ADD | N/A | FTX349|FTX.009.349|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|32|813|814|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.009.350 | Entire New Data Element | ADD | N/A | FTX350|FTX.009.350|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00009| FQHC-WRAP-PAYMENT|X(2)|33|815|816|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.009.351 | Entire New Data Element | ADD | N/A | FTX351|FTX.009.351|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(15)|34|817|831|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.009.352 | Entire New Data Element | ADD | N/A | FTX352|FTX.009.352|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|35|832|833|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.009.353 | Entire New Data Element | ADD | N/A | FTX353|FTX.009.353|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(100)|36|834|933|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.009.354 | Entire New Data Element | ADD | N/A | FTX354|FTX.009.354|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(500)|37|934|1433|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.009.355 | Entire New Data Element | ADD | N/A | FTX355|FTX.009.355|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(500)|38|1434|1933|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | RECORD-ID/FTX.095.357 | Entire New Data Element | ADD | N/A | FTX357|FTX.095.357|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00095 |MISCELLANEOUS-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00095" 4. Mandatory |
| 2023-09-28 | SUBMITTING-STATE/FTX.095.358 | Entire New Data Element | ADD | N/A | FTX358|FTX.095.358|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|2|9|10|1. Value must be in State Code list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-NUMBER/FTX.095.359 | Entire New Data Element | ADD | N/A | FTX359|FTX.095.359|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | ICN-ORIG/FTX.095.360 | Entire New Data Element | ADD | N/A | FTX360|FTX.095.360|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
| 2023-09-28 | ICN-ADJ/FTX.095.361 | Entire New Data Element | ADD | N/A | FTX361|FTX.095.361|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
| 2023-09-28 | UNIQUE-TRANSACTION-ID/FTX.095.362 | Entire New Data Element | ADD | N/A | FTX362|FTX.095.362|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
| 2023-09-28 | ADJUSTMENT-IND/FTX.095.363 | Entire New Data Element | ADD | N/A | FTX363|FTX.095.363|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-DATE/FTX.095.364 | Entire New Data Element | ADD | N/A | FTX364|FTX.095.364|PAYMENT-OR-RECOUPMENT-DATE|Payment Or Recoupment Date|Mandatory|The date that the payment or recoupment was executed by the payer. |N/A|FTX00095 |MISCELLANEOUS-PAYMENT|9(8)|8|173|180|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value of the CC component must be in ['19', '20'] 4. Mandatory |
| 2023-09-28 | PAYMENT-OR-RECOUPMENT-AMOUNT/FTX.095.365 | Entire New Data Element | ADD | N/A | FTX365|FTX.095.365|PAYMENT-OR-RECOUPMENT-AMOUNT|Payment Or Recoupment Amount|Mandatory|The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|S9(11)V99|9|181|193|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Mandatory |
| 2023-09-28 | CHECK-EFF-DATE/FTX.095.366 | Entire New Data Element | ADD | N/A | FTX366|FTX.095.366|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
| 2023-09-28 | CHECK-NUM/FTX.095.367 | Entire New Data Element | ADD | N/A | FTX367|FTX.095.367|CHECK-NUM|Check Num|Conditional|The check or electronic funds transfer number.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(15)|11|202|216|1. Value must be 15 characters or less 2. Value must have an associated Check Effective Date 3. Value must not contain a pipe or asterisk symbols 4. Conditional |
| 2023-09-28 | PAYER-ID/FTX.095.368 | Entire New Data Element | ADD | N/A | FTX368|FTX.095.368|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE/FTX.095.369 | Entire New Data Element | ADD | N/A | FTX369|FTX.095.369|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYER-ID-TYPE-OTHER-TEXT/FTX.095.370 | Entire New Data Element | ADD | N/A | FTX370|FTX.095.370|PAYER-ID-TYPE-OTHER-TEXT|Payer ID Type Other Text|Conditional|This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|14|249|348|1. Value must be 100 characters or less 2. PAYER-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYER-MCR-PLAN-TYPE/FTX.095.371 | Entire New Data Element | ADD | N/A | FTX371|FTX.095.371|PAYER-MCR-PLAN-TYPE|Payer MCR Plan Type|Conditional|This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|15|349|350|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYER-ID-TYPE is '02' then PAYER-MCR-PLAN-TYPE must be populated 4. If PAYER-ID-TYPE is not '02' then PAYER-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYER-MCR-PLAN-TYPE-OTHER-TEXT/FTX.095.372 | Entire New Data Element | ADD | N/A | FTX372|FTX.095.372|PAYER-MCR-PLAN-TYPE-OTHER-TEXT|Payer MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|16|351|450|1. Value must be 100 characters or less 2. PAYER-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-ID/FTX.095.373 | Entire New Data Element | ADD | N/A | FTX373|FTX.095.373|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|17|451|480|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE /FTX.095.374 | Entire New Data Element | ADD | N/A | FTX374|FTX.095.374|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-ID-TYPE-OTHER-TEXT/FTX.095.375 | Entire New Data Element | ADD | N/A | FTX375|FTX.095.375|PAYEE-ID-TYPE-OTHER-TEXT|Payee ID Type Other Text|Conditional|This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|19|483|582|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE/FTX.095.376 | Entire New Data Element | ADD | N/A | FTX376|FTX.095.376|PAYEE-MCR-PLAN-TYPE|Payee MCR Plan Type |Conditional|This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models.|MANAGED-CARE-PLAN-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|20|583|584|1. Value must be 2 characters 2. Value must be in MANAGED-CARE-PLAN-TYPE list (VVL) 3. If PAYEE-ID-TYPE is '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must be populated 4. If PAYEE-ID-TYPE is not '02' or ‘03’ then PAYEE-MCR-PLAN-TYPE must not be populated 5. Conditional |
| 2023-09-28 | PAYEE-MCR-PLAN-TYPE-OTHER-TEXT/FTX.095.377 | Entire New Data Element | ADD | N/A | FTX377|FTX.095.377|PAYEE-MCR-PLAN-TYPE-OTHER-TEXT|Payee MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|21|585|684|1. Value must be 100 characters or less 2. PAYEE-MCR-PLAN-TYPE must = '95' 3. Conditional |
| 2023-09-28 | PAYEE-TAX-ID/FTX.095.378 | Entire New Data Element | ADD | N/A | FTX378|FTX.095.378|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresonds with the payee's role in relation to the Medicaid/CHIP system.The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|22|685|714|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
| 2023-09-28 | PAYEE-TAX-ID-TYPE/FTX.095.379 | Entire New Data Element | ADD | N/A | FTX379|FTX.095.379|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|23|715|716|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.095.380 | Entire New Data Element | ADD | N/A | FTX380|FTX.095.380|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|24|717|816|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
| 2023-09-28 | CONTRACT-ID/FTX.095.381 | Entire New Data Element | ADD | N/A | FTX381|FTX.095.381|CONTRACT-ID|Contract ID|Conditional| Managed care plan contract ID|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|25|817|916|1. Value must be 100 characters or less 2. Conditional |
| 2023-09-28 | INSURANCE-CARRIER-ID-NUM/FTX.095.382 | Entire New Data Element | ADD | N/A | FTX382|FTX.095.382|INSURANCE-CARRIER-ID-NUM|Insurance Carrier ID Num|Conditional| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(12)|26|917|928|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/FTX.095.383 | Entire New Data Element | ADD | N/A | FTX383|FTX.095.383|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(20)|27|929|948|1. Value must be 20 characters or less 2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN 3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN 4. Conditional |
| 2023-09-28 | PAYMENT-PERIOD-BEGIN-DATE/FTX.095.384 | Entire New Data Element | ADD | N/A | FTX384|FTX.095.384|PAYMENT-PERIOD-BEGIN-DATE|Payment Period Begin Date|Mandatory|The date representing the beginning of the time period that the payment is expected to be used by the provider. |N/A|FTX00095 |MISCELLANEOUS-PAYMENT|9(8)|28|949|956|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated PAYMENT-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PAYMENT-PERIOD-END-DATE/FTX.095.385 | Entire New Data Element | ADD | N/A | FTX385|FTX.095.385|PAYMENT-PERIOD-END-DATE|Payment Period End Date|Mandatory|The date representing the end of the time period that the payment is expected to be used by the provider.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|9(8)|29|957|964|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be after or the same as the associated PAYMENT-PERIOD-START-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
| 2023-09-28 | PAYMENT-PERIOD-TYPE/FTX.095.386 | Entire New Data Element | ADD | N/A | FTX386|FTX.095.386|PAYMENT-PERIOD-TYPE|Payment Period Type|Conditional|A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an dend dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment.|PAYMENT-PERIOD-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|30|965|966|1. Value must be 2 characters 2. Value must be in PAYMENT-PERIOD-TYPE list 3. Conditional |
| 2023-09-28 | PAYMENT-PERIOD-TYPE-OTHER-TEXT/FTX.095.387 | Entire New Data Element | ADD | N/A | FTX387|FTX.095.387|PAYMENT-PERIOD-TYPE-OTHER-TEXT|Payment Period Type Other Text|Conditional|This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|31|967|1066|1. Value must be 100 characters or less 2. PAYMENT-PERIOD-TYPE must = '95' 3. Conditional |
| 2023-09-28 | TRANSACTION-TYPE/FTX.095.388 | Entire New Data Element | ADD | N/A | FTX388|FTX.095.388|TRANSACTION-TYPE|Transaction Type|Conditional|This is a code that classifies the type of financial transaction when the financial transaction does not fit into any other financial transaction segment type (e.g., FTX00002, FTX00003, FTX00004, etc.). |TRANSACTION-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|32|1067|1068|1. Value must be 2 characters 2. Value must be in TRANSACTION-TYPE list 3. Conditional |
| 2023-09-28 | TRANSACTION-TYPE-OTHER-TEXT/FTX.095.389 | Entire New Data Element | ADD | N/A | FTX389|FTX.095.389|TRANSACTION-TYPE-OTHER-TEXT|Transaction Type Other Text|Conditional|This is a description of the type of financial transaction when the TRANSACTION-TYPE is "Other".|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|33|1069|1168|1. Value must be 100 characters or less 2. PAYEE-ID-TYPE must = '95' 2. Conditional |
| 2023-09-28 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.095.390 | Entire New Data Element | ADD | N/A | FTX390|FTX.095.390|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|34|1169|1170|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-CATEGORY-OF-SERVICE/FTX.095.391 | Entire New Data Element | ADD | N/A | FTX391|FTX.095.391|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00095 |MISCELLANEOUS-PAYMENT|X(5)|35|1171|1175|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM/FTX.095.392 | Entire New Data Element | ADD | N/A | FTX392|FTX.095.392|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditured will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|36|1176|1225|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
| 2023-09-28 | MBESCBES-FORM-GROUP/FTX.095.393 | Entire New Data Element | ADD | N/A | FTX393|FTX.095.393|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Mandatory|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|37|1226|1226|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Mandatory |
| 2023-09-28 | WAIVER-ID/FTX.095.394 | Entire New Data Element | ADD | N/A | FTX394|FTX.095.394|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(20)|38|1227|1246|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
| 2023-09-28 | WAIVER-TYPE/FTX.095.395 | Entire New Data Element | ADD | N/A | FTX395|FTX.095.395|WAIVER-TYPE|Waiver Type|Conditional|A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted.|WAIVER-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|39|1247|1248|1. Value must have a corresponding value in WAIVER-ID 2. Value must be in WAIVER-TYPE list (VVL) 3. Value must be 2 characters 4. Conditional |
| 2023-09-28 | FUNDING-CODE/FTX.095.396 | Entire New Data Element | ADD | N/A | FTX396|FTX.095.396|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|40|1249|1250|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Mandatory |
| 2023-09-28 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.095.397 | Entire New Data Element | ADD | N/A | FTX397|FTX.095.397|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|41|1251|1252|1. Value must be in FUNDING-SOURCE-NONFEDERAL-SHARE list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SDP-IND/FTX.095.398 | Entire New Data Element | ADD | N/A | FTX398|FTX.095.398|SDP-IND|State Directed Payment Indicator|Mandatory|Indicates whether the financial transaction from an MC plan plan to a provider or other entity is a type of State Directed Payment.|SDP-IND|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|42|1253|1253|1. Value must be 1 character 2. Value must be in SPD-IND list (VVL) 3. Mandatory |
| 2023-09-28 | SOURCE-LOCATION/FTX.095.399 | Entire New Data Element | ADD | N/A | FTX399|FTX.095.399|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims/transaction processing system in which the claims/transactions were originally processed.|SOURCE-LOCATION|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|43|1254|1255|1. Value must be in SOURCE-LOCATION list (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | SPA-NUMBER/FTX.095.400 | Entire New Data Element | ADD | N/A | FTX400|FTX.095.400|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(15)|44|1256|1270|1. Value must be 15 characters or less 2. Conditional |
| 2023-09-28 | PAYMENT-CAT-XREF/FTX.095.401 | Entire New Data Element | ADD | N/A | FTX401|FTX.095.401|PAYMENT-CAT-XREF|Payment Cat Xref|Conditional|Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|45|1271|1320|1. Value must be 50 characters or less 2. Conditional |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE/FTX.095.402 | Entire New Data Element | ADD | N/A | FTX402|FTX.095.402|EXPENDITURE-AUTHORITY-TYPE|Expenditure Authority Type|Mandatory|This is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text.|EXPENDITURE-AUTHORITY-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|46|1321|1322|1. Value must be 2 characters 2. Value must be in EXPENDITURE-AUTHORITY-TYPE list (VVL) 3. Mandatory |
| 2023-09-28 | EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT/FTX.095.403 | Entire New Data Element | ADD | N/A | FTX403|FTX.095.403|EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT|Expenditure Authority Type Other Text|Conditional|This field is only to be used if EXPENDITURE-AUTHORITY-TYPE "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(100)|47|1323|1422|1. Value must be 100 characters or less 2. EXPENDITURE-AUTHORITY-TYPE must = '95' 3. Conditional |
| 2023-09-28 | MEMO/FTX.095.404 | Entire New Data Element | ADD | N/A | FTX404|FTX.095.404|MEMO|Memo|Conditional|This represents any notes from the state's ledger/accounting system associated with the payment/recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(500)|48|1423|1922|1. Value must be 500 characters or less 2. Conditional |
| 2023-09-28 | STATE-NOTATION /FTX.095.405 | Entire New Data Element | ADD | N/A | FTX405|FTX.095.405|STATE-NOTATION |State Notation |Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(500)|49|1923|2422|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | FILE-SUBMISSION-METHOD/MCR.001.113 | Entire New Data Element | ADD | N/A | MCR113|MCR.001.113|FILE-SUBMISSION-METHOD|File Submission Method|Mandatory|The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period.|FILE-SUBMISSION-METHOD|MCR00001|FILE-SUBMISSION-METHOD|X(2)|13|78|79|1. Value must be in File Submission Method List (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | RECORD-ID/MCR.010.114 | Entire New Data Element | ADD | N/A | MCR114|MCR.010.114|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|MCR00010|MANAGED-CARE-ID|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
| 2023-09-28 | SUBMITTING-STATE/MCR.010.115 | Entire New Data Element | ADD | N/A | MCR115|MCR.010.115|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|MCR00010|MANAGED-CARE-ID|X(2)|2|9|10|1. Value must be in State Code List (VVL) 2. Value must be 2 characters 3. Mandatory 4. Value must be the same as Submitting State (MCR.001.007) |
| 2023-09-28 | RECORD-NUMBER/MCR.010.116 | Entire New Data Element | ADD | N/A | MCR116|MCR.010.116|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|MCR00010|MANAGED-CARE-ID|9(11)|3|11|21|1. Value must be unique within record segment over all records associated with a given Record ID (CE) 2. Value must be 11 digits or less 3. Mandatory |
| 2023-09-28 | STATE-PLAN-ID-NUM/MCR.010.117 | Entire New Data Element | ADD | N/A | MCR117|MCR.010.117|STATE-PLAN-ID-NUM|State Plan ID Number|Mandatory|The ID number a state issues to a managed care entity|N/A|MCR00010|MANAGED-CARE-ID|X(12)|4|22|33|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2023-09-28 | MANAGED-CARE-PLAN-ID-TYPE/MCR.010.118 | Entire New Data Element | ADD | N/A | MCR118|MCR.010.118|MANAGED-CARE-PLAN-ID-TYPE|Managed Care Plan ID Type|Mandatory|A code to identify the kind of managed care identifier that is captured in the Managed Care Identifier data element. The state should submit updates to T-MSIS whenever an identifier is retired or issued.|MANAGED-CARE-PLAN-ID-TYPE|MCR00010|MANAGED-CARE-ID|X(2)|5|34|35|1. Value must be in Managed Care Plan ID Type List (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | MANAGED-CARE-PLAN-ID/MCR.010.119 | Entire New Data Element | ADD | N/A | MCR119|MCR.010.119|MANAGED-CARE-PLAN-ID|Managed Care Plan ID|Mandatory|A data element to capture the various IDs used to identify a managed care plan. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Identifier Type data element.|N/A|MCR00010|MANAGED-CARE-ID|X(30)|6|36|65|1. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | MANAGED-CARE-ID-EFF-DATE/MCR.010.120 | Entire New Data Element | ADD | N/A | MCR120|MCR.010.120|MANAGED-CARE-ID-EFF-DATE|Managed Care ID Effective Date|Mandatory|The date the organization achieved accreditation.|N/A|MCR00010|MANAGED-CARE-ID|9(8)|7|66|73|1. Value must be 8 characters in the form 'CCYYMMDD' 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated Segment End Date value 4. Mandatory 5. Value of the CC component must be in ['18', '19', '20'] |
| 2023-09-28 | MANAGED-CARE-ID-END-DATE/MCR.010.121 | Entire New Data Element | ADD | N/A | MCR121|MCR.010.121|MANAGED-CARE-ID-END-DATE|Managed Care ID End Date|Mandatory|The date when organization's accreditation ends.|N/A|MCR00010|MANAGED-CARE-ID|9(8)|8|74|81|1. Value must be 8 characters in the form 'CCYYMMDD' 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be greater than or equal to associated Segment Effective Date value 4. Mandatory 5. Value of the CC component must be in ['18', '19', '20', '99'] |
| 2023-09-28 | STATE-NOTATION/MCR.010.122 | Entire New Data Element | ADD | N/A | MCR122|MCR.010.122|STATE-NOTATION|State Notation|Optional|A free text field for the submitting state to enter whatever information it chooses.|N/A|MCR00010|MANAGED-CARE-ID|X(500)|9|82|581|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Optional |
| 2023-09-28 | FILE-SUBMISSION-METHOD/PRV.001.139 | Entire New Data Element | ADD | N/A | PRV139|PRV.001.139|FILE-SUBMISSION-METHOD|File Submission Method|Mandatory|The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period.|FILE-SUBMISSION-METHOD|PRV00001|FILE-SUBMISSION-METHOD|X(2)|13|78|79|1. Value must be in File Submission Method List (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | ATYPICAL-PROV-IND/PRV.002.140 | Entire New Data Element | ADD | N/A | PRV140|PRV.002.140|ATYPICAL-PROV-IND|Ayptical Provider Indicator|Mandatory|An indicator to identify whether the provider is an atypical provider and therefore not eligible for an NPI.|ATYPICAL-PROV-IND|PRV00002|PROV-ATTRIBUTES-MAIN|X(1)|22|514|514|1. Value must be 1 character 2. Value must be in Atypical Provider Indicator code list (VVL) 3. Mandatory |
| 2023-09-28 | FILE-SUBMISSION-METHOD/TPL.001.095 | Entire New Data Element | ADD | N/A | TPL095|TPL.001.095|FILE-SUBMISSION-METHOD|File Submission Method|Mandatory|The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period.|FILE-SUBMISSION-METHOD|TPL00001|FILE-SUBMISSION-METHOD|X(2)|14|79|80|1. Value must be in File Submission Method List (VVL) 2. Value must be 2 characters 3. Mandatory |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/TPL.002.019 | Definition | UPDATE | TPL019|TPL.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
TPL019|TPL.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/TPL.003.032 | Definition | UPDATE | TPL032|TPL.003.032|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00003|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
TPL032|TPL.003.032|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00003|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2023-09-28 | MSIS-IDENTIFICATION-NUM/TPL.005.066 | Definition | UPDATE | TPL066|TPL.005.066|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00005|TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION|X(20)|N/A|22|41|1. Mandatory 2. Value must be 20 characters or less |
TPL066|TPL.005.066|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00005|TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
| 2024-04-12 | DATA-DICTIONARY-VERSION/CIP.001.002 | Coding requirement | UPDATE | CIP002|CIP.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|DATA-DICTIONARY-VERSION|CIP00001|FILE-HEADER-RECORD-IP|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
CIP002|CIP.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|CIP00001|FILE-HEADER-RECORD-IP|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | FILE-NAME/CIP.001.006 | Definition | UPDATE | CIP006|CIP.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|CIP00001|FILE-HEADER-RECORD-IP|X(8)|6|32|39|1. Value must equal 'CLAIM-IP' 2. Mandatory |
CIP006|CIP.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|CIP00001|FILE-HEADER-RECORD-IP|X(8)|6|32|39|1. Value must equal "CLAIM-IP" 2. Mandatory |
| 2024-04-12 | ICN-ADJ/CIP.002.020 | Coding Requirement | UPDATE | CIP020|CIP.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CIP020|CIP.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/CIP.002.022 | Definition, Coding Requirement | UPDATE | CIP022|CIP.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(20)|7|134|153|1. Mandatory 2. Value must be 20 characters or less. 3. When Type of Claim not in (U, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254). |
CIP022|CIP.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(20)|7|134|153|1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 2024-04-12 | CROSSOVER-INDICATOR/CIP.002.023 | Coding Requirement | UPDATE | CIP023|CIP.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|8|154|154|1. Value must be in Crossover Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) 5. Value must be 1 character 6. Mandatory |
CIP023|CIP.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|8|154|154|1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 2024-04-12 | ADJUSTMENT-IND/CIP.002.026 | Coding Requirement | UPDATE | CIP026|CIP.002.026|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record. |ADJUSTMENT-IND|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|11|158|158|1. Value must be in Adjustment Indicator List (VVL). 2. Value must be in [ 0, 1, 4 ]. 3. Value must be 1 character. 4. Mandatory |
CIP026|CIP.002.026|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|11|158|158|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" |
| 2024-04-12 | PROCEDURE-CODE-1/CIP.002.070 | Coding requirement | UPDATE | CIP070|CIP.002.070|PROCEDURE-CODE-1|Procedure Code 1|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code1, Procedure Code Date-1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|17|191|198|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
CIP070|CIP.002.070|PROCEDURE-CODE-1|Procedure Code 1|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code1, Procedure Code Date-1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|PROCEDURE-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|17|191|198|1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 2024-04-12 | PROCEDURE-CODE-2/CIP.002.074 | Coding requirement | UPDATE | CIP074|CIP.002.074|PROCEDURE-CODE-2|Procedure Code 2|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|20|209|216|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
CIP074|CIP.002.074|PROCEDURE-CODE-2|Procedure Code 2|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|PROCEDURE-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|20|209|216|1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 2024-04-12 | PROCEDURE-CODE-3/CIP.002.078 | Coding requirement | UPDATE | CIP078|CIP.002.078|PROCEDURE-CODE-3|Procedure Code 3|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|23|227|234|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
CIP078|CIP.002.078|PROCEDURE-CODE-3|Procedure Code 3|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|PROCEDURE-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|23|227|234|1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 2024-04-12 | PROCEDURE-CODE-4/CIP.002.082 | Coding requirement | UPDATE | CIP082|CIP.002.082|PROCEDURE-CODE-4|Procedure Code 4|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|26|245|252|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
CIP082|CIP.002.082|PROCEDURE-CODE-4|Procedure Code 4|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|PROCEDURE-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|26|245|252|1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 2024-04-12 | PROCEDURE-CODE-5/CIP.002.086 | Coding requirement | UPDATE | CIP086|CIP.002.086|PROCEDURE-CODE-5|Procedure Code 5|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|29|263|270|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
CIP086|CIP.002.086|PROCEDURE-CODE-5|Procedure Code 5|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|PROCEDURE-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|29|263|270|1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 2024-04-12 | PROCEDURE-CODE-6/CIP.002.090 | Coding requirement | UPDATE | CIP090|CIP.002.090|PROCEDURE-CODE-6|Procedure Code 6|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|32|281|288|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
CIP090|CIP.002.090|PROCEDURE-CODE-6|Procedure Code 6|Conditional|A procedure code based on ICD-9 and ICD-10 used by the state to identify the procedures performed during the hospital stay referenced by this claim. The principal procedure and related info should be recorded in Procedure Code 1, Procedure Code Date 1, and Procedure Code Flag 1. The principal procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes. It is closely related to either the principal diagnosis or to complications that arise during other treatments. Use Procedure Code 2 through Procedure Code 6 (and related data elements) to record secondary, tertiary, etc. procedures.|PROCEDURE-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(8)|32|281|288|1. Value must be 8 characters or less 2. When populated, there must be a corresponding Procedure Code Flag 3. If associated Procedure Code Flag value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code 4. If associated Procedure Code Flag value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. Value must be in Procedure Code List (VVL) 7. Conditional |
| 2024-04-12 | TYPE-OF-CLAIM/CIP.002.100 | Coding requirement | UPDATE | CIP100|CIP.002.100|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |TYPE-OF-CLAIM|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|41|335|335|1. Value must be in Type of Claim List (VVL) 2. Value must be 1 character 3. Mandatory 4. When value equals 'Z', claim denied indicator must equal '0' |
CIP100|CIP.002.100|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = "3" for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.|TYPE-OF-CLAIM|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|41|335|335|1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 2024-04-12 | SOURCE-LOCATION/CIP.002.104 | Coding requirement; Definition | UPDATE | CIP104|CIP.002.104|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |SOURCE-LOCATION|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|45|346|347|1. Value must be in Source Location List (VVL) 2. Value must be 2 characters 3. Mandatory |
CIP104|CIP.002.104|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee.|SOURCE-LOCATION|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|45|346|347|1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 2024-04-12 | TOT-MEDICAID-PAID-AMT/CIP.002.114 | Coding Requirement; Definition | UPDATE | CIP114|CIP.002.114|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(11)V99|54|417|429|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be greater than Total Allowed Amount (CIP.002.113) |
CIP114|CIP.002.114|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(11)V99|54|417|429|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 2024-04-12 | FUNDING-CODE/CIP.002.126 | Coding requirement | UPDATE | CIP126|CIP.002.126|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|62|487|488|1. Value must be in Funding Code List (VVL) 2. Value must be 1 character 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
CIP126|CIP.002.126|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|62|487|488|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | FUNDING-SOURCE-NONFEDERAL-SHARE/CIP.002.127 | Coding requirement | UPDATE | CIP127|CIP.002.127|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Non-Federal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. |FUNDING-SOURCE-NONFEDERAL-SHARE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|63|489|490|1. Value must be in Funding Source Non-Federal Share List (VVL) 2. Value must be 2 characters 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
CIP127|CIP.002.127|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Non-Federal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|63|489|490|1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | MEDICAID-COV-INPATIENT-DAYS/CIP.002.136 | Coding Requirement | UPDATE | CIP136|CIP.002.136|MEDICAID-COV-INPATIENT-DAYS|Medicaid Covered Inpatient Days|Conditional|The number of days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(7)|71|527|533|1. Value must be a positive integer 2. Value must be between 0:99999999999 (inclusive) 3. Conditional 4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day 5. Value must be 7 digits or less 6. Value is required if the associated Type of Service (CIP.002.257) is in [001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132] 7. Value is required if at least one associated Revenue Code (CIP.003.245) is in [100-219] |
CIP136|CIP.002.136|MEDICAID-COV-INPATIENT-DAYS|Medicaid Covered Inpatient Days|Conditional|The number of days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(7)|71|527|533|1. Value must be a positive integer 2. Value must be between 0000000:9999999 (inclusive) 3. Conditional 4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day 5. Value must be 7 digits or less 6. Value is required if the associated Type of Service (CIP.002.257) in [001,058,060,084,086,090,091,092,093,123,132] 7. Value is required if at least one associated Revenue Code (CIP.003.245) in [100-219] |
| 2024-04-12 | CLAIM-LINE-COUNT/CIP.002.137 | Coding Requirement | UPDATE | CIP137|CIP.002.137|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|9(4)|72|534|537|1. Value must be a positive integer 2. Value must be between 0:9999 (inclusive) 3. Value must not include commas or other non-numeric characters 4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 5. Value must be 4 characters or less 6. Mandatory |
CIP137|CIP.002.137|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|9(4)|72|534|537|1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 6. Mandatory |
| 2024-04-12 | HEALTH-HOME-PROV-IND/CIP.002.176 | Coding Requirement | UPDATE | CIP176|CIP.002.176|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|111|818|818|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If there is an associated Health Home Entity Name value, then value must be "1" 5. Value must be 1 character 6. Conditional |
CIP176|CIP.002.176|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|111|818|818|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 2024-04-12 | WAIVER-ID/CIP.002.178 | Coding Requirement | UPDATE | CIP178|CIP.002.178|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(20)|113|821|840|1. Value must be associated with a populated Waiver Type 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
CIP178|CIP.002.178|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(20)|113|821|840|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | BILLING-PROV-NUM/CIP.002.179 | Coding Requirement | UPDATE | CIP179|CIP.002.179|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(30)|114|841|870|1. Value must be 30 characters or less. 2. Conditional 3. When Type of Claim not in ['3','C','W'] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in ['3','C','W'] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier. 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080). |
CIP179|CIP.002.179|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(30)|114|841|870|1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 2024-04-12 | BILLING-PROV-NPI-NUM/CIP.002.180 | Coding Requirement | UPDATE | CIP180|CIP.002.180|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|115|871|880|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' |
CIP180|CIP.002.180|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|115|871|880|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | ADMITTING-PROV-NPI-NUM/CIP.002.184 | Coding Requirement | UPDATE | CIP184|CIP.002.184|ADMITTING-PROV-NPI-NUM|Admitting Provider NPI Number|Conditional|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|119|897|906|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Conditional 3. Value must have an associated Provider Identifier Type equal to '2' |
CIP184|CIP.002.184|ADMITTING-PROV-NPI-NUM|Admitting Provider NPI Number|Conditional|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|119|897|906|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 2024-04-12 | REFERRING-PROV-NPI-NUM/CIP.002.190 | Coding Requirement | UPDATE | CIP190|CIP.002.190|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|125|983|992|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CIP190|CIP.002.190|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|125|983|992|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | SPLIT-CLAIM-IND/CIP.002.203 | Coding Requirement | UPDATE | CIP203|CIP.002.203|SPLIT-CLAIM-IND|Split Claim Indicator|Conditional|An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing.|SPLIT-CLAIM-IND|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|133|1065|1065|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in Split Claim Indicator List (VVL). 4. Value must be 1 character 5. Conditional |
CIP203|CIP.002.203|SPLIT-CLAIM-IND|Split Claim Indicator|Conditional|An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing.|SPLIT-CLAIM-IND|CIP00002|CLAIM-HEADER-RECORD-IP|X(1)|133|1065|1065|1. Value must be 1 character 2. Value must be in Split Claim Indicator List (VVL) 3. Conditional |
| 2024-04-12 | HEALTH-HOME-PROVIDER-NPI/CIP.002.221 | Coding Requirement | UPDATE | CIP221|CIP.002.221|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|149|1237|1246|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CIP221|CIP.002.221|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|149|1237|1246|1. Value must be 10 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | BILLING-PROV-ADDR-LN-1/CIP.002.298 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CIP298|CIP.002.298|BILLING-PROV-ADDR-LINE-1|Billing Provider Address Line 1|Mandatory|Billing provider address line 1 from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|161|1370|1429|1. Value must not be more than 60 characters long 2. Mandatory |
CIP298|CIP.002.298|BILLING-PROV-ADDR-LN-1|Billing Provider Address Line 1|Mandatory|Billing provider address line 1 from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|161|1370|1429|1. Value must not be more than 60 characters long 2. Mandatory 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | BILLING-PROV-ADDR-LN-2/CIP.002.299 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CIP299|CIP.002.299|BILLING-PROV-ADDR-LINE-2|Billing Provider Address Line 2|Conditional|Billing provider address line 2 from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|162|1430|1489|1. Value must not be more than 60 characters long 2. Conditional |
CIP299|CIP.002.299|BILLING-PROV-ADDR-LN-2|Billing Provider Address Line 2|Conditional|Billing provider address line 2 from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|162|1430|1489|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. Value must not contain a pipe or asterisk symbols 5. There must be an Address Line 1 in order to have an Address Line 2 |
| 2024-04-12 | BILLING-PROV-CITY/CIP.002.300 | Data Element Name; Data Element Name Text | UPDATE | CIP300|CIP.002.300|BILLING-PROV-ADDR-CITY-NAME|Billing Provider Address City Name|Mandatory|Billing provider address city name from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(28)|163|1490|1517|1. Value must not be more than 28 characters long 2. Mandatory |
CIP300|CIP.002.300|BILLING-PROV-CITY|Billing Provider City |Mandatory|Billing provider address city name from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(28)|163|1490|1517|1. Value must not be more than 28 characters long 2. Mandatory |
| 2024-04-12 | BILLING-PROV-STATE/CIP.002.301 | Data Element Name; Data Element Name Text | UPDATE | CIP301|CIP.002.301|BILLING-PROV-ADDR-STATE-CODE|Billing Provider Address State Code|Mandatory|Billing provider address state code from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|164|1518|1519|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Mandatory |
CIP301|CIP.002.301|BILLING-PROV-STATE|Billing Provider State Code|Mandatory|Billing provider address state code from X12 837I loop 2010AA.|STATE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|164|1518|1519|1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 2024-04-12 | BILLING-PROV-ZIP-CODE/CIP.002.302 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CIP302|CIP.002.302|BILLING-PROV-ADDR-ZIP-CODE|Billing Provider Address ZIP Code|Mandatory|Billing provider address ZIP code from X12 837I loop 2010AA.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(9)|165|1520|1528|1. Value must contain a string of either 5 or 9 numeric values 2. Value must be in ZIP Code list (VVL) 3. Mandatory |
CIP302|CIP.002.302|BILLING-PROV-ZIP-CODE|Billing Provider ZIP Code|Mandatory|Billing provider address ZIP code from X12 837I loop 2010AA.|ZIP-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(9)|165|1520|1528|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ORG-NPI/CIP.002.303 | Coding Requirement | UPDATE | CIP303|CIP.002.303|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|166|1529|1538|1. Value must contain a sting of 10 numeric values. 2. Value must be in NPPES (external reference). 3. Conditional |
CIP303|CIP.002.303|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(10)|166|1529|1538|1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-1/CIP.002.304 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CIP304|CIP.002.304|SERVICE-FACILITY-LOCATION-ADDR-LINE-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|167|1539|1598|1. Value must not be more than 60 characters long. 2. Conditional |
CIP304|CIP.002.304|SERVICE-FACILITY-LOCATION-ADDR-LN-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|167|1539|1598|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-2/CIP.002.305 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CIP305|CIP.002.305|SERVICE-FACILITY-LOCATION-ADDR-LINE-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|168|1599|1658|1. Value must not be more than 60 characters long. 2. Conditional |
CIP305|CIP.002.305|SERVICE-FACILITY-LOCATION-ADDR-LN-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(60)|168|1599|1658|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-CITY/CIP.002.306 | Data Element Name; Data Element Name Text | UPDATE | CIP306|CIP.002.306|SERVICE-FACILITY-LOCATION-ADDR-CITY-NAME|Service Facility Location Address City Name|Conditional|Service facility location address city name from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(28)|169|1659|1686|1. Value must not be more than 28 characters long. 2. Conditional |
CIP306|CIP.002.306|SERVICE-FACILITY-LOCATION-CITY|Service Facility Location City|Conditional|Service facility location address city name from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(28)|169|1659|1686|1. Value must not be more than 28 characters long 2. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-STATE/CIP.002.307 | Data Element Name; Data Element Name Text; VVL | UPDATE | CIP307|CIP.002.307|SERVICE-FACILITY-LOCATION-ADDR-STATE-CODE|Service Facility Location Address State Code|Conditional|Service facility location address state code from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|170|1687|1688|1. Value must not be more than 2 characters. 2. Value must be in State Code list (VVL). 3. Conditional |
CIP307|CIP.002.307|SERVICE-FACILITY-LOCATION-STATE|Service Facility Location State |Conditional|Service facility location address state code from X12 837I loop 2310E.|STATE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|170|1687|1688|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ZIP-CODE/CIP.002.308 | Coding Requirement; VVL | UPDATE | CIP308|CIP.002.308|SERVICE-FACILITY-LOCATION-ADDR-ZIP-CODE|Service Facility Location Address ZIP Code|Conditional|Service facility location address ZIP code from X12 837I loop 2310E.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(9)|171|1689|1697|1. Value must contain a string of either 5 or 9 numeric values. 2. Value must be in ZIP Code list (VVL). 3. Conditional |
CIP308|CIP.002.308|SERVICE-FACILITY-LOCATION-ZIP-CODE|Service Facility Location ZIP Code|Conditional|Service facility location address ZIP code from X12 837I loop 2310E.|ZIP-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(9)|171|1689|1697|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/CIP.003.234 | Definition | UPDATE | CIP234|CIP.003.234|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less. |
CIP234|CIP.003.234|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | ICN-ADJ/CIP.003.236 | Coding Requirement | UPDATE | CIP236|CIP.003.236|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CIP236|CIP.003.236|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MEDICAID-PAID-AMT/CIP.003.254 | Coding Requirement | UPDATE | CIP254|CIP.003.254|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(11)V99|20|231|243|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
CIP254|CIP.003.254|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(11)V99|20|231|243|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 2024-04-12 | TYPE-OF-SERVICE/CIP.003.257 | VVL; coding requirement | UPDATE | CIP257|CIP.003.257|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee. |TYPE-OF-SERVICE|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|23|259|261|1. Value must be 3 characters 2. Mandatory 3. Value must not equal '086' if Sex (ELG.002.023) equals 'M' 4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] |
CIP257|CIP.003.257|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|23|259|261|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. If Sex (ELG.002.023) equals "M", then value must not equal "086" 5. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
| 2024-04-12 | SERVICING-PROV-NPI-NUM/CIP.003.261 | Coding Requirement | UPDATE | CIP261|CIP.003.261|SERVICING-PROV-NPI-NUM|Servicing Provider NPI Number|Conditional|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(10)|25|292|301|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CIP261|CIP.003.261|SERVICING-PROV-NPI-NUM|Servicing Provider NPI Number|Conditional|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(10)|25|292|301|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | OPERATING-PROV-NPI-NUM/CIP.003.265 | Coding Requirement | UPDATE | CIP265|CIP.003.265|OPERATING-PROV-NPI-NUM|Operating Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(10)|28|306|315|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CIP265|CIP.003.265|OPERATING-PROV-NPI-NUM|Operating Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(10)|28|306|315|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Conditional 4. Value must exist in the NPPES NPI data file |
| 2024-04-12 | IHS-SERVICE-IND/CIP.003.296 | Coding Requirement | UPDATE | CIP296|CIP.003.296|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |IHS-SERVICE-IND|CIP00003|CLAIM-LINE-RECORD-IP|X(1)|39|404|404|1. Value must be 1 character 2. Value must be in [0, 1] 3. Mandatory |
CIP296|CIP.003.296|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|IHS-SERVICE-IND|CIP00003|CLAIM-LINE-RECORD-IP|X(1)|39|404|404|1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/CIP.003.315 | Coding Requirement; Description; Valid Value Code Set | UPDATE | CIP315|CIP.003.315|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|CIP00003|CLAIM-LINE-RECORD-IP|X(5)|41|481|485|1. Value must not be more than 5 characters 2. Value must be in MBES or CBES Category of Service Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
CIP315|CIP.003.315|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|CIP00003|CLAIM-LINE-RECORD-IP|X(5)|43|532|536|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 2024-04-12 | MBESCBES-FORM/CIP.003.316 | Coding Requirement; definition | UPDATE | CIP316|CIP.003.316|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CIP00003|CLAIM-LINE-RECORD-IP|X(50)|42|486|535|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
CIP316|CIP.003.316|MBESCBES-FORM|MBESCBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CIP00003|CLAIM-LINE-RECORD-IP|X(50)|42|482|531|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | REFERRING-PROV-NPI-NUM/CIP.003.319 | Coding Requirement | UPDATE | CIP319|CIP.003.319|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(10)|45|579|588|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CIP319|CIP.003.319|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(10)|46|580|589|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | MBESCBES-FORM-GROUP/CIP.003.340 | All Data Element Attributes | ADD | N/A | CIP340|CIP.003.340|MBESCBES-FORM-GROUP|MBESCBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).|MBESCBES-FORM-GROUP|CIP00003|CLAIM-LINE-RECORD-IP|X(1)|41|481|481|1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | RECORD-ID/CIP.004.322 | VVL; coding requirement | UPDATE | CIP322|CIP.004.322|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|CIP00004|CLAIM-DX-IP|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
CIP322|CIP.004.322|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|CIP00004|CLAIM-DX-IP|X(8)|1|1|8|1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CIP00004" |
| 2024-04-12 | SUBMITTING-STATE/CIP.004.323 | VVL; coding requirement | UPDATE | CIP323|CIP.004.323|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|CIP00004|CLAIM-DX-IP|X(2)|2|9|10|1. Value must be in State Code List (VVL) 2. Value must be 2 characters 3. Mandatory 4. Value must be the same as Submitting State (CIP.001.007) |
CIP323|CIP.004.323|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|CIP00004|CLAIM-DX-IP|X(2)|2|9|10|1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (CIP.001.007) |
| 2024-04-12 | ICN-ADJ/CIP.004.326 | Coding Requirement | UPDATE | CIP326|CIP.004.326|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CIP00004|CLAIM-DX-IP|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CIP326|CIP.004.326|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CIP00004|CLAIM-DX-IP|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | ADJUSTMENT-IND/CIP.004.327 | Coding Requirement | UPDATE | CIP327|CIP.004.327|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|LINE-ADJUSTMENT-IND|CIP00004|CLAIM-DX-IP|X(1)|6|122|122|1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory |
CIP327|CIP.004.327|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|CIP00004|CLAIM-DX-IP|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (CIP.002.026) |
| 2024-04-12 | DIAGNOSIS-SEQUENCE-NUMBER/CIP.004.330 | Coding Requirement | UPDATE | CIP330|CIP.004.330|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837I claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes).|N/A|CIP00004|CLAIM-DX-IP|9(2)|9|132|133|1. Value must be between 1 and 24 2. Mandatory |
CIP330|CIP.004.330|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837I claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes).|N/A|CIP00004|CLAIM-DX-IP|9(2)|9|132|133|1. Value must be in [01-24] 2. Mandatory |
| 2024-04-12 | FILE-NAME/CLT.001.006 | Definition | UPDATE | CLT006|CLT.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|CLT00001|FILE-HEADER-RECORD-LT|X(8)|6|32|39|1. Value must equal 'CLAIM-LT' 2. Mandatory |
CLT006|CLT.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|CLT00001|FILE-HEADER-RECORD-LT|X(8)|6|32|39|1. Value must equal "CLAIM-LT" 2. Mandatory |
| 2024-04-12 | ICN-ADJ/CLT.002.020 | Coding Requirement | UPDATE | CLT020|CLT.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CLT020|CLT.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/CLT.002.022 | Definition | UPDATE | CLT022|CLT.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(20)|7|134|153|1. Mandatory 2. Value must be 20 characters or less. 3. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date. |
CLT022|CLT.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(20)|7|134|153|1. Mandatory 2. Value must be 20 characters or less. 3. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 2024-04-12 | CROSSOVER-INDICATOR/CLT.002.023 | Coding Requirement | UPDATE | CLT023|CLT.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|8|154|154|1. Value must be in Crossover Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) 5. Value must be 1 character 6. Mandatory |
CLT023|CLT.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|8|154|154|1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 2024-04-12 | ADJUSTMENT-IND/CLT.002.025 | Coding Requirement | UPDATE | CLT025|CLT.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record. |ADJUSTMENT-IND|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|10|156|156|1. Value must be in Adjustment Indicator List (VVL). 2. Value must be in [0, 1, 4]. 3. Value must be 1 character. 4. Mandatory |
CLT025|CLT.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|10|156|156|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (CIP.002.026) |
| 2024-04-12 | TYPE-OF-CLAIM/CLT.002.052 | Coding requirement | UPDATE | CLT052|CLT.002.052|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |TYPE-OF-CLAIM|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|20|212|212|1. Value must be in Type of Claim List (VVL) 2. Value must be 1 character 3. Mandatory 4. When value equals 'Z', claim denied indicator must equal '0' |
CLT052|CLT.002.052|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.|TYPE-OF-CLAIM|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|20|212|212|1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 2024-04-12 | TOT-MEDICAID-PAID-AMT/CLT.002.065 | Coding Requirement; definition | UPDATE | CLT065|CLT.002.065|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CLT00002|CLAIM-HEADER-RECORD-LT|S9(11)V99|33|294|306|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be greater than Total Allowed Amount |
CLT065|CLT.002.065|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|S9(11)V99|33|294|306|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (CLT.002.064) |
| 2024-04-12 | FUNDING-CODE/CLT.002.076 | Coding requirement | UPDATE | CLT076|CLT.002.076|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|41|364|365|1. Value must be in Funding Code List (VVL) 2. Value must be 1 character 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
CLT076|CLT.002.076|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|41|364|365|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | MEDICAID-COV-INPATIENT-DAYS/CLT.002.086 | Coding Requirement | UPDATE | CLT086|CLT.002.086|MEDICAID-COV-INPATIENT-DAYS|Medicaid Covered Inpatient Days|Conditional|The number of inpatient psychiatric days covered by Medicaid on this claim.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|S9(5)|50|404|408|1. Value must be a positive integer 2. Value must be between 0:99999999999 (inclusive) 3. Conditional 4. Value must be less than or equal to double the number of days between Admission Date (CLT.002.044) and Discharge Date (CLT.002.046) plus one day 5. Value must be 5 digits or less 6. (inpatient mental health/psychiatric services) when associated Type of Service (CLT.003.211) in [044, 048, 050], this field must be populated |
CLT086|CLT.002.086|MEDICAID-COV-INPATIENT-DAYS|Medicaid Covered Inpatient Days|Conditional|The number of inpatient psychiatric days covered by Medicaid on this claim.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|S9(5)|50|404|408|1. Value must be a positive integer 2. Value must be between 00000:99999 (inclusive) 3. Conditional 4. Value must be less than or equal to double the number of days between Admission Date (CLT.002.044) and Discharge Date (CLT.002.046) plus one day 5. Value must be 5 digits or less 6. (inpatient mental health/psychiatric services) when associated Type of Service (CLT.003.211) in [044,048,050], this field must be populated |
| 2024-04-12 | CLAIM-LINE-COUNT/CLT.002.087 | Coding Requirement | UPDATE | CLT087|CLT.002.087|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|9(4)|51|409|412|1. Value must be a positive integer 2. Value must be between 0:9999 (inclusive) 3. Value must not include commas or other non-numeric characters 4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 5. Value must be 4 characters or less 6. Mandatory |
CLT087|CLT.002.087|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|9(4)|51|409|412|1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 6. Mandatory |
| 2024-04-12 | HEALTH-HOME-PROV-IND/CLT.002.127 | Coding Requirement | UPDATE | CLT127|CLT.002.127|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|89|684|684|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If there is an associated Health Home Entity Name value, then value must be "1" 5. Value must be 1 character 6. Conditional |
CLT127|CLT.002.127|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|89|684|684|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 2024-04-12 | WAIVER-ID/CLT.002.129 | Coding Requirement | UPDATE | CLT129|CLT.002.129|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(20)|91|687|706|1. Value must be associated with a populated Waiver Type 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
CLT129|CLT.002.129|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(20)|91|687|706|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | BILLING-PROV-NPI-NUM/CLT.002.131 | Coding Requirement | UPDATE | CLT131|CLT.002.131|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|93|737|746|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
CLT131|CLT.002.131|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|93|737|746|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | REFERRING-PROV-NPI-NUM/CLT.002.136 | Coding Requirement | UPDATE | CLT136|CLT.002.136|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|98|793|802|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CLT136|CLT.002.136|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|98|793|802|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | SPLIT-CLAIM-IND/CLT.002.150 | Coding Requirement | UPDATE | CLT150|CLT.002.150|SPLIT-CLAIM-IND|Split Claim Indicator|Conditional|An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing.|SPLIT-CLAIM-IND|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|106|875|875|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in Split Claim Indicator List (VVL). 4. Value must be 1 character 5. Conditional |
CLT150|CLT.002.150|SPLIT-CLAIM-IND|Split Claim Indicator|Conditional|An indicator that denotes that claims in excess of a pre-determined number of claim lines (threshold determined by the individual state) will be split during processing.|SPLIT-CLAIM-IND|CLT00002|CLAIM-HEADER-RECORD-LT|X(1)|106|875|875|1. Value must be 1 character 2. Value must be in Split Claim Indicator List (VVL) 3. Conditional |
| 2024-04-12 | HEALTH-HOME-PROVIDER-NPI/CLT.002.167 | Coding Requirement | UPDATE | CLT167|CLT.002.167|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(12)|121|1034|1045|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CLT167|CLT.002.167|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(12)|121|1034|1045|1. Value must be 12 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | ADMITTING-PROV-NPI-NUM/CLT.002.174 | Coding Requirement | UPDATE | CLT174|CLT.002.174|ADMITTING-PROV-NPI-NUM|Admitting Provider NPI Number|Conditional|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|123|1058|1067|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CLT174|CLT.002.174|ADMITTING-PROV-NPI-NUM|Admitting Provider NPI Number|Conditional|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|123|1058|1067|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 2024-04-12 | BILLING-PROV-ADDR-LN-1/CLT.002.244 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CLT244|CLT.002.244|BILLING-PROV-ADDR-LINE-1|Billing Provider Address Line 1|Mandatory|Billing provider address line 1 from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|134|1184|1243|1. Value must not be more than 60 characters long 2. Mandatory |
CLT244|CLT.002.244|BILLING-PROV-ADDR-LN-1|Billing Provider Address Line 1|Mandatory|Billing provider address line 1 from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|134|1184|1243|1. Value must not be more than 60 characters long 2. Mandatory 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | BILLING-PROV-ADDR-LN-2/CLT.002.245 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CLT245|CLT.002.245|BILLING-PROV-ADDR-LINE-2|Billing Provider Address Line 2|Conditional|Billing provider address line 2 from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|135|1244|1303|1. Value must not be more than 60 characters long 2. Conditional |
CLT245|CLT.002.245|BILLING-PROV-ADDR-LN-2|Billing Provider Address Line 2|Conditional|Billing provider address line 2 from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|135|1244|1303|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. Value must not contain a pipe or asterisk symbols 5. There must be an Address Line 1 in order to have an Address Line 2 |
| 2024-04-12 | BILLING-PROV-CITY/CLT.002.246 | Data Element Name; Data Element Name Text | UPDATE | CLT246|CLT.002.246|BILLING-PROV-ADDR-CITY-NAME|Billing Provider Address City Name|Mandatory|Billing provider address city name from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(28)|136|1304|1331|1. Value must not be more than 28 characters long 2. Mandatory |
CLT246|CLT.002.246|BILLING-PROV-CITY|Billing Provider City |Mandatory|Billing provider address city name from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(28)|136|1304|1331|1. Value must not be more than 28 characters long 2. Mandatory |
| 2024-04-12 | BILLING-PROV-STATE/CLT.002.247 | Data Element Name; Coding Requirement; VVL | UPDATE | CLT247|CLT.002.247|BILLING-PROV-ADDR-STATE-CODE|Billing Provider Address State Code|Mandatory|Billing provider address state code from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|137|1332|1333|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Mandatory |
CLT247|CLT.002.247|BILLING-PROV-STATE|Billing Provider State Code|Mandatory|Billing provider address state code from X12 837I loop 2010AA.|STATE|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|137|1332|1333|1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 2024-04-12 | BILLING-PROV-ZIP-CODE/CLT.002.248 | Data Element Name; Coding Requirement; VVL | UPDATE | CLT248|CLT.002.248|BILLING-PROV-ADDR-ZIP-CODE|Billing Provider Address ZIP Code|Mandatory|Billing provider address ZIP code from X12 837I loop 2010AA.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(9)|138|1334|1342|1. Value must contain a string of either 5 or 9 numeric values 2. Value must be in ZIP Code list (VVL) 3. Mandatory |
CLT248|CLT.002.248|BILLING-PROV-ZIP-CODE|Billing Provider ZIP Code|Mandatory|Billing provider address ZIP code from X12 837I loop 2010AA.|ZIP-CODE|CLT00002|CLAIM-HEADER-RECORD-LT|X(9)|138|1334|1342|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ORG-NPI/CLT.002.249 | Coding Requirement | UPDATE | CLT249|CLT.002.249|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|139|1343|1352|1. Value must contain a sting of 10 numeric values. 2. Value must be in NPPES (external reference). 3. Conditional |
CLT249|CLT.002.249|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(10)|139|1343|1352|1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-1/CLT.002.250 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CLT250|CLT.002.250|SERVICE-FACILITY-LOCATION-ADDR-LINE-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|140|1353|1412|1. Value must not be more than 60 characters long. 2. Conditional |
CLT250|CLT.002.250|SERVICE-FACILITY-LOCATION-ADDR-LN-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|140|1353|1412|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-2/CLT.002.251 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CLT251|CLT.002.251|SERVICE-FACILITY-LOCATION-ADDR-LINE-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|141|1413|1472|1. Value must not be more than 60 characters long. 2. Conditional |
CLT251|CLT.002.251|SERVICE-FACILITY-LOCATION-ADDR-LN-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(60)|141|1413|1472|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-CITY/CLT.002.252 | Data Element Name; Data Element Name Text | UPDATE | CLT252|CLT.002.252|SERVICE-FACILITY-LOCATION-ADDR-CITY-NAME|Service Facility Location Address City Name|Conditional|Service facility location address city name from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(28)|142|1473|1500|1. Value must not be more than 28 characters long. 2. Conditional |
CLT252|CLT.002.252|SERVICE-FACILITY-LOCATION-CITY|Service Facility Location City|Conditional|Service facility location address city name from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(28)|142|1473|1500|1. Value must not be more than 28 characters long 2. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-STATE/CLT.002.253 | Coding Requirement; VVL | UPDATE | CLT253|CLT.002.253|SERVICE-FACILITY-LOCATION-ADDR-STATE-CODE|Service Facility Location Address State Code|Conditional|Service facility location address state code from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|143|1501|1502|1. Value must not be more than 2 characters. 2. Value must be in State Code list (VVL). 3. Conditional |
CLT253|CLT.002.253|SERVICE-FACILITY-LOCATION-STATE|Service Facility Location State |Conditional|Service facility location address state code from X12 837I loop 2310E.|STATE|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|143|1501|1502|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ZIP-CODE/CLT.002.254 | Coding Requirement; VVL | UPDATE | CLT254|CLT.002.254|SERVICE-FACILITY-LOCATION-ADDR-ZIP-CODE|Service Facility Location Address ZIP Code|Conditional|Service facility location address ZIP code from X12 837I loop 2310E.|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(9)|144|1503|1511|1. Value must contain a string of either 5 or 9 numeric values. 2. Value must be in ZIP Code list (VVL). 3. Conditional |
CLT254|CLT.002.254|SERVICE-FACILITY-LOCATION-ZIP-CODE|Service Facility Location ZIP Code|Conditional|Service facility location address ZIP code from X12 837I loop 2310E.|ZIP-CODE|CLT00002|CLAIM-HEADER-RECORD-LT|X(9)|144|1503|1511|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/CLT.003.187 | Definition | UPDATE | CLT187|CLT.003.187|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less. |
CLT187|CLT.003.187|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | ICN-ADJ/CLT.003.189 | Coding Requirement | UPDATE | CLT189|CLT.003.189|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CLT189|CLT.003.189|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MEDICAID-PAID-AMT/CLT.003.208 | Coding Requirement; Definition | UPDATE | CLT208|CLT.003.208|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(11)V99|22|257|269|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
CLT208|CLT.003.208|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(11)V99|22|257|269|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 2024-04-12 | SERVICING-PROV-NPI-NUM/CLT.003.213 | Coding Requirement | UPDATE | CLT213|CLT.003.213|SERVICING-PROV-NPI-NUM|Servicing Provider NPI Number|Conditional|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(10)|27|318|327|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) |
CLT213|CLT.003.213|SERVICING-PROV-NPI-NUM|Servicing Provider NPI Number|Conditional|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(10)|27|318|327|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Conditional 4. If Type of Claim (CLT.002.052) not in [3,C,W], then value must match Provider Identifier (PRV.005.081) 5. Value must exist in the NPPES NPI data file |
| 2024-04-12 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/CLT.003.219 | Coding Requirement | UPDATE | CLT219|CLT.003.219|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|CLT00003|CLAIM-LINE-RECORD-LT|X(2)|31|335|336|1. Value must be in Category for Federal Reimbursement List (VVL). 2. Value must be 2 characters. 3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']. 4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'. 5. Conditional 6. If Type of Claim is in ['1','A','U'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. |
CLT219|CLT.003.219|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|CLT00003|CLAIM-LINE-RECORD-LT|X(2)|31|335|336|1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 2024-04-12 | ADJUDICATION-DATE/CLT.003.233 | Coding Requirement | UPDATE | CLT233|CLT.003.233|ADJUDICATION-DATE|Adjudication Date|Mandatory|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|9(8)|36|378|385|1. Value must be 8 characters in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value should be on or before End of Time Period value found in associated T-MSIS File Header Record 4. Mandatory 5. Value should be on or after associated Admission Date value |
CLT233|CLT.003.233|ADJUDICATION-DATE|Adjudication Date|Mandatory|The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|9(8)|36|378|385|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value should be on or before End of Time Period (CLT.001.010) 3. Mandatory 4. Value should be on or after associated Admission Date value |
| 2024-04-12 | IHS-SERVICE-IND/CLT.003.243 | Coding Requirement | UPDATE | CLT243|CLT.003.243|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |IHS-SERVICE-IND|CLT00003|CLAIM-LINE-RECORD-LT|X(1)|39|407|407|1. Value must be 1 character 2. Value must be in [0, 1] 3. Mandatory |
CLT243|CLT.003.243|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|IHS-SERVICE-IND|CLT00003|CLAIM-LINE-RECORD-LT|X(1)|39|407|407|1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/CLT.003.261 | Coding Requirement; Description; Valid Value Code Set | UPDATE | CLT261|CLT.003.261|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|CLT00003|CLAIM-LINE-RECORD-LT|X(5)|41|484|488|1. Value must not be more than 5 characters 2. Value must be in MBES or CBES Category of Service Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
CLT261|CLT.003.261|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|CLT00003|CLAIM-LINE-RECORD-LT|X(5)|43|535|539|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 2024-04-12 | MBESCBES-FORM/CLT.003.262 | Coding Requirement; Definition | UPDATE | CLT262|CLT.003.262|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CLT00003|CLAIM-LINE-RECORD-LT|X(50)|42|489|538|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
CLT262|CLT.003.262|MBESCBES-FORM|MBESCBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CLT00003|CLAIM-LINE-RECORD-LT|X(50)|42|485|534|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | REFERRING-PROV-NPI-NUM/CLT.003.265 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | CLT265|CLT.003.265|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(10)|45|582|591|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CLT265|CLT.003.265|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(10)|46|583|592|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 2024-04-12 | MBESCBES-FORM-GROUP/CLT.003.282 | All Data Element Attributes | ADD | N/A | CLT282|CLT.003.282|MBESCBES-FORM-GROUP|MBESCBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).|MBESCBES-FORM-GROUP|CLT00003|CLAIM-LINE-RECORD-LT|X(1)|41|484|484|1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | RECORD-ID/CLT.004.268 | Coding Requirement; VVL | UPDATE | CLT268|CLT.004.268|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|CLT00004|CLAIM-DX-LT|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
CLT268|CLT.004.268|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|CLT00004|CLAIM-DX-LT|X(8)|1|1|8|1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CLT00004" |
| 2024-04-12 | ICN-ADJ/CLT.004.272 | Coding Requirement | UPDATE | CLT272|CLT.004.272|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CLT00004|CLAIM-DX-LT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CLT272|CLT.004.272|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CLT00004|CLAIM-DX-LT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | ADJUSTMENT-IND/CLT.004.273 | Coding Requirement | UPDATE | CLT273|CLT.004.273|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|LINE-ADJUSTMENT-IND|CLT00004|CLAIM-DX-LT|X(1)|6|122|122|1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory |
CLT273|CLT.004.273|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|CLT00004|CLAIM-DX-LT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (CLT.002.025) |
| 2024-04-12 | DIAGNOSIS-SEQUENCE-NUMBER/CLT.004.276 | Coding Requirement; Necessity | UPDATE | CLT276|CLT.004.276|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837I claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes).|N/A|CLT00004|CLAIM-DX-LT|9(2)|9|132|133|1. Value must be between 1 and 24 2. Mandatory |
CLT276|CLT.004.276|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837I claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes).|N/A|CLT00004|CLAIM-DX-LT|9(2)|9|132|133|1. Value must be in [01-24] 2. Mandatory |
| 2024-04-12 | ICN-ADJ/COT.002.020 | Coding Requirement | UPDATE | COT020|COT.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
COT020|COT.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/COT.002.022 | Definition | UPDATE | COT022|COT.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(20)|7|134|153|1. Mandatory 2. Value must be 20 characters or less. 3. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254). |
COT022|COT.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(20)|7|134|153|1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 2024-04-12 | CROSSOVER-INDICATOR/COT.002.023 | Coding Requirement | UPDATE | COT023|COT.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|8|154|154|1. Value must be in Crossover Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) 5. Value must be 1 character 6. Mandatory |
COT023|COT.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|8|154|154|1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 2024-04-12 | ADJUSTMENT-IND/COT.002.025 | Coding Requirement | UPDATE | COT025|COT.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record. |ADJUSTMENT-IND|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|10|156|156|1. Value must be in Adjustment Indicator List (VVL). 2. Value must be in [0, 1, 4]. 3. Value must be 1 character. 4. Mandatory |
COT025|COT.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|10|156|156|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" |
| 2024-04-12 | TYPE-OF-CLAIM/COT.002.037 | Coding Requirement; Definition | UPDATE | COT037|COT.002.037|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |TYPE-OF-CLAIM|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|16|192|192|1. Value must be in Type of Claim List (VVL) 2. Value must be 1 character 3. Mandatory 4. When value equals 'Z', claim denied indicator must equal '0' |
COT037|COT.002.037|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record|TYPE-OF-CLAIM|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|16|192|192|1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 2024-04-12 | SOURCE-LOCATION/COT.002.041 | Definition | UPDATE | COT041|COT.002.041|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |SOURCE-LOCATION|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|20|203|204|1. Value must be in Source Location List (VVL) 2. Value must be 2 characters 3. Mandatory |
COT041|COT.002.041|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee.|SOURCE-LOCATION|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|20|203|204|1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 2024-04-12 | TOT-BILLED-AMT/COT.002.048 | Coding Requirement | UPDATE | COT048|COT.002.048|TOT-BILLED-AMT|Total Billed Amount|Conditional|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|COT00002|CLAIM-HEADER-RECORD-OT|S9(11)V99|27|248|260|1. Value must be between -99999999999.99 and 99999999999.99. 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ). 3. Value must equal the sum of all Billed Amount instances for the associated claim. 4. Conditional |
COT048|COT.002.048|TOT-BILLED-AMT|Total Billed Amount|Conditional|The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|S9(11)V99|27|248|260|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Value must equal the sum of all Billed Amount instances for the associated claim 4. Conditional 5. (individual line item payments) when populated and Payment Level Indicator (COT.002.068) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (COT.003.168) |
| 2024-04-12 | TOT-MEDICAID-PAID-AMT/COT.002.050 | Coding Requirement | UPDATE | COT050|COT.002.050|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |N/A|COT00002|CLAIM-HEADER-RECORD-OT|S9(11)V99|29|274|286|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be greater than Total Allowed Amount (COT.002.049) |
COT050|COT.002.050|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|S9(11)V99|29|274|286|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (COT.002.049) |
| 2024-04-12 | OTHER-INSURANCE-IND/COT.002.057 | Coding Requirement | UPDATE | COT057|COT.002.057|OTHER-INSURANCE-IND|Other Insurance Indicator|Conditional|The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. |OTHER-INSURANCE-IND|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|34|339|339|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in Other Insurance Indicator List (VVL) 4. Conditional |
COT057|COT.002.057|OTHER-INSURANCE-IND|Other Insurance Indicator|Conditional|The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid.|OTHER-INSURANCE-IND|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|34|339|339|1. Value must be 1 character 2. Value must be in Other Insurance Indicator List (VVL) 3. Conditional |
| 2024-04-12 | FUNDING-CODE/COT.002.062 | Coding Requirement | UPDATE | COT062|COT.002.062|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|37|344|345|1. Value must be in Funding Code List (VVL) 2. Value must be 1 character 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
COT062|COT.002.062|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|37|344|345|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | FUNDING-SOURCE-NONFEDERAL-SHARE/COT.002.063 | Coding Requirement | UPDATE | COT063|COT.002.063|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Non-Federal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. |FUNDING-SOURCE-NONFEDERAL-SHARE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|38|346|347|1. Value must be in Funding Source Non-Federal Share List (VVL) 2. Value must be 2 characters 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
COT063|COT.002.063|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Non-Federal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|38|346|347|1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | PLAN-ID-NUMBER/COT.002.066 | Coding Requirement; Definition | UPDATE | COT066|COT.002.066|PLAN-ID-NUMBER|Plan ID Number|Conditional|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|41|351|362|1. Value must be 12 characters or less. 2. Value must not contain a pipe or asterisk symbols. 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192). 5. Value must match State Plan ID Number (MCR.002.019). 6. When Type of Claim in [3, C, W] value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (CLT.002.048) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198). 7. When Type of Claim in [3, C, W] value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (CLT.002.048) occurs between the managed care contract eff/end dates (MCR.002.020/021). |
COT066|COT.002.066|PLAN-ID-NUMBER|Plan ID Number|Conditional|A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|41|351|362|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional 4. Value must match Managed Care Plan ID (ELG.014.192) 5. Value must match State Plan ID Number (MCR.002.019) 6. When Type of Claim (COT.002.037) in [3,C,W] value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198) 7. When Type of Claim (COT.002.037) in [3,C,W] value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.037) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 2024-04-12 | CLAIM-LINE-COUNT/COT.002.070 | Coding Requirement | UPDATE | COT070|COT.002.070|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|9(4)|44|366|369|1. Value must be a positive integer 2. Value must be between 0:9999 (inclusive) 3. Value must not include commas or other non-numeric characters 4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 5. Value must be 4 characters or less 6. Mandatory |
COT070|COT.002.070|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|9(4)|44|366|369|1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 6. Mandatory |
| 2024-04-12 | HEALTH-HOME-PROV-IND/COT.002.109 | Coding Requirement | UPDATE | COT109|COT.002.109|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|82|641|641|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If there is an associated Health Home Entity Name value, then value must be "1" 5. Value must be 1 character 6. Conditional |
COT109|COT.002.109|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|COT00002|CLAIM-HEADER-RECORD-OT|X(1)|82|641|641|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 2024-04-12 | WAIVER-ID/COT.002.111 | Coding Requirement | UPDATE | COT111|COT.002.111|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(20)|84|644|663|1. Value must be associated with a populated Waiver Type 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
COT111|COT.002.111|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(20)|84|644|663|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | BILLING-PROV-NUM/COT.002.112 | Coding Requirement | UPDATE | COT112|COT.002.112|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(30)|85|664|693|1. Value must be 30 characters or less. 2. Conditional 3. When Type of Claim not in ['3','C','W'] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in ['3','C','W'] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier. 5. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080). 7. Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'. |
COT112|COT.002.112|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(30)|85|664|693|1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080). 7. Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'. |
| 2024-04-12 | BILLING-PROV-NPI-NUM/COT.002.113 | Coding Requirement | UPDATE | COT113|COT.002.113|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|86|694|703|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
COT113|COT.002.113|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|86|694|703|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | BILLING-PROV-TAXONOMY/COT.002.114 | Coding Requirement | UPDATE | COT114|COT.002.114|BILLING-PROV-TAXONOMY|Billing Provider Taxonomy|Conditional|The taxonomy code for the provider billing for the service. |PROV-TAXONOMY|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|87|704|715|1. Value must be in Provider Taxonomy List (VVL) 2. Value must be 12 characters or less 3. Conditional 4. Value is in [119, 120, 121, 122 ], then value should not be populated |
COT114|COT.002.114|BILLING-PROV-TAXONOMY|Billing Provider Taxonomy|Conditional|The taxonomy code for the provider billing for the service.|PROV-TAXONOMY|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|87|704|715|1. Value must be in Provider Taxonomy List (VVL) 2. Value must be 12 characters or less 3. Conditional 4. If associated Type of Service value is in [119,120,121,122], then value should not be populated |
| 2024-04-12 | REFERRING-PROV-NPI-NUM/COT.002.118 | Coding Requirement | UPDATE | COT118|COT.002.118|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|91|750|759|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
COT118|COT.002.118|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|91|750|759|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 2024-04-12 | HEALTH-HOME-PROVIDER-NPI/COT.002.146 | Coding Requirement | UPDATE | COT146|COT.002.146|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|110|969|978|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When Type of Service (COT.003.186) equals '121', value must not be populated |
COT146|COT.002.146|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|110|969|978|1. Value must be 10 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | BILLING-PROV-ADDR-LN-1/COT.002.236 | Data Element Name; Coding Requirement | UPDATE | COT236|COT.002.236|BILLING-PROV-ADDR-LINE-1|Billing Provider Address Line 1|Mandatory|Billing provider address line 1 from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|118|1061|1120|1. Value must not be more than 60 characters long 2. Mandatory |
COT236|COT.002.236|BILLING-PROV-ADDR-LN-1|Billing Provider Address Line 1|Mandatory|Billing provider address line 1 from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|118|1061|1120|1. Value must not be more than 60 characters long 2. Mandatory 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | BILLING-PROV-ADDR-LN-2/COT.002.237 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT237|COT.002.237|BILLING-PROV-ADDR-LINE-2|Billing Provider Address Line 2|Conditional|Billing provider address line 2 from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|119|1121|1180|1. Value must not be more than 60 characters long 2. Conditional |
COT237|COT.002.237|BILLING-PROV-ADDR-LN-2|Billing Provider Address Line 2|Conditional|Billing provider address line 2 from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|119|1121|1180|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. Value must not contain a pipe or asterisk symbols 5. There must be an Address Line 1 in order to have an Address Line 2 |
| 2024-04-12 | BILLING-PROV-CITY/COT.002.238 | Data Element Name; Data Element Name Text | UPDATE | COT238|COT.002.238|BILLING-PROV-ADDR-CITY-NAME|Billing Provider Address City Name|Mandatory|Billing provider address city name from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(28)|120|1181|1208|1. Value must not be more than 28 characters long 2. Mandatory |
COT238|COT.002.238|BILLING-PROV-CITY|Billing Provider City |Mandatory|Billing provider address city name from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(28)|120|1181|1208|1. Value must not be more than 28 characters long 2. Mandatory |
| 2024-04-12 | BILLING-PROV-STATE/COT.002.239 | Data Element Name; Coding Requirement | UPDATE | COT239|COT.002.239|BILLING-PROV-ADDR-STATE-CODE|Billing Provider Address State Code|Mandatory|Billing provider address state code from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|121|1209|1210|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Mandatory |
COT239|COT.002.239|BILLING-PROV-STATE|Billing Provider State Code|Mandatory|Billing provider address state code from X12 837I, 837P, and 837D loop 2010AA.|STATE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|121|1209|1210|1. Value must not be more than 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory |
| 2024-04-12 | BILLING-PROV-ZIP-CODE/COT.002.240 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT240|COT.002.240|BILLING-PROV-ADDR-ZIP-CODE|Billing Provider Address ZIP Code|Mandatory|Billing provider address ZIP code from X12 837I, 837P, and 837D loop 2010AA.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(9)|122|1211|1219|1. Value must contain a string of either 5 or 9 numeric values 2. Value must be in ZIP Code list (VVL) 3. Mandatory |
COT240|COT.002.240|BILLING-PROV-ZIP-CODE|Billing Provider ZIP Code|Mandatory|Billing provider address ZIP code from X12 837I, 837P, and 837D loop 2010AA.|ZIP-CODE|COT00002|CLAIM-HEADER-RECORD-OT|X(9)|122|1211|1219|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ORG-NPI/COT.002.241 | Coding Requirement | UPDATE | COT241|COT.002.241|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|123|1220|1229|1. Value must contain a sting of 10 numeric values. 2. Value must be in NPPES (external reference). 3. Conditional |
COT241|COT.002.241|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|123|1220|1229|1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-1/COT.002.242 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT242|COT.002.242|SERVICE-FACILITY-LOCATION-ADDR-LINE-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|124|1230|1289|1. Value must not be more than 60 characters long. 2. Conditional |
COT242|COT.002.242|SERVICE-FACILITY-LOCATION-ADDR-LN-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|124|1230|1289|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-2/COT.002.243 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT243|COT.002.243|SERVICE-FACILITY-LOCATION-ADDR-LINE-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|125|1290|1349|1. Value must not be more than 60 characters long. 2. Conditional |
COT243|COT.002.243|SERVICE-FACILITY-LOCATION-ADDR-LN-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(60)|125|1290|1349|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-CITY/COT.002.244 | Data Element Name; Data Element Name Text | UPDATE | COT244|COT.002.244|SERVICE-FACILITY-LOCATION-ADDR-CITY-NAME|Service Facility Location Address City Name|Conditional|Service facility location address city name from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(28)|126|1350|1377|1. Value must not be more than 28 characters long. 2. Conditional |
COT244|COT.002.244|SERVICE-FACILITY-LOCATION-CITY|Service Facility Location City|Conditional|Service facility location address city name from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(28)|126|1350|1377|1. Value must not be more than 28 characters long 2. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-STATE/COT.002.245 | Data Element Name; Data Element Name Text; VVL | UPDATE | COT245|COT.002.245|SERVICE-FACILITY-LOCATION-ADDR-STATE-CODE|Service Facility Location Address State Code|Conditional|Service facility location address state code from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|127|1378|1379|1. Value must not be more than 2 characters. 2. Value must be in State Code list (VVL). 3. Conditional |
COT245|COT.002.245|SERVICE-FACILITY-LOCATION-STATE|Service Facility Location State |Conditional|Service facility location address state code from X12 837I loop 2310E or 837P and 837D loop 2310C.|STATE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|127|1378|1379|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ZIP-CODE/COT.002.246 | Data Element Name; Data Element Name Text; VVL | UPDATE | COT246|COT.002.246|SERVICE-FACILITY-LOCATION-ADDR-ZIP-CODE|Service Facility Location Address ZIP Code|Conditional|Service facility location address ZIP code from X12 837I loop 2310E or 837P and 837D loop 2310C.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(9)|128|1380|1388|1. Value must contain a string of either 5 or 9 numeric values. 2. Value must be in ZIP Code list (VVL). 3. Conditional |
COT246|COT.002.246|SERVICE-FACILITY-LOCATION-ZIP-CODE|Service Facility Location ZIP Code|Conditional|Service facility location address ZIP code from X12 837I loop 2310E or 837P and 837D loop 2310C.|ZIP-CODE|COT00002|CLAIM-HEADER-RECORD-OT|X(9)|128|1380|1388|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 2024-04-12 | REFERRING-PROV-NUM-2/COT.002.250 | Coding Requirement; Definition | UPDATE | COT250|COT.002.250|REFERRING-PROV-NUM-2|Referring Provider Number 2|Conditional|A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(30)|132|1454|1483|1. Value must be 30 characters or less 2. Conditional |
COT250|COT.002.250|REFERRING-PROV-NUM-2|Referring Provider Number 2|Conditional|A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(30)|132|1454|1483|1. Value must be 30 characters or less 2. Conditional 3. Value must not be populated when Referring Provider Number is not populated. 4. Value must not equal Referring Provider Number |
| 2024-04-12 | REFERRING-PROV-NPI-NUM-2/COT.002.251 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT251|COT.002.251|REFERRING-PROV-NPI-NUM-2|Referring Provider NPI Number 2|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the header of their claim.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|133|1484|1493|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
COT251|COT.002.251|REFERRING-PROV-NPI-NUM-2|Referring Provider NPI Number 2|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the header of their claim.|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(10)|133|1484|1493|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File 5. Value must not be populated when Referring Provider NPI Number is not populated 6. Value must not equal Referring Provider NPI Number |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/COT.003.157 | Definition | UPDATE | COT157|COT.003.157|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|COT00003|CLAIM-LINE-RECORD-OT|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less. |
COT157|COT.003.157|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | ICN-ADJ/COT.003.159 | Coding Requirement | UPDATE | COT159|COT.003.159|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
COT159|COT.003.159|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | PROCEDURE-CODE/COT.003.169 | VVL; Coding Requirement | UPDATE | COT169|COT.003.169|PROCEDURE-CODE|Procedure Code|Conditional|A field to capture the CPT or HCPCS code that describes a service or good rendered by the provider to an enrollee on the specified date of service. |N/A|COT00003|CLAIM-LINE-RECORD-OT|X(8)|16|187|194|1. When populated, there must be a corresponding Procedure Code Flag 2. If associated Procedure Code Flag List (VVL) value indicates an CPT-4 encoding '01', then value must be a valid CPT-4 procedure code 3. If associated Procedure Code Flag List (VVL) value indicates an 'Other' encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 4. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding '06', then value must be a valid HCPCS code 5. Value must be 8 characters or less 6. Value must be in Procedure Code List (VVL) 7. Conditional |
COT169|COT.003.169|PROCEDURE-CODE|Procedure Code|Conditional|A field to capture the CPT or HCPCS code that describes a service or good rendered by the provider to an enrollee on the specified date of service.|PROCEDURE-CODE|COT00003|CLAIM-LINE-RECORD-OT|X(8)|16|187|194|1. Value must be 8 characters or less 2. Value must be in Procedure Code List (VVL) 3. When populated, there must be a corresponding Procedure Code Flag 4. If associated Procedure Code Flag value indicates an CPT-4 encoding "01", then value must be a valid CPT-4 procedure code 5. If associated Procedure Code Flag value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code 6. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding "06", then value must be a valid HCPCS code 7. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-1/COT.003.172 | VVL | UPDATE | COT172|COT.003.172|PROCEDURE-CODE-MOD-1|Procedure Code Modifier 1|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(2)|19|205|206|1. Must be associated with a Procedure Code 2. Value must be 2 characters 3. Value must be in Procedure Code Mod List (VVL) 4. Conditional |
COT172|COT.003.172|PROCEDURE-CODE-MOD-1|Procedure Code Modifier 1|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|PROCEDURE-CODE-MOD|COT00003|CLAIM-LINE-RECORD-OT|X(2)|19|205|206|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | MEDICAID-PAID-AMT/COT.003.178 | Coding Requirement | UPDATE | COT178|COT.003.178|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(11)V99|24|259|271|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
COT178|COT.003.178|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(11)V99|24|259|271|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 2024-04-12 | TYPE-OF-SERVICE/COT.003.186 | Coding Requirement; VVL | UPDATE | COT186|COT.003.186|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee. |TYPE-OF-SERVICE|COT00003|CLAIM-LINE-RECORD-OT|X(3)|29|320|322|1. Value must be 3 characters. 2. Mandatory 3. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115','127', '136', '137', '144', '145', '147']. 4. Value must be 3 characters. 5. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'. |
COT186|COT.003.186|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|COT00003|CLAIM-LINE-RECORD-OT|X(3)|29|320|322|1. Value must be 3 characters. 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020, 021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066, 067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085, 086,087,088,089,115,127,136,137,144,145,147] 5. When value is not in [025,085], Sex (ELG.002.023) equals "M" |
| 2024-04-12 | SERVICING-PROV-NPI-NUM/COT.003.190 | Coding Requirement | UPDATE | COT190|COT.003.190|SERVICING-PROV-NPI-NUM|Servicing Provider NPI Number|Conditional|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The SERVICING-PROV-NPI-NUM is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|33|359|368|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) |
COT190|COT.003.190|SERVICING-PROV-NPI-NUM|Servicing Provider NPI Number|Conditional|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The SERVICING-PROV-NPI-NUM is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|33|359|368|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Conditional 4. If Type of Claim (COT.002.037) not in [3,C,W], then value must match Provider Identifier (PRV.005.081) 5. Value must exist in the NPPES NPI data file |
| 2024-04-12 | ORIGINATION-ZIP-CODE/COT.003.203 | Coding Requirement; VVL | UPDATE | COT203|COT.003.203|ORIGINATION-ZIP-CODE|Origination ZIP Code|Conditional|The zip code of the origination city from which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(9)|46|545|553|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Conditional |
COT203|COT.003.203|ORIGINATION-ZIP-CODE|Origination ZIP Code|Conditional|The zip code of the origination city from which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa.|ZIP-CODE|COT00003|CLAIM-LINE-RECORD-OT|X(9)|46|545|553|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 2024-04-12 | DESTINATION-ZIP-CODE/COT.003.208 | Coding Requirement; VVL | UPDATE | COT208|COT.003.208|DESTINATION-ZIP-CODE|Destination ZIP Code|Conditional|The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(9)|51|704|712|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Conditional |
COT208|COT.003.208|DESTINATION-ZIP-CODE|Destination ZIP Code|Conditional|The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.|ZIP-CODE|COT00003|CLAIM-LINE-RECORD-OT|X(9)|51|704|712|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 2024-04-12 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/COT.003.210 | Coding Requirement | UPDATE | COT210|COT.003.210|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|COT00003|CLAIM-LINE-RECORD-OT|X(2)|52|713|714|1. Value must be in Category for Federal Reimbursement List (VVL). 2. Value must be 2 characters. 3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']. 4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'. 5. Conditional 6. If Type of Claim is in ['1','A','U'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. |
COT210|COT.003.210|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|COT00003|CLAIM-LINE-RECORD-OT|X(2)|52|713|714|1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 2024-04-12 | PROCEDURE-CODE-MOD-3/COT.003.218 | VVL | UPDATE | COT218|COT.003.218|PROCEDURE-CODE-MOD-3|Procedure Code Modifier 3|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(2)|56|742|743|1. Must be associated with a Procedure Code 2. Value must be 2 characters 3. Value must be in Procedure Code Mod List (VVL) 4. Conditional |
COT218|COT.003.218|PROCEDURE-CODE-MOD-3|Procedure Code Modifier 3|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|PROCEDURE-CODE-MOD|COT00003|CLAIM-LINE-RECORD-OT|X(2)|56|742|743|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-4/COT.003.219 | VVL | UPDATE | COT219|COT.003.219|PROCEDURE-CODE-MOD-4|Procedure Code Modifier 4|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(2)|57|744|745|1. Must be associated with a Procedure Code 2. Value must be 2 characters 3. Value must be in Procedure Code Mod List (VVL) 4. Conditional |
COT219|COT.003.219|PROCEDURE-CODE-MOD-4|Procedure Code Modifier 4|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|PROCEDURE-CODE-MOD|COT00003|CLAIM-LINE-RECORD-OT|X(2)|57|744|745|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-2/COT.003.227 | VVL | UPDATE | COT227|COT.003.227|PROCEDURE-CODE-MOD-2|Procedure Code Modifier 2|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(2)|55|740|741|1. Must be associated with a Procedure Code 2. Value must be 2 characters 3. Value must be in Procedure Code Mod List (VVL) 4. Conditional |
COT227|COT.003.227|PROCEDURE-CODE-MOD-2|Procedure Code Modifier 2|Conditional|The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.|PROCEDURE-CODE-MOD|COT00003|CLAIM-LINE-RECORD-OT|X(2)|55|740|741|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | IHS-SERVICE-IND/COT.003.234 | Coding Requirement | UPDATE | COT234|COT.003.234|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |IHS-SERVICE-IND|COT00003|CLAIM-LINE-RECORD-OT|X(1)|63|795|795|1. Value must be 1 character 2. Value must be in [0, 1] 3. Mandatory |
COT234|COT.003.234|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|IHS-SERVICE-IND|COT00003|CLAIM-LINE-RECORD-OT|X(1)|63|795|795|1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/COT.003.256 | Coding Requirement; Description; VVL | UPDATE | COT256|COT.003.256|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|COT00003|CLAIM-LINE-RECORD-OT|X(5)|69|880|884|1. Value must not be more than 5 characters 2. Value must be in MBES or CBES Category of Service Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
COT256|COT.003.256|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|COT00003|CLAIM-LINE-RECORD-OT|X(5)|71|931|935|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 2024-04-12 | MBESCBES-FORM/COT.003.257 | Coding Requirement; Definition | UPDATE | COT257|COT.003.257|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|COT00003|CLAIM-LINE-RECORD-OT|X(50)|70|885|934|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
COT257|COT.003.257|MBESCBES-FORM|MBESCBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|COT00003|CLAIM-LINE-RECORD-OT|X(50)|70|881|930|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ORG-NPI/COT.003.258 | Coding Requirement | UPDATE | COT258|COT.003.258|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|71|935|944|1. Value must contain a sting of 10 numeric values. 2. Value must be in NPPES (external reference). 3. Conditional |
COT258|COT.003.258|SERVICE-FACILITY-LOCATION-ORG-NPI|Service Facility Location Organization NPI|Conditional|Service facility location organization NPI from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|72|936|945|1.Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-1/COT.003.259 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT259|COT.003.259|SERVICE-FACILITY-LOCATION-ADDR-LINE-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(60)|72|945|1004|1. Value must not be more than 60 characters long. 2. Conditional |
COT259|COT.003.259|SERVICE-FACILITY-LOCATION-ADDR-LN-1|Service Facility Location Address Line 1|Conditional|Service facility location address line 1 from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(60)|73|946|1005|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ADDR-LN-2/COT.003.260 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT260|COT.003.260|SERVICE-FACILITY-LOCATION-ADDR-LINE-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(60)|73|1005|1064|1. Value must not be more than 60 characters long. 2. Conditional |
COT260|COT.003.260|SERVICE-FACILITY-LOCATION-ADDR-LN-2|Service Facility Location Address Line 2|Conditional|Service facility location address line 2 from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(60)|74|1006|1065|1. Value must not be more than 60 characters long 2. Conditional 3. Value must not be equal to associated Address Line 1 4. There must be an Address Line 1 in order to have an Address Line 2 5. Value must not contain a pipe or asterisk symbols |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-CITY/COT.003.261 | Data Element Name; Data Element Name Text | UPDATE | COT261|COT.003.261|SERVICE-FACILITY-LOCATION-ADDR-CITY-NAME|Service Facility Location Address City Name|Conditional|Service facility location address city name from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(28)|74|1065|1092|1. Value must not be more than 28 characters long. 2. Conditional |
COT261|COT.003.261|SERVICE-FACILITY-LOCATION-CITY|Service Facility Location City|Conditional|Service facility location address city name from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(28)|75|1066|1093|1. Value must not be more than 28 characters long 2. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-STATE/COT.003.262 | Data Element Name; Data Element Name Text; VVL | UPDATE | COT262|COT.003.262|SERVICE-FACILITY-LOCATION-ADDR-STATE-CODE|Service Facility Location Address State Code|Conditional|Service facility location address state code from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(2)|75|1093|1094|1. Value must not be more than 2 characters. 2. Value must be in State Code list (VVL). 3. Conditional |
COT262|COT.003.262|SERVICE-FACILITY-LOCATION-STATE|Service Facility Location State |Conditional|Service facility location address state code from X12 837P loop 2420C and 837D loop 2420D.|STATE|COT00003|CLAIM-LINE-RECORD-OT|X(2)|76|1094|1095|1. Value must not be more than 2 characters 2. Value must be in State Code list (VVL) 3. Conditional |
| 2024-04-12 | SERVICE-FACILITY-LOCATION-ZIP-CODE/COT.003.263 | Data Element Name; Data Element Name Text; VVL | UPDATE | COT263|COT.003.263|SERVICE-FACILITY-LOCATION-ADDR-ZIP-CODE|Service Facility Location Address ZIP Code|Conditional|Service facility location address ZIP code from X12 837P loop 2420C and 837D loop 2420D.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(9)|76|1095|1103|1. Value must contain a string of either 5 or 9 numeric values. 2. Value must be in ZIP Code list (VVL). 3. Conditional |
COT263|COT.003.263|SERVICE-FACILITY-LOCATION-ZIP-CODE|Service Facility Location ZIP Code|Conditional|Service facility location address ZIP code from X12 837P loop 2420C and 837D loop 2420D.|ZIP-CODE|COT00003|CLAIM-LINE-RECORD-OT|X(9)|77|1096|1104|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Conditional |
| 2024-04-12 | REFERRING-PROV-NUM/COT.003.266 | Data Element Name; Data Element Name Text; Definition | UPDATE | COT266|COT.003.266|REFERRING-PROV-NUM-1|Referring Provider Number|Conditional|A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(30)|79|1119|1148|1. Value must be 30 characters or less 2. Conditional |
COT266|COT.003.266|REFERRING-PROV-NUM|Referring Provider Number|Conditional|A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(30)|80|1120|1149|1. Value must be 30 characters or less 2. Conditional |
| 2024-04-12 | REFERRING-PROV-NPI-NUM/COT.003.267 | Data Element Name; Data Element Name Text; Coding Requirement | UPDATE | COT267|COT.003.267|REFERRING-PROV-NPI-NUM-1|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|80|1149|1158|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
COT267|COT.003.267|REFERRING-PROV-NPI-NUM|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|81|1150|1159|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File |
| 2024-04-12 | REFERRING-PROV-NUM-2/COT.003.268 | Data Element Name; Data Element Name Text; Definition | UPDATE | COT268|COT.003.268|REFERRING-PROV-NUM-2|Referring Provider Number|Conditional|A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the line/detail of their claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(30)|81|1159|1188|1. Value must be 30 characters or less 2. Conditional |
COT268|COT.003.268|REFERRING-PROV-NUM-2|Referring Provider Number 2|Conditional|A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(30)|82|1160|1189|1. Value must be 30 characters or less 2. Conditional |
| 2024-04-12 | REFERRING-PROV-NPI-NUM-2/COT.003.269 | Coding Requirement | UPDATE | COT269|COT.003.269|REFERRING-PROV-NPI-NUM-2|Referring Provider NPI Number|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the line/detail of their claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|82|1189|1198|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
COT269|COT.003.269|REFERRING-PROV-NPI-NUM-2|Referring Provider NPI Number 2|Conditional|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the line/detail of their claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|83|1190|1199|1. Value must be 10 digits 2. Conditional 3. Value must have an associated Provider Identifier Type equal to "2" 4. Value must exist in the NPPES NPI File 5. Value must not be populated when Referring Provider NPI Number is not populated. 6. Value must not equal Referring Provider NPI Number |
| 2024-04-12 | ORDERING-PROV-NPI-NUM/COT.003.271 | Coding Requirement; Definition | UPDATE | COT271|COT.003.271|ORDERING-PROV-NPI-NUM|Ordering Provider NPI Number|Conditional|The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|84|1229|1238|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
COT271|COT.003.271|ORDERING-PROV-NPI-NUM|order Provider NPI Number|Conditional|The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(10)|85|1230|1239|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | MBESCBES-FORM-GROUP/COT.003.290 | All Data Element Attributes | ADD | N/A | COT290|COT.003.290|MBESCBES-FORM-GROUP|MBESCBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).|MBESCBES-FORM-GROUP|COT00003|CLAIM-LINE-RECORD-OT|X(1)|69|880|880|1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | RECORD-ID/COT.004.274 | Coding Requirement; VVL | UPDATE | COT274|COT.004.274|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|COT00004|CLAIM-DX-OT|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
COT274|COT.004.274|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|COT00004|CLAIM-DX-OT|X(8)|1|1|8|1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "COT00004" |
| 2024-04-12 | ICN-ADJ/COT.004.278 | Coding Requirement | UPDATE | COT278|COT.004.278|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|COT00004|CLAIM-DX-OT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
COT278|COT.004.278|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|COT00004|CLAIM-DX-OT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | ADJUSTMENT-IND/COT.004.279 | Coding Requirement | UPDATE | COT279|COT.004.279|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|LINE-ADJUSTMENT-IND|COT00004|CLAIM-DX-OT|X(1)|6|122|122|1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory |
COT279|COT.004.279|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|COT00004|CLAIM-DX-OT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" 7. Value must match the adjustment indicator in the header (COT.002.025) |
| 2024-04-12 | DIAGNOSIS-SEQUENCE-NUMBER/COT.004.282 | Coding Requirement | UPDATE | COT282|COT.004.282|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837P claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes).|N/A|COT00004|CLAIM-DX-OT|9(2)|9|132|133|1. Value must be between 1 and 24 2. Mandatory |
COT282|COT.004.282|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an 837P claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes).|N/A|COT00004|CLAIM-DX-OT|9(2)|9|132|133|1. Value must be in [01-24] 2. Mandatory |
| 2024-04-12 | DATA-DICTIONARY-VERSION/CRX.001.002 | VVL | UPDATE | CRX002|CRX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|DATA-DICTIONARY-VERSION|CRX00001|FILE-HEADER-RECORD-RX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
CRX002|CRX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|CRX00001|FILE-HEADER-RECORD-RX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | FILE-NAME/CRX.001.006 | VVL; Definition | UPDATE | CRX006|CRX.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|CRX00001|FILE-HEADER-RECORD-RX|X(8)|6|32|39|1. Value must equal 'CLAIM-RX' 2. Mandatory |
CRX006|CRX.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|CRX00001|FILE-HEADER-RECORD-RX|X(8)|6|32|39|1. Value must equal "CLAIM-RX" 2. Mandatory |
| 2024-04-12 | ICN-ADJ/CRX.002.020 | Coding Requirement | UPDATE | CRX020|CRX.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CRX020|CRX.002.020|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/CRX.002.022 | Definition | UPDATE | CRX022|CRX.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(20)|7|134|153|1. Mandatory 2. Value must be 20 characters or less 3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
CRX022|CRX.002.022|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(20)|7|134|153|1. Value must be 20 characters or less 2. Mandatory 3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
| 2024-04-12 | CROSSOVER-INDICATOR/CRX.002.023 | Coding Requirement | UPDATE | CRX023|CRX.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|8|154|154|1. Value must be in Crossover Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service) 5. Value must be 1 character 6. Mandatory |
CRX023|CRX.002.023|CROSSOVER-INDICATOR|Crossover Indicator|Mandatory|An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.|CROSSOVER-INDICATOR|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|8|154|154|1. Value must be 1 character 2. Value must be in Crossover Indicator List (VVL) 3. If Crossover Indicator value equals "1", then associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service) 4. Mandatory |
| 2024-04-12 | ADJUSTMENT-IND/CRX.002.025 | Coding Requirement | UPDATE | CRX025|CRX.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record. |ADJUSTMENT-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|10|156|156|1. Value must be in Adjustment Indicator List (VVL). 2. Value must be in [0, 1, 4]. 3. Value must be 1 character. 4. Mandatory |
CRX025|CRX.002.025|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|10|156|156|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686" |
| 2024-04-12 | TYPE-OF-CLAIM/CRX.002.029 | Coding Requirement | UPDATE | CRX029|CRX.002.029|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record. |TYPE-OF-CLAIM|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|14|176|176|1. Value must be in Type of Claim List (VVL) 2. Value must be 1 character 3. Mandatory 4. When value equals 'Z', claim denied indicator must equal '0' |
CRX029|CRX.002.029|TYPE-OF-CLAIM|Type of Claim|Mandatory|A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.|TYPE-OF-CLAIM|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|14|176|176|1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory |
| 2024-04-12 | SOURCE-LOCATION/CRX.002.032 | Definition | UPDATE | CRX032|CRX.002.032|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee. |SOURCE-LOCATION|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|17|183|184|1. Value must be in Source Location List (VVL) 2. Value must be 2 characters 3. Mandatory |
CRX032|CRX.002.032|SOURCE-LOCATION|Source Location|Mandatory|The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee.|SOURCE-LOCATION|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|17|183|184|1. Value must be 2 characters 2. Value must be in Source Location List (VVL) 3. Mandatory |
| 2024-04-12 | TOT-MEDICAID-PAID-AMT/CRX.002.041 | Coding Requirement; Definition | UPDATE | CRX041|CRX.002.041|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. |N/A|CRX00002|CLAIM-HEADER-RECORD-RX|S9(11)V99|26|254|266|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional |
CRX041|CRX.002.041|TOT-MEDICAID-PAID-AMT|Total Medicaid Paid Amount|Conditional|The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|S9(11)V99|26|254|266|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts. 6. Conditional 7. Value must be populated, when Type of Claim is in [1,A] 8. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 9. Value must not be greater than Total Allowed Amount (CRX.002.040) |
| 2024-04-12 | OTHER-INSURANCE-IND/CRX.002.048 | Coding Requirement | UPDATE | CRX048|CRX.002.048|OTHER-INSURANCE-IND|Other Insurance Indicator|Conditional|The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. |OTHER-INSURANCE-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|31|319|319|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in Other Insurance Indicator List (VVL) 4. Conditional |
CRX048|CRX.002.048|OTHER-INSURANCE-IND|Other Insurance Indicator|Conditional|The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid.|OTHER-INSURANCE-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|31|319|319|1. Value must be 1 character 2. Value must be in Other Insurance Indicator List (VVL) 3. Conditional |
| 2024-04-12 | FUNDING-CODE/CRX.002.053 | Coding Requirement | UPDATE | CRX053|CRX.002.053|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|34|324|325|1. Value must be in Funding Code List (VVL) 2. Value must be 1 character 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
CRX053|CRX.002.053|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|34|324|325|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | FUNDING-SOURCE-NONFEDERAL-SHARE/CRX.002.054 | Coding Requirement | UPDATE | CRX054|CRX.002.054|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Non-Federal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. |FUNDING-SOURCE-NONFEDERAL-SHARE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|35|326|327|1. Value must be in Funding Source Non-Federal Share List (VVL) 2. Value must be 2 characters 3. Value must be populated if TYPE-OF-CLAIM equals ‘3', ‘C’, ‘W’, or '6’ 4. Conditional |
CRX054|CRX.002.054|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Non-Federal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|35|326|327|1. Value must be 2 characters 2. Value must be in Funding Source Non-Federal Share List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | CLAIM-LINE-COUNT/CRX.002.060 | Coding Requirement | UPDATE | CRX060|CRX.002.060|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|9(4)|40|345|348|1. Value must be a positive integer 2. Value must be between 0:9999 (inclusive) 3. Value must not include commas or other non-numeric characters 4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 5. Value must be 4 characters or less 6. Mandatory |
CRX060|CRX.002.060|CLAIM-LINE-COUNT|Claim Line Count|Mandatory|The total number of lines on the claim.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|9(4)|40|345|348|1. Value must be 4 characters or less 2. Value must be a positive integer 3. Value must be between 0000:9999 (inclusive) 4. Value must not include commas or other non-numeric characters 5. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported 6. Mandatory |
| 2024-04-12 | HEALTH-HOME-PROV-IND/CRX.002.067 | Coding Requirement | UPDATE | CRX067|CRX.002.067|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|47|439|439|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If there is an associated Health Home Entity Name value, then value must be "1" 5. Value must be 1 character 6. Conditional |
CRX067|CRX.002.067|HEALTH-HOME-PROV-IND|Health Home Provider Indicator|Conditional|Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.|HEALTH-HOME-PROV-IND|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|47|439|439|1. Value must be in Health Home Provider Indicator List (VVL) 2. Value must be 1 character 3. If there is an associated Health Home Entity Name value, then value must be "1" 4. Conditional |
| 2024-04-12 | WAIVER-ID/CRX.002.069 | Coding Requirement | UPDATE | CRX069|CRX.002.069|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(20)|49|442|461|1. Value must be associated with a populated Waiver Type 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
CRX069|CRX.002.069|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(20)|49|442|461|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | BILLING-PROV-NUM/CRX.002.070 | Coding Requirement | UPDATE | CRX070|CRX.002.070|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(30)|50|462|491|1. Value must be 30 characters or less. 2. Conditional 3. When Type of Claim not in ('3','C','W') then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in ('3','C','W') then value may match (PRV.005.081) Provider Identifier where the Provider Identifier. 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080). |
CRX070|CRX.002.070|BILLING-PROV-NUM|Billing Provider Number|Conditional|A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(30)|50|462|491|1. Value must be 30 characters or less 2. Conditional 3. When Type of Claim not in [3,C,W] then value may match (PRV.002.019) Submitting State Provider ID or 4. When Type of Claim not in [3,C,W] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.077) equals "1" 5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 2024-04-12 | BILLING-PROV-NPI-NUM/CRX.002.071 | Coding Requirement | UPDATE | CRX071|CRX.002.071|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|51|492|501|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional 4. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
CRX071|CRX.002.071|BILLING-PROV-NPI-NUM|Billing Provider NPI Number|Conditional|The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|51|492|501|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01" 6. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 2024-04-12 | PRESCRIBING-PROV-NPI-NUM/CRX.002.075 | Coding Requirement | UPDATE | CRX075|CRX.002.075|PRESCRIBING-PROV-NPI-NUM|Prescribing Provider NPI Number|Mandatory|The National Provider ID (NPI) of the provider who prescribed a medication to a patient.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|55|546|555|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Mandatory |
CRX075|CRX.002.075|PRESCRIBING-PROV-NPI-NUM|Prescribing Provider NPI Number|Mandatory|The National Provider ID (NPI) of the provider who prescribed a medication to a patient.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|55|546|555|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type equal to "2" 3. Mandatory 4. Value must exist in the NPPES NPI data file 5. NPPES Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 2024-04-12 | DISPENSING-PRESCRIPTION-DRUG-PROV-NPI/CRX.002.102 | Coding Requirement | UPDATE | CRX102|CRX.002.102|DISPENSING-PRESCRIPTION-DRUG-PROV-NPI|Dispensing Prescription Drug Provider NPI Number|Mandatory|The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|75|773|782|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) 4. Mandatory |
CRX102|CRX.002.102|DISPENSING-PRESCRIPTION-DRUG-PROV-NPI|Dispensing Prescription Drug Provider NPI Number|Mandatory|The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|75|773|782|1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. When Type of Claim not in [3,C,W], then value must match Provider Identifier (PRV.005.081) 4. Mandatory 5. Value must exist in the NPPES NPI data file 6. NPPES Entity Type Code associate with this NPI must equal "1" (Individual) |
| 2024-04-12 | HEALTH-HOME-PROVIDER-NPI/CRX.002.104 | Coding Requirement | UPDATE | CRX104|CRX.002.104|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|76|783|792|1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm) 2. Value must have an associated Provider Identifier Type equal to '2' 3. Conditional |
CRX104|CRX.002.104|HEALTH-HOME-PROVIDER-NPI|Health Home Provider NPI Number|Conditional|The National Provider ID (NPI) of the health home provider.|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(10)|76|783|792|1. Value must be 10 digits 2. Value must have an associated Provider Identifier, where Provider Identifier Type (PRV.005.077) equals "2" 3. Value must exist in the NPPES NPI data file 4. Conditional |
| 2024-04-12 | PRESCRIPTION-ORIGIN-CODE/CRX.002.162 | Coding Requirement | UPDATE | CRX162|CRX.002.162|PRESCRIPTION-ORIGIN-CODE|Prescription Origin Code|Conditional|How the prescription was sent to the pharmacy.|PRESCRIPTION-ORIGIN-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|81|841|841|1. Value must be one digit 2. Value must be 1:4 3. Conditional |
CRX162|CRX.002.162|PRESCRIPTION-ORIGIN-CODE|Prescription Origin Code|Conditional|How the prescription was sent to the pharmacy.|PRESCRIPTION-ORIGIN-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(1)|81|841|841|1. Value must be one digit 2. Value must be in Prescription Origin Code List (VVL) 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/CRX.003.111 | Definition | UPDATE | CRX111|CRX.003.111|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less. |
CRX111|CRX.003.111|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | ICN-ADJ/CRX.003.113 | Coding Requirement | UPDATE | CRX113|CRX.003.113|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CRX113|CRX.003.113|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(50)|6|92|141|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | MEDICAID-PAID-AMT/CRX.003.125 | Coding Requirement | UPDATE | CRX125|CRX.003.125|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(11)V99|18|225|237|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) 3. Conditional |
CRX125|CRX.003.125|MEDICAID-PAID-AMT|Medicaid Paid Amount|Conditional|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(11)V99|18|225|237|1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654] |
| 2024-04-12 | PRESCRIPTION-QUANTITY-ACTUAL/CRX.003.132 | Coding Requirement | UPDATE | CRX132|CRX.003.132|PRESCRIPTION-QUANTITY-ACTUAL|Prescription Quantity Actual|Mandatory|The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|24|308|325|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Mandatory 3. When populated, corresponding Unit of Measure must be populated |
CRX132|CRX.003.132|PRESCRIPTION-QUANTITY-ACTUAL|Prescription Quantity Actual|Mandatory|The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|24|308|325|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Mandatory |
| 2024-04-12 | UNIT-OF-MEASURE/CRX.003.133 | Coding Requirement; Necessity | UPDATE | CRX133|CRX.003.133|UNIT-OF-MEASURE|Unit of Measure|Conditional|A code to indicate the basis by which the quantity of the drug or supply is expressed.|UNIT-OF-MEASURE|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|25|326|327|1. Value must be in NDC Unit of Measure List (VVL). 2. Value must be 2 characters 3. Conditional |
CRX133|CRX.003.133|UNIT-OF-MEASURE|Unit of Measure|Mandatory|A code to indicate the basis by which the quantity of the drug or supply is expressed.|NDC-UNIT-OF-MEASURE|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|25|326|327|1. Value must be 2 characters 2. Value must be in Unit of Measure List (VVL) 3. Mandatory |
| 2024-04-12 | TYPE-OF-SERVICE/CRX.003.134 | VVL | UPDATE | CRX134|CRX.003.134|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee. |TYPE-OF-SERVICE|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|26|328|330|1. Value must be 3 characters 2. Mandatory 3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] |
CRX134|CRX.003.134|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|26|328|330|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. Value must be in [011,018,033,034,036,085,089,127,131,136,137,145] |
| 2024-04-12 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/CRX.003.149 | Coding Requirement | UPDATE | CRX149|CRX.003.149|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|39|387|388|1. Value must be in Category for Federal Reimbursement List (VVL). 2. Value must be 2 characters. 3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']. 4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'. 5. Conditional 6. If Type of Claim is in ['1','A','U'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported. |
CRX149|CRX.003.149|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|39|387|388|1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3] 4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1" 5. Conditional 6. If Type of Claim is in [1,A,U] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported |
| 2024-04-12 | IHS-SERVICE-IND/CRX.003.172 | Coding Requirement | UPDATE | CRX172|CRX.003.172|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |IHS-SERVICE-IND|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|49|496|496|1. Value must be 1 character 2. Value must be in [0, 1] 3. Mandatory |
CRX172|CRX.003.172|IHS-SERVICE-IND|IHS Service Indicator|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|IHS-SERVICE-IND|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|49|496|496|1. Value must be 1 character 2. Value must be in the IHS Service Indicator List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/CRX.003.180 | Coding Requirement; Definition; VVL | UPDATE | CRX180|CRX.003.180|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|CRX00003|CLAIM-LINE-RECORD-RX|X(5)|51|573|577|1. Value must not be more than 5 characters 2. Value must be in MBES or CBES Category of Service Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
CRX180|CRX.003.180|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|CRX00003|CLAIM-LINE-RECORD-RX|X(5)|53|624|628|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Conditional 11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 12. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 2024-04-12 | MBESCBES-FORM/CRX.003.181 | Coding Requirement; Definition | UPDATE | CRX181|CRX.003.181|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CRX00003|CLAIM-LINE-RECORD-RX|X(50)|52|578|627|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form Code List (VVL) 3. Value must be populated on all FFS claim lines with a paid amount greater than $0 4. Conditional |
CRX181|CRX.003.181|MBESCBES-FORM|MBESCBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|CRX00003|CLAIM-LINE-RECORD-RX|X(50)|52|574|623|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | PROCEDURE-CODE-MOD-1/CRX.003.183 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX183|CRX.003.183|PROCEDURE-CODE-MODIFIER-1|Procedure Code Modifier 1|Conditional|The first modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|54|634|635|1. Value must be 2 characters. 2. Conditional |
CRX183|CRX.003.183|PROCEDURE-CODE-MOD-1|Procedure Code Modifier 1|Conditional|The first modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|55|635|636|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-2/CRX.003.184 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX184|CRX.003.184|PROCEDURE-CODE-MODIFIER-2|Procedure Code Modifier 2|Conditional|The second modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|55|636|637|1. Value must be 2 characters. 2. Conditional |
CRX184|CRX.003.184|PROCEDURE-CODE-MOD-2|Procedure Code Modifier 2|Conditional|The second modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|56|637|638|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-3/CRX.003.185 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX185|CRX.003.185|PROCEDURE-CODE-MODIFIER-3|Procedure Code Modifier 3|Conditional|The third modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|56|638|639|1. Value must be 2 characters. 2. Conditional |
CRX185|CRX.003.185|PROCEDURE-CODE-MOD-3|Procedure Code Modifier 3|Conditional|The third modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|57|639|640|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-4/CRX.003.186 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX186|CRX.003.186|PROCEDURE-CODE-MODIFIER-4|Procedure Code Modifier 4|Conditional|The fourth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|57|640|641|1. Value must be 2 characters. 2. Conditional |
CRX186|CRX.003.186|PROCEDURE-CODE-MOD-4|Procedure Code Modifier 4|Conditional|The fourth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|58|641|642|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-5/CRX.003.187 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX187|CRX.003.187|PROCEDURE-CODE-MODIFIER-5|Procedure Code Modifier 5|Conditional|The fifth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|58|642|643|1. Value must be 2 characters. 2. Conditional |
CRX187|CRX.003.187|PROCEDURE-CODE-MOD-5|Procedure Code Modifier 5|Conditional|The fifth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|59|643|644|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-6/CRX.003.188 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX188|CRX.003.188|PROCEDURE-CODE-MODIFIER-6|Procedure Code Modifier 6|Conditional|The sixth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|59|644|645|1. Value must be 2 characters. 2. Conditional |
CRX188|CRX.003.188|PROCEDURE-CODE-MOD-6|Procedure Code Modifier 6|Conditional|The sixth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|60|645|646|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-7/CRX.003.189 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX189|CRX.003.189|PROCEDURE-CODE-MODIFIER-7|Procedure Code Modifier 7|Conditional|The seventh modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|60|646|647|1. Value must be 2 characters. 2. Conditional |
CRX189|CRX.003.189|PROCEDURE-CODE-MOD-7|Procedure Code Modifier 7|Conditional|The seventh modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|61|647|648|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-8/CRX.003.190 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX190|CRX.003.190|PROCEDURE-CODE-MODIFIER-8|Procedure Code Modifier 8|Conditional|The eighth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|61|648|649|1. Value must be 2 characters. 2. Conditional |
CRX190|CRX.003.190|PROCEDURE-CODE-MOD-8|Procedure Code Modifier 8|Conditional|The eighth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|62|649|650|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-9/CRX.003.191 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX191|CRX.003.191|PROCEDURE-CODE-MODIFIER-9|Procedure Code Modifier 9|Conditional|The ninth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|62|650|651|1. Value must be 2 characters 2. Conditional |
CRX191|CRX.003.191|PROCEDURE-CODE-MOD-9|Procedure Code Modifier 9|Conditional|The ninth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|63|651|652|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | PROCEDURE-CODE-MOD-10/CRX.003.192 | Data Element name; Data Element Name Text; VVL; Coding Requirement | UPDATE | CRX192|CRX.003.192|PROCEDURE-CODE-MODIFIER-10|Procedure Code Modifier 10|Conditional|The tenth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|63|652|653|1. Value must be 2 characters. 2. Conditional |
CRX192|CRX.003.192|PROCEDURE-CODE-MOD-10|Procedure Code Modifier 10|Conditional|The tenth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier).|PROCEDURE-CODE-MOD|CRX00003|CLAIM-LINE-RECORD-RX|X(2)|64|653|654|1. Value must be 2 characters 2. Value must be in Procedure Code Mod List (VVL) 3. Must be associated with a Procedure Code 4. Conditional |
| 2024-04-12 | MBESCBES-FORM-GROUP/CRX.003.209 | All Data Element Attributes | ADD | N/A | CRX209|CRX.003.209|MBESCBES-FORM-GROUP|MBESCBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).|MBESCBES-FORM-GROUP|CRX00003|CLAIM-LINE-RECORD-RX|X(1)|51|573|573|1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 |
| 2024-04-12 | RECORD-ID/CRX.004.196 | Coding Requirement; VVL | UPDATE | CRX196|CRX.004.196|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|CRX00004|CLAIM-DX-RX|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
CRX196|CRX.004.196|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|CRX00004|CLAIM-DX-RX|X(8)|1|1|8|1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "CRX00004" |
| 2024-04-12 | ICN-ADJ/CRX.004.200 | Coding Requirement | UPDATE | CRX200|CRX.004.200|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00004|CLAIM-DX-RX|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional |
CRX200|CRX.004.200|ICN-ADJ|Adjustment ICN|Conditional|A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.|N/A|CRX00004|CLAIM-DX-RX|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | ADJUSTMENT-IND/CRX.004.201 | Coding Requirement | UPDATE | CRX201|CRX.004.201|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|LINE-ADJUSTMENT-IND|CRX00004|CLAIM-DX-RX|X(1)|6|122|122|1. Value must be in Adjustment Indicator List (VVL) 2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ] 3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ] 4. Value must be 1 character 5. Mandatory |
CRX201|CRX.004.201|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|CRX00004|CLAIM-DX-RX|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. If value is in [4,1] then Adjustment ICN must be populated 7. Value must equal "1", when associated Claim Status equals "686" 8. Value must match the adjustment indicator in the header (CRX.002.025) |
| 2024-04-12 | DIAGNOSIS-SEQUENCE-NUMBER/CRX.004.204 | Coding Requirement | UPDATE | CRX204|CRX.004.204|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an NCPDP claim can have up to 5 diagnosis codes).|N/A|CRX00004|CLAIM-DX-RX|9(2)|9|132|133|1. Value must be between 1 and 24 2. Mandatory |
CRX204|CRX.004.204|DIAGNOSIS-SEQUENCE-NUMBER|Diagnosis Sequence Number|Mandatory|The order in which the diagnosis occurred on the provider's claim for a given type of diagnosis code (e.g., an NCPDP claim can have up to 5 diagnosis codes).|N/A|CRX00004|CLAIM-DX-RX|9(2)|9|132|133|1. Value must be in [01-24] 2. Mandatory |
| 2024-04-12 | DATA-DICTIONARY-VERSION/ELG.001.002 | VVL | UPDATE | ELG002|ELG.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|DATA-DICTIONARY-VERSION|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
ELG002|ELG.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | SUBMISSION-TRANSACTION-TYPE/ELG.001.003 | VVL | UPDATE | ELG003|ELG.001.003|SUBMISSION-TRANSACTION-TYPE|Submission Transaction Type|Mandatory|A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects.|SUBMISSION-TRANSACTION-TYPE|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(1)|3|19|19|1. Value must be in Submission Transaction Type List (VVL) 2. Value must be 1 character 3. Mandatory |
ELG003|ELG.001.003|SUBMISSION-TRANSACTION-TYPE|Submission Transaction Type|Mandatory|A data element to identify the whether the transactions in the file are original submissions of the data, a resubmission of a previously submitted file, or corrections of edit rejects.|SUBMISSION-TRANSACTION-TYPE|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(1)|3|19|19|1. Value must be 1 characters 2. Value must be in Submission Transaction Type List (VVL) 3. Mandatory |
| 2024-04-12 | FILE-NAME/ELG.001.006 | Definition | UPDATE | ELG006|ELG.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(8)|6|32|39|1. Value must equal 'ELIGIBLE' 2. Mandatory |
ELG006|ELG.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(8)|6|32|39|1. Value must equal "ELIGIBLE" 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.002.019 | Definition | UPDATE | ELG019|ELG.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00002|PRIMARY-DEMOGRAPHICS-ELIGIBILITY|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG019|ELG.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00002|PRIMARY-DEMOGRAPHICS-ELIGIBILITY|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.003.033 | Definition, Coding Requirement | UPDATE | ELG033|ELG.003.033|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(20)|4|22|41|1. Mandatory 2. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN 3. Value must be 20 characters or less |
ELG033|ELG.003.033|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | VETERAN-IND/ELG.003.039 | Coding Requirement | UPDATE | ELG039|ELG.003.039|VETERAN-IND|Veteran Indicator|Conditional|A flag indicating if a non-citizen is exempt from the 5-year bar on benefits because they are a veteran or an active member of the military, naval or air service.|VETERAN-IND|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(1)|10|106|106|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in Veteran Indicator List (VVL) 4. Value must be 1 character 5. Conditional 6. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
ELG039|ELG.003.039|VETERAN-IND|Veteran Indicator|Conditional|A flag indicating if a non-citizen is exempt from the 5-year bar on benefits because they are a veteran or an active member of the military, naval or air service.|VETERAN-IND|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(1)|10|106|106|1. Value must be 1 character 2. Value must be in Veteran Indicator List (VVL) 3. Conditional 4. Value must be populated when Immigration Status (ELG.003.042) is in [1,2,3] |
| 2024-04-12 | CITIZENSHIP-IND/ELG.003.040 | Coding Requirement | UPDATE | ELG040|ELG.003.040|CITIZENSHIP-IND|Citizenship Indicator|Mandatory|Indicates if the individual is identified as a U.S. Citizen. |CITIZENSHIP-IND|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(1)|11|107|107|1. Value must be 1 character 2. Value must be in [0, 1, 2] or not populated 3. Value must be in Citizenship Indicator List (VVL) 4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ] 5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8' 6. Value must be 1 character 7. Mandatory |
ELG040|ELG.003.040|CITIZENSHIP-IND|Citizenship Indicator|Mandatory|Indicates if the individual is identified as a U.S. Citizen.|CITIZENSHIP-IND|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(1)|11|107|107|1. Value must be 1 character 2. Value must be in [0,1,2] 3. Value must be in Citizenship Indicator List (VVL) 4. If value equals "0", then associated Immigration Status (ELG.003.042) value must be in [1,2,3] 5. If value is coded as "1", then associated Immigration Status (ELG.003.042) value must equal "8" 6. Mandatory |
| 2024-04-12 | IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE/ELG.003.044 | Coding Requirement | UPDATE | ELG044|ELG.003.044|IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE|Immigration Status Five Year Bar End Date|Conditional|The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified alien."|N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(8)|15|111|118|1. Conditional 2. (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' |
ELG044|ELG.003.044|IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE|Immigration Status Five Year Bar End Date|Conditional|The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified alien."|N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(8)|15|111|118|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. If Immigration Status (ELG.003.042) equals "8" (U.S. Citizen), then value should not be populated |
| 2024-04-12 | ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE/ELG.003.269 | Coding requirement | UPDATE | ELG269|ELG.003.269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|Eligibile Federal Poverty Level Percentage|Conditional|This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group. A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(3)|25|167|169|1. Value must be between 0 and 400 inclusively 2. Conditional |
ELG269|ELG.003.269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|Eligibile Federal Poverty Level Percentage|Conditional|This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group. A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group.|N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(3)|25|167|169|1. Value must be between 000 and 400 inclusively 2. Conditional |
| 2024-04-12 | APPLICATION-SIGNATURE-DATE/ELG.003.273 | Coding Requirement | UPDATE | ELG273|ELG.003.273|APPLICATION-SIGNATURE-DATE|Application Signature Date|Conditional|The date that a beneficiary signed their Medicaid or CHIP application. If the beneficiary was deemed eligible via an administrative determination then a signature may not be applicable/available. |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(8)|26|170|177|1. Value must be a valid date 2. Conditional 3. Value must be less than the VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE |
ELG273|ELG.003.273|APPLICATION-SIGNATURE-DATE|Application Signature Date|Conditional|The date that a beneficiary signed their Medicaid or CHIP application. If the beneficiary was deemed eligible via an administrative determination then a signature may not be applicable/available. |N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|9(8)|26|170|177|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. Value must be less than the Variable Demographic Element End Date |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.004.064 | Definition | UPDATE | ELG064|ELG.004.064|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG064|ELG.004.064|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | ELIGIBLE-ZIP-CODE/ELG.004.071 | Coding Requirement; VVL | UPDATE | ELG071|ELG.004.071|ELIGIBLE-ZIP-CODE|Eligible ZIP Code|Mandatory|U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)|N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(9)|11|254|262|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Mandatory |
ELG071|ELG.004.071|ELIGIBLE-ZIP-CODE|Eligible ZIP Code|Mandatory|U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)|ZIP-CODE|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(9)|11|254|262|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.005.082 | Definition | UPDATE | ELG082|ELG.005.082|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG082|ELG.005.082|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | SSDI-IND/ELG.005.089 | Coding Requirement | UPDATE | ELG089|ELG.005.089|SSDI-IND|SSDI Indicator|Conditional|A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA).|SSDI-IND|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|10|62|62|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in SSDI Indicator List (VVL) 4. Value must be 1 character 5. Conditional |
ELG089|ELG.005.089|SSDI-IND|SSDI Indicator|Conditional|A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA).|SSDI-IND|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|10|62|62|1. Value must be 1 character 2. Value must be in SSDI Indicator List (VVL) 3. Conditional |
| 2024-04-12 | SSI-IND/ELG.005.090 | Coding Requirement | UPDATE | ELG090|ELG.005.090|SSI-IND|SSI Indicator|Conditional|A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).|SSI-IND|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|11|63|63|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in SSI Indicator List (VVL) 4. Value must be 1 character 5. Conditional 6. Value must equal '0' when SSI status (ELG.005.092) equals '000' or '003' or is not populated 7. Value must equal '1' when SSI status (ELG.005.092) equals '001' or '002' |
ELG090|ELG.005.090|SSI-IND|SSI Indicator|Conditional|A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).|SSI-IND|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|11|63|63|1. Value must be 1 character 2. Value must be in SSI Indicator List (VVL) 3. Conditional 4. Value must equal "0" when SSI status (ELG.005.092) equals "000" or "003" or is not populated 5. Value must equal "1" when SSI status (ELG.005.092) equals "001" or "002" |
| 2024-04-12 | CONCEPTION-TO-BIRTH-IND/ELG.005.094 | Coding Requirement | UPDATE | ELG094|ELG.005.094|CONCEPTION-TO-BIRTH-IND|Conception To Birth Indicator|Conditional|A flag to identify children eligible through the conception to birth option, which is available only through a separate State CHIP Program.|CONCEPTION-TO-BIRTH-IND|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|15|76|76|1. Value must be in Conception to Birth Indicator List (VVL) 2. Value must be 1 character 3. Value must be in [0, 1] or not populated 4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64" 5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP) 6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program) 7. Value must be 1 character 8. Conditional |
ELG094|ELG.005.094|CONCEPTION-TO-BIRTH-IND|Conception To Birth Indicator|Conditional|A flag to identify children eligible through the conception to birth option, which is available only through a separate State CHIP Program.|CONCEPTION-TO-BIRTH-IND|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|15|76|76|1. Value must be 1 character 2. Value must be in Conception to Birth Indicator List (VVL) 3. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64" 4. If the value is equal to "1", then any associated claims must indicate the Program Type equals "14" (State Plan CHIP) 5. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program) 6. Conditional |
| 2024-04-12 | ELIGIBILITY-REDETERMINTATION-DATE/ELG.005.274 | Coding Requirement | UPDATE | ELG274|ELG.005.274|ELIGIBILITY-REDETERMINTATION-DATE|Eligibility Redetermination Date|Conditional|The date by which a person's Medicaid or CHIP eligibility must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|21|97|104|1. Value must be a valid date 2. Conditional 3. Value must be greater than the ELIGIBILITY-DETERMINANTS-EFF-DATE |
ELG274|ELG.005.274|ELIGIBILITY-REDETERMINTATION-DATE|Eligibility Redetermination Date|Conditional|The date by which a person's Medicaid or CHIP eligibility must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|21|97|104|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. Value must be greater than the Eligibility Determinant Effective Date |
| 2024-04-12 | CONTINUOUS-ELIGIBILITY-CODE/ELG.005.277 | Coding Requirement | UPDATE | ELG277|ELG.005.277|CONTINUOUS-ELIGIBILITY-CODE|Continuous Eligibility Code|Conditional|A code to identify the authority used to provide continuous eligibility during the period of coverage|CONTINUOUS-ELIGIBILITY-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(3)|24|158|160|1. Value must not be more than 3 characters 2. Value must be in Continuous Eligibility Code List (VVL) 3. Conditional |
ELG277|ELG.005.277|CONTINUOUS-ELIGIBILITY-CODE|Continuous Eligibility Code|Conditional|A code to identify the authority used to provide continuous eligibility during the period of coverage|CONTINUOUS-ELIGIBILITY-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(3)|24|158|160|1. Value must be 3 characters 2. Value must be in Continuous Eligibility Code List (VVL) 3. Conditional |
| 2024-04-12 | ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT/ELG.005.281 | Coding Requirement | UPDATE | ELG281|ELG.005.281|ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT|Eligibility Termination Reason Other Type Text|Conditional|Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(100)|28|263|362|1. Value must be 100 characters or less 2. Value must not be populated when Eligibility Termination Reason = 22 (Other) 3. Value must be populated when Eligibility Termination Reason <> 22 (Other) 3. Conditional |
ELG281|ELG.005.281|ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT|Eligibility Termination Reason Other Type Text|Conditional|Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(100)|28|263|362|1. Value must be 100 characters or less 2. Value must not be populated when Eligibility Termination Reason equals "22" (Other) 3. Value must be populated when Eligibility Termination Reason does not equal "22" (Other) 4. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.006.106 | Definition | UPDATE | ELG106|ELG.006.106|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00006|HEALTH-HOME-SPA-PARTICIPATION-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG106|ELG.006.106|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00006|HEALTH-HOME-SPA-PARTICIPATION-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.007.117 | Definition | UPDATE | ELG117|ELG.007.117|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG117|ELG.007.117|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.008.129 | Definition | UPDATE | ELG129|ELG.008.129|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00008|HEALTH-HOME-CHRONIC-CONDITIONS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG129|ELG.008.129|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00008|HEALTH-HOME-CHRONIC-CONDITIONS|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.009.139 | Definition | UPDATE | ELG139|ELG.009.139|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00009|LOCK-IN-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG139|ELG.009.139|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00009|LOCK-IN-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | LOCKED-IN-SRVCS/ELG.009.270 | Coding Requirement; VVL | UPDATE | ELG270|ELG.009.270|LOCKED-IN-SRVCS|Locked In Services|Conditional|The type(s) of services that are locked-in. |TYPE-OF-SERVICE|ELG00009|LOCK-IN-INFORMATION|X(3)|9|90|92|1. Value must be 3 characters 2. Conditional 3. Must be a 3 digit value from the Type-of-Service valid value list |
ELG270|ELG.009.270|LOCKED-IN-SRVCS|Locked In Services|Conditional|The type(s) of services that are locked-in.|TYPE-OF-SERVICE|ELG00009|LOCK-IN-INFORMATION|X(3)|9|90|92|1. Value must be 3 characters 2. Conditional 3. Value must be in Type of Service List (VVL) |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.010.149 | Definition | UPDATE | ELG149|ELG.010.149|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00010|MFP-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG149|ELG.010.149|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00010|MFP-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.011.162 | Definition | UPDATE | ELG162|ELG.011.162|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00011|STATE-PLAN-OPTION-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG162|ELG.011.162|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00011|STATE-PLAN-OPTION-PARTICIPATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.012.171 | Definition | UPDATE | ELG171|ELG.012.171|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00012|WAIVER-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG171|ELG.012.171|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00012|WAIVER-PARTICIPATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | WAIVER-ID/ELG.012.172 | Coding Requirement | UPDATE | ELG172|ELG.012.172|WAIVER-ID|Waiver ID|Mandatory|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|ELG00012|WAIVER-PARTICIPATION|X(20)|5|42|61|1. Value must be associated with a populated Waiver Type 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must have a corresponding value in Waiver Type (ELG.012.173) 6. Mandatory |
ELG172|ELG.012.172|WAIVER-ID|Waiver ID|Mandatory|Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|ELG00012|WAIVER-PARTICIPATION|X(20)|5|42|61|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Value must have a corresponding value in Waiver Type (ELG.012.173) 7. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.013.181 | Definition | UPDATE | ELG181|ELG.013.181|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00013|LTSS-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG181|ELG.013.181|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00013|LTSS-PARTICIPATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.014.191 | Definition | UPDATE | ELG191|ELG.014.191|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00014|MANAGED-CARE-PARTICIPATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG191|ELG.014.191|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00014|MANAGED-CARE-PARTICIPATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MANAGED-CARE-PLAN-ID/ELG.014.192 | Definition | UPDATE | ELG192|ELG.014.192|MANAGED-CARE-PLAN-ID|Managed Care Plan ID|Mandatory|The managed care plan identification number under which the eligible individual is enrolled. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File". https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47565 See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting". https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/52896|N/A|ELG00014|MANAGED-CARE-PARTICIPATION|X(12)|5|42|53|1. Value must not contain a pipe or asterisk symbol 2. Value must be 12 characters or less 3. Value reported must match the value reported on State Plan Identification Number (MCR.002.019) 4. Mandatory |
ELG192|ELG.014.192|MANAGED-CARE-PLAN-ID|Managed Care Plan ID|Mandatory|The managed care plan identification number under which the eligible individual is enrolled. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-eligible-file-managed-care/ See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-guidance-primary-care-case-management-reporting-updated/|N/A|ELG00014|MANAGED-CARE-PARTICIPATION|X(12)|5|42|53|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Value reported must match the value reported on State Plan Identification Number (MCR.002.019) 4. Mandatory |
| 2024-04-12 | MANAGED-CARE-PLAN-TYPE/ELG.014.193 | Definition | UPDATE | ELG193|ELG.014.193|MANAGED-CARE-PLAN-TYPE|Managed Care Plan Type|Mandatory|A model of health care delivery organized to provide a defined set of services. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47540 See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47564|MANAGED-CARE-PLAN-TYPE|ELG00014|MANAGED-CARE-PARTICIPATION|X(2)|6|54|55|1. Value must be in Managed Care Plan Type List (VVL) 2. Value must be 2 characters 3. Mandatory 4. Value must not be populated when Managed Care Plan ID (ELG.014.192) is not populated 5. Value must equal the Managed Care Plan Type (MCR.002.024) associated with the State Plan Identification Number (MCR.002.018) |
ELG193|ELG.014.193|MANAGED-CARE-PLAN-TYPE|Managed Care Plan Type|Mandatory|A model of health care delivery organized to provide a defined set of services. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/|MANAGED-CARE-PLAN-TYPE|ELG00014|MANAGED-CARE-PARTICIPATION|X(2)|6|54|55|1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. Mandatory 4. Value must not be populated when Managed Care Plan ID (ELG.014.192) is not populated 5. Value must equal the Managed Care Plan Type (MCR.002.024) associated with the State Plan Identification Number (MCR.002.018) |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.015.203 | Definition | UPDATE | ELG203|ELG.015.203|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00015|ETHNICITY-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG203|ELG.015.203|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00015|ETHNICITY-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.016.212 | Definition | UPDATE | ELG212|ELG.016.212|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00016|RACE-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG212|ELG.016.212|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00016|RACE-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.017.223 | Definition | UPDATE | ELG223|ELG.017.223|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00017|DISABILITY-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG223|ELG.017.223|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00017|DISABILITY-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.018.232 | Definition | UPDATE | ELG232|ELG.018.232|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00018|1115A-DEMONSTRATION-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG232|ELG.018.232|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00018|1115A-DEMONSTRATION-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.020.241 | Definition | UPDATE | ELG241|ELG.020.241|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00020|HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG241|ELG.020.241|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572|N/A|ELG00020|HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.021.251 | Definition | UPDATE | ELG251|ELG.021.251|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00021|ENROLLMENT-TIME-SPAN-SEGMENT|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG251|ELG.021.251|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00021|ENROLLMENT-TIME-SPAN-SEGMENT|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.022.260 | Definition | UPDATE | ELG260|ELG.022.260|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|ELG00022|ELG-IDENTIFIERS|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
ELG260|ELG.022.260|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00022|ELG-IDENTIFIERS|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | RECORD-ID/ELG.023.282 | All Data Element Attributes | ADD | N/A | ELG282|ELG.023.282|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements, so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|ELG00023|SOGI|X(8) |1|1|8|1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "ELG00023" |
| 2024-04-12 | SUBMITTING-STATE/ELG.023.283 | All Data Element Attributes | ADD | N/A | ELG283|ELG.023.283|SUBMITTING-STATE|Submitting State|Mandatory|A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.|STATE|ELG00023|SOGI|X(2)|2|9|10|1. Value must be 2 characters 2. Value must be in State Code List (VVL) 3. Mandatory 4. Value must be the same as Submitting State (ELG.001.007) |
| 2024-04-12 | RECORD-NUMBER/ELG.023.284 | All Data Element Attributes | ADD | N/A | ELG284|ELG.023.284|RECORD-NUMBER|Record Number|Mandatory|A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.|N/A|ELG00023|SOGI|9(11)|3|11|21|1. Value must be 11 digits or less 2. Value must be unique within record segment over all records associated with a given Record ID 3. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/ELG.023.285 | All Data Element Attributes | ADD | N/A | ELG285|ELG.023.285|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|ELG00023|SOGI|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | SEX-ASSIGNED-AT-BIRTH/ELG.023.286 | All Data Element Attributes | ADD | N/A | ELG286|ELG.023.286|SEX-ASSIGNED-AT-BIRTH|Sex Assigned at Birth|Conditional|This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sex assigned at birth (e.g., according to an original birth certificate or similar document). T-MSIS does not define or maintain these questions or responses. They are defined and maintained via the CMS single streamlined application and state Medicaid and CHIP agencies. T-MSIS is intended to reflect those sources and may be updated periodically as necessary to align with national standards and common practices. For more information, see https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf.|SEX-ASSIGNED-AT-BIRTH|ELG00023|SOGI|X(1)|5|42|42|1. Value must be 1 character 2. Value must be in Sex Assigned at Birth List (VVL) 3. Conditional |
| 2024-04-12 | SEX-ASSIGNED-AT-BIRTH-OTHER-TEXT/ELG.023.287 | All Data Element Attributes | ADD | N/A | ELG287|ELG.023.287|SEX-ASSIGNED-AT-BIRTH-OTHER-TEXT|Sex Assigned at Birth Other Text|Conditional|This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sex assigned at birth (e.g., according to an original birth certificate or similar document), if their response is not reflected by the values available for Sex Assigned at Birth.|N/A|ELG00023|SOGI|X(100)|6|43|142|1. Value must be 100 characters or less 2. Conditional 3. If Sex Assigned at Birth equals "5" (Other), then value must be populated |
| 2024-04-12 | GENDER-IDENTITY/ELG.023.288 | All Data Element Attributes | ADD | N/A | ELG288|ELG.023.288|GENDER-IDENTITY|Gender Identity|Conditional|This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s gender identify.T-MSIS does not define or maintain these questions or responses. They are defined and maintained via the CMS single streamlined application and state Medicaid and CHIP agencies. T-MSIS is intended to reflect those sources and may be updated periodically as necessary to align with national standards and common practices. For more information, see https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf.|GENDER-IDENTITY|ELG00023|SOGI|X(1)|7|143|143|1. Value must be 1 character 2. Value must be in Gender Identity List (VVL) 3. Conditional |
| 2024-04-12 | GENDER-IDENTITY-OTHER-TEXT/ELG.023.289 | All Data Element Attributes | ADD | N/A | ELG289|ELG.023.289|GENDER-IDENTITY-OTHER-TEXT|Gender Identity Other Text|Conditional|This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s gender identify if their response is not reflected by the values available for Gender Identity.|N/A|ELG00023|SOGI|X(100)|8|144|243|1. Value must be 100 characters or less 2. Conditional 3. If Gender Identity equals "7" (Other), then value must be populated |
| 2024-04-12 | SEXUAL-ORIENTATION/ELG.023.290 | All Data Element Attributes | ADD | N/A | ELG290|ELG.023.290|SEXUAL-ORIENTATION|Sexual Orientation|Conditional|This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sexual orientation. T-MSIS does not define or maintain these questions or responses. They are defined and maintained via the CMS single streamlined application and state Medicaid and CHIP agencies. T-MSIS is intended to reflect those sources and may be updated periodically as necessary to align with national standards and common practices. For more information, see https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf.|SEXUAL-ORIENTATION|ELG00023|SOGI|X(1)|9|244|244|1. Value must be 1 character 2. Value must be in Sexual Orientation List (VVL) 3. Conditional |
| 2024-04-12 | SEXUAL-ORIENTATION-OTHER-TEXT/ELG.023.291 | All Data Element Attributes | ADD | N/A | ELG291|ELG.023.291|SEXUAL-ORIENTATION-OTHER-TEXT|Sexual Orientation Other Text|Conditional|This is the response from the beneficiary to an optional question posed to them on their Medicaid or CHIP application regarding the individual’s sexual orientation if their response is not reflected by the values available for Sexual Orientation.|N/A|ELG00023|SOGI|X(100)|10|245|344|1. Value must be 100 characters or less 2. Conditional 3. If Sex Orientation equals "6" (Other), then value must be populated |
| 2024-04-12 | SOGI-EFF-DATE/ELG.023.292 | All Data Element Attributes | ADD | N/A | ELG292|ELG.023.292|SOGI-EFF-DATE|SOGI Effective Date|Mandatory|The first calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00023|SOGI|9(8)|11|345|352|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be "20" |
| 2024-04-12 | SOGI-END-DATE/ELG.023.293 | All Data Element Attributes | ADD | N/A | ELG293|ELG.023.293|SOGI-END-DATE|SOGI End Date|Mandatory|The last calendar day on which all the other data elements in the same segment were effective.|N/A|ELG00023|SOGI|9(8)|12|353|360|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [20,99] |
| 2024-04-12 | STATE-NOTATION/ELG.023.294 | All Data Element Attributes | ADD | N/A | ELG294|ELG.023.294|STATE-NOTATION|State Notation |Situational|A free text field for the submitting state to enter whatever information it chooses.|N/A|ELG00023|SOGI|X(500)|13|361|860|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 2024-04-12 | DATA-DICTIONARY-VERSION/FTX.001.002 | Coding Requirement; VVL | UPDATE | FTX002|FTX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
FTX002|FTX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|FTX00001|FILE-HEADER-RECORD-FTX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | FILE-NAME/FTX.001.006 | Definition | UPDATE | FTX006|FTX.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|FTX00001|FILE-HEADER-RECORD-FTX|X(8)|6|32|39|1. Value must equal 'FINTRANS' 2. Mandatory |
FTX006|FTX.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(8)|6|32|39|1. Value must equal "FINTRANS" 2. Mandatory |
| 2024-04-12 | ICN-ORIG/FTX.002.020 | Coding Requirement; Necessity | UPDATE | FTX020|FTX.002.020|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX020|FTX.002.020|ICN-ORIG|Original ICN|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 2024-04-12 | ICN-ADJ/FTX.002.021 | Coding Requirement | UPDATE | FTX021|FTX.002.021|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX021|FTX.002.021|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.002.022 | All Data Element Attributes | DELETE | FTX022|FTX.002.022|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.002.023 | Coding Requirement | UPDATE | FTX023|FTX.002.023|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX023|FTX.002.023|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | CHECK-EFF-DATE/FTX.002.026 | Coding Requirement | UPDATE | FTX026|FTX.002.026|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
FTX026|FTX.002.026|CHECK-EFF-DATE|Check Effective Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|9|144|151|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 2024-04-12 | PAYER-ID/FTX.002.028 | Coding Requirement; Definition | UPDATE | FTX028|FTX.002.028|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
FTX028|FTX.002.028|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.002.029 | Coding Requirement | UPDATE | FTX029|FTX.002.029|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX029|FTX.002.029|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 2024-04-12 | PAYEE-ID/FTX.002.033 | Coding Requirement; Definition | UPDATE | FTX033|FTX.002.033|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|17|451|480|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX033|FTX.002.033|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|16|401|430|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.002.034 | Coding Requirement | UPDATE | FTX034|FTX.002.034|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX034|FTX.002.034|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|17|431|432|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.002.038 | 0 | UPDATE | FTX038|FTX.002.038|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|22|685|714|1. Value must be 12 characters or less 2. Mandatory |
FTX038|FTX.002.038|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(30)|21|635|664|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | PAYEE-TAX-ID-TYPE/FTX.002.039 | 0 | UPDATE | FTX039|FTX.002.039|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|23|715|716|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
FTX039|FTX.002.039|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|22|665|666|1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.002.040 | 0 | UPDATE | FTX040|FTX.002.040|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|24|717|816|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
FTX040|FTX.002.040|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|23|667|766|1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/FTX.002.042 | Definition, Coding Requirement | UPDATE | FTX042|FTX.002.042|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(20)|26|917|936|1. Value must be 20 characters or less 2. Mandatory |
FTX042|FTX.002.042|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(20)|25|867|886|1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal 1, there must be a valid record of type Enrollment Time Span where the Capitation Period Start Date is equal to or greater than Enrollment Start Date and Capitation Period End Date is less than or equal to Enrollment End Date |
| 2024-04-12 | CATEGORY-FOR-FEDERAL-REIMBURSEMENT/FTX.002.045 | Coding Requirement; Necessity | UPDATE | FTX045|FTX.002.045|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category For Federal Reimbursement|Conditional|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|29|953|954|1. Value must be 2 characters 2. Value must be in CATEGORY-OF-FEDERAL-REIMBURSEMENT list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
FTX045|FTX.002.045|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|Category for Federal Reimbursement|Mandatory|A code to indicate the Federal funding source for the payment.|CATEGORY-FOR-FEDERAL-REIMBURSEMENT|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|28|903|904|1. Value must be 2 characters 2. Value must be in Category for Federal Reimbursement List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.002.046 | Coding Requirement; Definition, VVL | UPDATE | FTX046|FTX.002.046|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(5)|30|955|959|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
FTX046|FTX.002.046|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(5)|31|956|960|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. If Subcapitation Indicator equals "01", then value must be populated 12. Conditional 13. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 2024-04-12 | MBESCBES-FORM/FTX.002.047 | Coding Requirement; Definitions | UPDATE | FTX047|FTX.002.047|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|31|960|1009|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
FTX047|FTX.002.047|MBESCBES-FORM|MBESCBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(50)|30|906|955|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. If Subcapitation Indicator equals "01", then value must be populated 6. Conditional |
| 2024-04-12 | MBESCBES-FORM-GROUP/FTX.002.048 | Coding Requirement | UPDATE | FTX048|FTX.002.048|MBESCBES-FORM-GROUP|MBES or CBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to.|MBESCBES-FORM-GROUP|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|32|1010|1010|1. Value must be one character 2. Value must be in MBESCBES-FORM-GROUP list (VVL) 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
FTX048|FTX.002.048|MBESCBES-FORM-GROUP|MBESCBES Form Group|Conditional|Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).|MBESCBES-FORM-GROUP|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|29|905|905|1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 2024-04-12 | WAIVER-ID/FTX.002.049 | Coding Requirement | UPDATE | FTX049|FTX.002.049|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(20)|33|1011|1030|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must match Eligible Waiver ID (ELG.012.172) for the enrollee for the same time period 6. Conditional |
FTX049|FTX.002.049|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(20)|32|961|980|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | FUNDING-CODE/FTX.002.051 | Coding Requirement | UPDATE | FTX051|FTX.002.051|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds. |FUNDING-CODE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|35|1033|1034|1. Value must be in FUNDING-CODE list (VVL) 2. Value must be 2 character 3. Value must be populated if SUBCAPITATION-IND = '01' 4. Conditional |
FTX051|FTX.002.051|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|34|983|984|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
| 2024-04-12 | SPA-NUMBER/FTX.002.055 | Definition | UPDATE | FTX055|FTX.002.055|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(15)|39|1040|1054|1. Value must be 15 characters or less 2. Conditional |
FTX055|FTX.002.055|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(15)|38|990|1004|1. Value must be 15 characters or less 2. Conditional |
| 2024-04-12 | RECORD-ID/FTX.003.064 | Coding Requirement; VVL | UPDATE | FTX064|FTX.003.064|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00003" 4. Mandatory |
FTX064|FTX.003.064|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00003" |
| 2024-04-12 | ICN-ORIG/FTX.003.067 | Coding Requirement; Necessity | UPDATE | FTX067|FTX.003.067|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX067|FTX.003.067|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.003.068 | Coding Requirement | UPDATE | FTX068|FTX.003.068|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX068|FTX.003.068|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.003.069 | All Data Element Attributes | DELETE | FTX069|FTX.003.069|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.003.070 | Coding Requirement | UPDATE | FTX070|FTX.003.070|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX070|FTX.003.070|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.003.075 | Coding Requirement; Definition | UPDATE | FTX075|FTX.003.075|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. Mandatory |
FTX075|FTX.003.075|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.003.076 | Coding Requirement | UPDATE | FTX076|FTX.003.076|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX076|FTX.003.076|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) |
| 2024-04-12 | PAYEE-ID/FTX.003.078 | Coding Requirement; Definition | UPDATE | FTX078|FTX.003.078|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX078|FTX.003.078|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|14|299|328|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.003.079 | Coding Requirement | UPDATE | FTX079|FTX.003.079|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX079|FTX.003.079|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.003.081 | Coding Requirement; Definition | UPDATE | FTX081|FTX.003.081|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|18|481|510|1. Value must be 12 characters or less 2. Mandatory |
FTX081|FTX.003.081|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(30)|17|431|460|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | INSURANCE-CARRIER-ID-NUM/FTX.003.084 | Data Element Name Text | UPDATE | FTX084|FTX.003.084|INSURANCE-CARRIER-ID-NUM|Insurance Carrier ID Num|Mandatory| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(12)|21|613|624|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
FTX084|FTX.003.084|INSURANCE-CARRIER-ID-NUM|Insurance Carrier Identification Number|Mandatory| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(12)|20|563|574|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | INSURANCE-PLAN-ID/FTX.003.085 | Data Element Name Text | UPDATE | FTX085|FTX.003.085|INSURANCE-PLAN-ID|Insurance Plan ID|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|22|625|644|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
FTX085|FTX.003.085|INSURANCE-PLAN-ID|Insurance Plan Identifier|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|21|575|594|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/FTX.003.086 | Definition, Coding Requirement | UPDATE | FTX086|FTX.003.086|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|23|645|664|1. Value must be 20 characters or less 2. Mandatory |
FTX086|FTX.003.086|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|22|595|614|1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal 1, there must be a valid record of type Enrollment Time Span where the Payment Period Start Date is equal to or greater than Enrollment Start Date and Payment Period End Date is less than or equal to Enrollment End Date. |
| 2024-04-12 | MEMBER-ID/FTX.003.087 | Data Element Name Text | UPDATE | FTX087|FTX.003.087|MEMBER-ID|Member ID|Conditional|Member identification number as it appears on the card issued by the TPL insurance carrier.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|24|665|684|1. Value must be 20 characters or less 2. Conditional |
FTX087|FTX.003.087|MEMBER-ID|Member Identifier|Conditional|Member identification number as it appears on the card issued by the TPL insurance carrier.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|23|615|634|1. Value must be 20 characters or less 2. Conditional |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.003.091 | Coding Requirement; Definition; VVL | UPDATE | FTX091|FTX.003.091|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(5)|28|703|707|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX091|FTX.003.091|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(5)|29|704|708|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.003.092 | Coding Requirement; Definition | UPDATE | FTX092|FTX.003.092|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|29|708|757|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX092|FTX.003.092|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(50)|28|654|703|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.003.094 | Coding Requirement | UPDATE | FTX094|FTX.003.094|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|31|759|778|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must match Eligible Waiver ID (ELG.012.172) for the enrollee for the same time period 6. Conditional |
FTX094|FTX.003.094|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(20)|30|709|728|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | SPA-NUMBER/FTX.003.099 | Definition | UPDATE | FTX099|FTX.003.099|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(15)|36|787|801|1. Value must be 15 characters or less 2. Conditional |
FTX099|FTX.003.099|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types|N/A|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(15)|35|737|751|1. Value must be 15 characters or less 2. Conditional |
| 2024-04-12 | RECORD-ID/FTX.004.105 | Coding Requirement | UPDATE | FTX105|FTX.004.105|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00004" 4. Mandatory |
FTX105|FTX.004.105|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00004" |
| 2024-04-12 | ICN-ORIG/FTX.004.108 | Coding Requirement; Necessity | UPDATE | FTX108|FTX.004.108|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX108|FTX.004.108|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.004.109 | Coding Requirement | UPDATE | FTX109|FTX.004.109|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX109|FTX.004.109|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.004.110 | All Data Element Attributes | DELETE | FTX110|FTX.004.110|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.004.111 | Coding Requirement | UPDATE | FTX111|FTX.004.111|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX111|FTX.004.111|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.004.116 | Coding Requirement; Definition | UPDATE | FTX116|FTX.004.116|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. Mandatory |
FTX116|FTX.004.116|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.004.117 | Coding Requirement | UPDATE | FTX117|FTX.004.117|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX117|FTX.004.117|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) |
| 2024-04-12 | PAYEE-ID/FTX.004.119 | Coding Requirement; Definition | UPDATE | FTX119|FTX.004.119|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX119|FTX.004.119|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|14|299|328|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.004.120 | Coding Requirement | UPDATE | FTX120|FTX.004.120|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX120|FTX.004.120|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.004.122 | Coding Requirement; Definition | UPDATE | FTX122|FTX.004.122|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|18|481|510|1. Value must be 12 characters or less 2. Mandatory |
FTX122|FTX.004.122|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(30)|17|431|460|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | PAYEE-TAX-ID-TYPE/FTX.004.123 | Coding Requirement | UPDATE | FTX123|FTX.004.123|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|19|511|512|1. Value must be 2 characters 2. Value must be in PAYEE-TAX-ID-TYPE list (VVL) 3. Mandatory |
FTX123|FTX.004.123|PAYEE-TAX-ID-TYPE|Payee Tax ID Type|Mandatory|This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN.|PAYEE-TAX-ID-TYPE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|18|461|462|1. Value must be 2 characters 2. Value must be in Payee Tax ID Type List (VVL) 3. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.004.124 | Coding Requirement | UPDATE | FTX124|FTX.004.124|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(100)|20|513|612|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
FTX124|FTX.004.124|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(100)|19|463|562|1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 2024-04-12 | INSURANCE-CARRIER-ID-NUM/FTX.004.125 | Data Element Name Text | UPDATE | FTX125|FTX.004.125|INSURANCE-CARRIER-ID-NUM|Insurance Carrier ID Num|Mandatory| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(12)|21|613|624|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
FTX125|FTX.004.125|INSURANCE-CARRIER-ID-NUM|Insurance Carrier Identification Number|Mandatory|The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(12)|20|563|574|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | INSURANCE-PLAN-ID/FTX.004.126 | Data Element Name | UPDATE | FTX126|FTX.004.126|INSURANCE-PLAN-ID|Insurance Plan ID|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|22|625|644|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
FTX126|FTX.004.126|INSURANCE-PLAN-ID|Insurance Plan Identifier|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|21|575|594|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/FTX.004.127 | Definition, Coding Requirement | UPDATE | FTX127|FTX.004.127|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|23|645|664|1. Value must be 20 characters or less 2. Conditional 3. If value is not populated, then SSN must be populated. |
FTX127|FTX.004.127|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ MSIS-IDENTIFICATION-NUM is conditional in the FTX00004 segment because some members of a private group policy may not be eligible for Medicaid or CHIP, though at least one member of the group policy must be eligible for Medicaid or CHIP. There should be one FTX00004 segment for each member of the group policy for which the premium assistance payment is being paid, regardless of whether the member of the group policy was eligible for and enrolled in Medicaid or CHIP. |N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|22|595|614|1. Value must be 20 characters or less 2. Conditional 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal 1, there must be a valid record of type Enrollment Time Span where the Premium Period Start Date is equal to or greater than Enrollment Start Date and Premium Period End Date is less than or equal to Enrollment End Date |
| 2024-04-12 | SSN/FTX.004.128 | Coding Requirement; Definition | UPDATE | FTX128|FTX.004.128|SSN|SSN|Conditional|The eligible individual's social security number. For newborns when value is unknown it is not required. For SSN states, in instances where the social security number is not known and a temporary MSIS Identification Number is used, the MSIS Identification Number field should be populated |N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(9)|24|665|673|1. Value must be 9-digit number 2. For any individual, the value must be the same over all segment effective and end dates 3. (SSN State) if associated SSN Indicator (ELG.001.012) value is coded as "1", then value must equal MSIS Identification Number (ELG.002.019) value 4. Value can only be reported with one MSIS Identification Number (ELG.002.019) 5. Conditional 6. (Non-SSN State) if associated SSN Indicator (ELG.001.012) value is coded as "0", then value must not equal MSIS Identification Number (ELG.002.019) |
FTX128|FTX.004.128|SSN|SSN|Conditional|The SSN of the member of the group insurance policy. Each FTX00004 segment represents a different member of a given group insurance policy. Typically all members of the group insurance policy will have both an MSIS ID and an SSN. Under some circumstances, it’s possible that or more members of a group insurance policy do not have an MSIS ID, but do have an SSN, if they are included on the group insurance policy but not eligible for Medicaid or CHIP. It’s also possible that one or more members of a group insurance policy do not have an SSN. If a member of a group insurance policy does not have an SSN, leave this field blank.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(9)|23|615|623|1. Value must be 9-digit number 2. Conditional |
| 2024-04-12 | MEMBER-ID/FTX.004.129 | Data Element Name Text | UPDATE | FTX129|FTX.004.129|MEMBER-ID|Member ID|Conditional|Member identification number as it appears on the card issued by the TPL insurance carrier.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|25|674|693|1. Value must be 20 characters or less 2. Conditional |
FTX129|FTX.004.129|MEMBER-ID|Member Identifier|Conditional|Member identification number as it appears on the card issued by the TPL insurance carrier.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|24|624|643|1. Value must be 20 characters or less 2. Conditional |
| 2024-04-12 | POLICY-OWNER-CODE/FTX.004.131 | VVL | UPDATE | FTX131|FTX.004.131|POLICY-OWNER-CODE|Policy Owner Code|Conditional|This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary.|POLICY-OWNER-CODE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|27|710|711|1. Value must be 2 characters 2. Value must be in VVL 3. Conditional |
FTX131|FTX.004.131|POLICY-OWNER-CODE|Policy Owner Code|Conditional|This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary.|POLICY-OWNER-CODE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|26|660|661|1. Value must be 2 characters 2. Value must be in Policy Owner Code List (VVL) 3. Conditional |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.004.135 | Coding Requirement; Definition; VVL | UPDATE | FTX135|FTX.004.135|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(5)|31|730|734|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
FTX135|FTX.004.135|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Conditional|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(5)|32|731|735|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 11. If Policy Owner Code equals "01", then value must be populated 12. Conditional 13. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated |
| 2024-04-12 | MBESCBES-FORM/FTX.004.136 | Coding Requirement; Definition | UPDATE | FTX136|FTX.004.136|MBESCBES-FORM|MBES or CBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|32|735|784|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Value must be populated if POLICY-OWNER-CODE = '01' 4. Conditional |
FTX136|FTX.004.136|MBESCBES-FORM|MBESCBES Form|Conditional|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(50)|31|681|730|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. If Policy Owner Code equals "01", then value must be populated 6. Conditional |
| 2024-04-12 | WAIVER-ID/FTX.004.138 | Coding Requirement | UPDATE | FTX138|FTX.004.138|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|34|786|805|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Value must match Eligible Waiver ID (ELG.012.172) for the enrollee for the same time period 6. Conditional |
FTX138|FTX.004.138|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(20)|33|736|755|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | RECORD-ID/FTX.005.149 | Coding Requirement | UPDATE | FTX149|FTX.005.149|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00005|COST-SHARING-OFFSET|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00005" 4. Mandatory |
FTX149|FTX.005.149|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00005|COST-SHARING-OFFSET|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00005" |
| 2024-04-12 | ICN-ORIG/FTX.005.152 | Coding Requirement; Necessity | UPDATE | FTX152|FTX.005.152|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX152|FTX.005.152|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.005.153 | Coding Requirement | UPDATE | FTX153|FTX.005.153|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX153|FTX.005.153|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.005.154 | All Data Element Attributes | DELETE | FTX154|FTX.005.154|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00005|COST-SHARING-OFFSET|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.005.155 | Coding Requirement | UPDATE | FTX155|FTX.005.155|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00005|COST-SHARING-OFFSET|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX155|FTX.005.155|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00005|COST-SHARING-OFFSET|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.005.160 | Coding Requirement; Definition | UPDATE | FTX160|FTX.005.160|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. For beneficiary Cost Sharing Offset, the payee is always the state and the payee is always a beneficiary.|N/A|FTX00005|COST-SHARING-OFFSET|X(30)|12|217|246|1. Value must be 30 characters or less 2. Value must equal SUBMITTING-STATE (FTX00001) 5. Mandatory |
FTX160|FTX.005.160|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. For beneficiary Cost Sharing Offset, the payer is always the state and the payee is always a beneficiary.|N/A|FTX00005|COST-SHARING-OFFSET|X(30)|11|167|196|1. Value must be 30 characters or less 2. Value must equal Submitting State (FTX.001.007) 3. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.005.161 | Coding Requirement | UPDATE | FTX161|FTX.005.161|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX161|FTX.005.161|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00005|COST-SHARING-OFFSET|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) |
| 2024-04-12 | PAYEE-ID/FTX.005.163 | Definition | UPDATE | FTX163|FTX.005.163|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. For beneficiary Cost Sharing Offset, the beneficiary is always the payee. |N/A|FTX00005|COST-SHARING-OFFSET|X(30)|15|349|378|1. Value must be 30 characters or less 2. Value must equal MSIS-IDENTIFICATION-NUM (ELG00002) 3. Mandatory |
FTX163|FTX.005.163|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. For beneficiary Cost Sharing Offset, the beneficiary is always the payee. |N/A|FTX00005|COST-SHARING-OFFSET|X(30)|14|299|328|1. Value must be 30 characters or less 2. Value must equal MSIS Identification Number (ELG.002.019) 3. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.005.164 | Coding Requirement | UPDATE | FTX164|FTX.005.164|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00005|COST-SHARING-OFFSET|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX164|FTX.005.164|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00005|COST-SHARING-OFFSET|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.005.168 | Coding Requirement | UPDATE | FTX168|FTX.005.168|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00005|COST-SHARING-OFFSET|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
FTX168|FTX.005.168|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00005|COST-SHARING-OFFSET|X(30)|19|533|562|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.005.170 | Coding Requirement | UPDATE | FTX170|FTX.005.170|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
FTX170|FTX.005.170|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00005|COST-SHARING-OFFSET|X(100)|21|565|664|1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 2024-04-12 | INSURANCE-PLAN-ID/FTX.005.172 | Data Element Name Text | UPDATE | FTX172|FTX.005.172|INSURANCE-PLAN-ID|Insurance Plan ID|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00005|COST-SHARING-OFFSET|X(20)|24|815|834|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
FTX172|FTX.005.172|INSURANCE-PLAN-ID|Insurance Plan Identifier|Conditional|The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card.|N/A|FTX00005|COST-SHARING-OFFSET|X(20)|23|765|784|1. Value must not contain a pipe or asterisk symbol 2. Value must be 20 characters or less 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/FTX.005.173 | Definition, Coding Requirement | UPDATE | FTX173|FTX.005.173|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00005|COST-SHARING-OFFSET|X(20)|25|835|854|1. Value must be 20 characters or less 2. Mandatory |
FTX173|FTX.005.173|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |N/A|FTX00005|COST-SHARING-OFFSET|X(20)|24|785|804|1. Value must be 20 characters or less 2. Mandatory 3. Value must match MSIS Identification Number (ELG.021.019) 4. When Adjustment Indicator does not equal 1, there must be a valid record of type Enrollment Time Span where the Coverage Period Start Date is equal to or greater than Enrollment Start Date and Coverage Period End Date is less than or equal to Enrollment End Date |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.005.177 | Coding Requirement; Description; Valid Value Code Set | UPDATE | FTX177|FTX.005.177|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00005|COST-SHARING-OFFSET|X(5)|29|873|877|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX177|FTX.005.177|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|221.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00005|COST-SHARING-OFFSET|X(5)|30|874|878|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.005.178 | Coding Requirement; Definition | UPDATE | FTX178|FTX.005.178|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00005|COST-SHARING-OFFSET|X(50)|30|878|927|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX178|FTX.005.178|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00005|COST-SHARING-OFFSET|X(50)|29|824|873|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.005.180 | Coding Requirement | UPDATE | FTX180|FTX.005.180|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00005|COST-SHARING-OFFSET|X(20)|32|929|948|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
FTX180|FTX.005.180|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00005|COST-SHARING-OFFSET|X(20)|31|879|898|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | SPA-NUMBER/FTX.005.186 | Definition | UPDATE | FTX186|FTX.005.186|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00005|COST-SHARING-OFFSET|X(15)|38|958|972|1. Value must be 15 characters or less 2. Conditional |
FTX186|FTX.005.186|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types|N/A|FTX00005|COST-SHARING-OFFSET|X(15)|37|908|922|1. Value must be 15 characters or less 2. Conditional |
| 2024-04-12 | RECORD-ID/FTX.006.192 | Coding Requirement | UPDATE | FTX192|FTX.006.192|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00006|VALUE-BASED-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00006" 4. Mandatory |
FTX192|FTX.006.192|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00006|VALUE-BASED-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00005" |
| 2024-04-12 | ICN-ORIG/FTX.006.195 | Coding Requirement; Necessity | UPDATE | FTX195|FTX.006.195|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX195|FTX.006.195|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.006.196 | Coding Requirement | UPDATE | FTX196|FTX.006.196|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX196|FTX.006.196|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.006.197 | All Data Element Attributes | DELETE | FTX197|FTX.006.197|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.006.198 | Coding Requirement | UPDATE | FTX198|FTX.006.198|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00006|VALUE-BASED-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX198|FTX.006.198|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00006|VALUE-BASED-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.006.203 | Coding Requirement; Definition | UPDATE | FTX203|FTX.006.203|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
FTX203|FTX.006.203|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.006.204 | Coding Requirement | UPDATE | FTX204|FTX.006.204|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX204|FTX.006.204|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00006|VALUE-BASED-PAYMENT|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 2024-04-12 | PAYEE-ID/FTX.006.206 | Coding Requirement | UPDATE | FTX206|FTX.006.206|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX206|FTX.006.206|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|14|299|328|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.006.207 | Coding Requirement | UPDATE | FTX207|FTX.006.207|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00006|VALUE-BASED-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX207|FTX.006.207|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00006|VALUE-BASED-PAYMENT|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.006.211 | Coding Requirement; Definition | UPDATE | FTX211|FTX.006.211|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
FTX211|FTX.006.211|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(30)|19|533|562|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/FTX.006.215 | Definition, Coding Requirement | UPDATE | FTX215|FTX.006.215|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00006|VALUE-BASED-PAYMENT|X(20)|24|815|834|1. Value must be 20 characters or less 2. Conditional |
FTX215|FTX.006.215|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |N/A|FTX00006|VALUE-BASED-PAYMENT|X(20)|23|765|784|1. Value must be 20 characters or less 2. Conditional 3. When populated, value must match MSIS Identification Number (ELG.002.019) 4. When Adjustment Indicator does not equal 1, there must be a valid record of type Enrollment Time Span where the Performance Period Start Date is equal to or greater than Enrollment Start Date and Performance Period End Date is less than or equal to Enrollment End Date |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.006.219 | Coding Requirement; Definition; VVL | UPDATE | FTX219|FTX.006.219|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00006|VALUE-BASED-PAYMENT|X(5)|28|853|857|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX219|FTX.006.219|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00006|VALUE-BASED-PAYMENT|X(5)|29|854|858|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.006.220 | Coding Requirement; Definition | UPDATE | FTX220|FTX.006.220|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00006|VALUE-BASED-PAYMENT|X(50)|29|858|907|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX220|FTX.006.220|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00006|VALUE-BASED-PAYMENT|X(50)|28|804|853|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.006.222 | Coding Requirement | UPDATE | FTX222|FTX.006.222|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(20)|31|909|928|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
FTX222|FTX.006.222|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00006|VALUE-BASED-PAYMENT|X(20)|30|859|878|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | SPA-NUMBER/FTX.006.228 | Definition | UPDATE | FTX228|FTX.006.228|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00006|VALUE-BASED-PAYMENT|X(15)|37|938|952|1. Value must be 15 characters or less 2. Conditional |
FTX228|FTX.006.228|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types|N/A|FTX00006|VALUE-BASED-PAYMENT|X(15)|36|888|902|1. Value must be 15 characters or less 2. Conditional |
| 2024-04-12 | RECORD-ID/FTX.007.236 | Coding Requirement; VVL | UPDATE | FTX236|FTX.007.236|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00007" 4. Mandatory |
FTX236|FTX.007.236|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00007" |
| 2024-04-12 | ICN-ORIG/FTX.007.239 | Coding Requirement; Necessity | UPDATE | FTX239|FTX.007.239|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX239|FTX.007.239|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.007.240 | Coding Requirement | UPDATE | FTX240|FTX.007.240|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX240|FTX.007.240|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.007.241 | All Data Element Attributes | DELETE | FTX241|FTX.007.241|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.007.242 | Coding Requirement | UPDATE | FTX242|FTX.007.242|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX242|FTX.007.242|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.007.247 | Coding Requirement; Definition | UPDATE | FTX247|FTX.007.247|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
FTX247|FTX.007.247|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.007.248 | Coding Requirement | UPDATE | FTX248|FTX.007.248|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX248|FTX.007.248|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 2024-04-12 | PAYEE-ID/FTX.007.250 | Coding Requirement | UPDATE | FTX250|FTX.007.250|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX250|FTX.007.250|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(30)|14|299|328|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.007.251 | Coding Requirement | UPDATE | FTX251|FTX.007.251|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX251|FTX.007.251|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.007.257 | Coding Requirement | UPDATE | FTX257|FTX.007.257|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
FTX257|FTX.007.257|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(100)|21|565|664|1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 2024-04-12 | PAYMENT-PERIOD-START-DATE/FTX.007.259 | Coding Requirement; Data Element Name Text; Definition | UPDATE | FTX259|FTX.007.259|PAYMENT-PERIOD-BEGIN-DATE|Payment Period Begin Date|Mandatory|The date representing the beginning of the time period that the payment is expected to be used by the provider. |N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|24|815|822|1. Value must be 8 characters in the form “CCYYMMDD” 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated PAYMENT-PERIOD-END-DATE 4. Value of the CC component must be in ['19', '20'] 5. Mandatory |
FTX259|FTX.007.259|PAYMENT-PERIOD-START-DATE|Payment Period Start Date|Mandatory|The date representing the start of the time period that the payment is expected to be used by the provider. |N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|23|765|772|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to 20 |
| 2024-04-12 | PAYMENT-PERIOD-TYPE/FTX.007.261 | Coding Requirement; Necessity; VVL | UPDATE | FTX261|FTX.007.261|PAYMENT-PERIOD-TYPE|Payment Period Type|Conditional|A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment.|PAYMENT-PERIOD-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|26|831|832|1. Value must be 2 characters 2. Value must be in PAYMENT-PERIOD-TYPE list 3. Conditional |
FTX261|FTX.007.261|PAYMENT-PERIOD-TYPE|Payment Period Type|Mandatory|A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment.|PAYMENT-PERIOD-TYPE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|25|781|782|1. Value must be 2 characters 2. Value must be in Payment Period Type List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.007.264 | Coding Requirement; Definition; VVL | UPDATE | FTX264|FTX.007.264|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(5)|29|935|939|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX264|FTX.007.264|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(5)|30|936|940|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.007.265 | Coding Requirement; Definition | UPDATE | FTX265|FTX.007.265|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|30|940|989|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX265|FTX.007.265|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(50)|29|886|935|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.007.267 | Coding Requirement | UPDATE | FTX267|FTX.007.267|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(20)|32|991|1010|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
FTX267|FTX.007.267|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(20)|31|941|960|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | RECORD-ID/FTX.008.279 | Coding Requirement | UPDATE | FTX279|FTX.008.279|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00008|COST-SETTLEMENT-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00008" 4. Mandatory |
FTX279|FTX.008.279|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00008|COST-SETTLEMENT-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00008" |
| 2024-04-12 | ICN-ORIG/FTX.008.282 | Coding Requirement; Necessity | UPDATE | FTX282|FTX.008.282|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX282|FTX.008.282|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.008.283 | Coding Requirement | UPDATE | FTX283|FTX.008.283|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX283|FTX.008.283|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.008.284 | All Data Element Attributes | DELETE | FTX284|FTX.008.284|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.008.284 | All Data Element Attributes | DELETE | FTX284|FTX.008.284|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.008.285 | Coding Requirement | UPDATE | FTX285|FTX.008.285|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00008|COST-SETTLEMENT-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX285|FTX.008.285|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00008|COST-SETTLEMENT-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | CHECK-EFF-DATE/FTX.008.288 | Coding Requirement | UPDATE | FTX288|FTX.008.288|CHECK-EFF-DATE|Check Eff Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|10|194|201|1. Value must be 8 digits in the form "CCYYMMDD" 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Must have an associated Check Number 4. Conditional |
FTX288|FTX.008.288|CHECK-EFF-DATE|Check Effective Date|Conditional|The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|9|144|151|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Must have an associated Check Number 3. Conditional 4. Value of the CC component must be equal to "20" |
| 2024-04-12 | PAYER-ID/FTX.008.290 | Coding Requirement; Definition | UPDATE | FTX290|FTX.008.290|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
FTX290|FTX.008.290|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.008.291 | Coding Requirement | UPDATE | FTX291|FTX.008.291|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX291|FTX.008.291|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 2024-04-12 | PAYEE-ID/FTX.008.293 | Coding Requirement | UPDATE | FTX293|FTX.008.293|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX293|FTX.008.293|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|14|299|328|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.008.294 | Coding Requirement | UPDATE | FTX294|FTX.008.294|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX294|FTX.008.294|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.008.298 | Coding Requirement; Definition | UPDATE | FTX298|FTX.008.298|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
FTX298|FTX.008.298|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(30)|19|533|562|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | PAYEE-TAX-ID-TYPE-OTHER-TEXT/FTX.008.300 | Coding Requirement | UPDATE | FTX300|FTX.008.300|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|22|615|714|1. Value must be 100 characters or less 2. PAYEE-TAX-ID-TYPE must = '95' 3. Conditional |
FTX300|FTX.008.300|PAYEE-TAX-ID-TYPE-OTHER-TEXT|Payee Tax ID Type Other Text|Conditional|This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other".|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(100)|21|565|664|1. Value must be 100 characters or less 2. Value must be populated when Payee Tax Identifier Type equals "95" 3. Conditional |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.008.304 | Coding Requirement; Definition; VVL | UPDATE | FTX304|FTX.008.304|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00008|COST-SETTLEMENT-PAYMENT|X(5)|26|733|737|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX304|FTX.008.304|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00008|COST-SETTLEMENT-PAYMENT|X(5)|27|734|738|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.008.305 | Coding Requirement; Definition | UPDATE | FTX305|FTX.008.305|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|27|738|787|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX305|FTX.008.305|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00008|COST-SETTLEMENT-PAYMENT|X(50)|26|684|733|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.008.307 | Coding Requirement | UPDATE | FTX307|FTX.008.307|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(20)|29|789|808|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
FTX307|FTX.008.307|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(20)|28|739|758|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | SPA-NUMBER/FTX.008.312 | Definition | UPDATE | FTX312|FTX.008.312|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(15)|34|817|831|1. Value must be 15 characters or less 2. Conditional |
FTX312|FTX.008.312|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types|N/A|FTX00008|COST-SETTLEMENT-PAYMENT|X(15)|33|767|781|1. Value must be 15 characters or less 2. Conditional |
| 2024-04-12 | RECORD-ID/FTX.009.318 | Coding Requirement | UPDATE | FTX318|FTX.009.318|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00009| FQHC-WRAP-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00009" 4. Mandatory |
FTX318|FTX.009.318|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00009|FQHC-WRAP-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00009" |
| 2024-04-12 | ICN-ORIG/FTX.009.321 | Coding Requirement; Necessity | UPDATE | FTX321|FTX.009.321|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX321|FTX.009.321|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00009|FQHC-WRAP-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.009.322 | Coding Requirement | UPDATE | FTX322|FTX.009.322|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX322|FTX.009.322|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00009|FQHC-WRAP-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.009.323 | All Data Element Attributes | DELETE | FTX323|FTX.009.323|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.009.324 | Coding Requirement | UPDATE | FTX324|FTX.009.324|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00009| FQHC-WRAP-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX324|FTX.009.324|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00009|FQHC-WRAP-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.009.329 | Coding Requirement; Definition | UPDATE | FTX329|FTX.009.329|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
FTX329|FTX.009.329|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00009|FQHC-WRAP-PAYMENT|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.009.330 | Coding Requirement | UPDATE | FTX330|FTX.009.330|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00009| FQHC-WRAP-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX330|FTX.009.330|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00009|FQHC-WRAP-PAYMENT|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 2024-04-12 | PAYEE-ID/FTX.009.332 | Coding Requirement | UPDATE | FTX332|FTX.009.332|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(30)|15|349|378|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX332|FTX.009.332|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00009|FQHC-WRAP-PAYMENT|X(30)|14|299|328|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.009.333 | Coding Requirement | UPDATE | FTX333|FTX.009.333|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00009| FQHC-WRAP-PAYMENT|X(2)|16|379|380|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX333|FTX.009.333|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00009|FQHC-WRAP-PAYMENT|X(2)|15|329|330|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.009.337 | Coding Requirement; Definition | UPDATE | FTX337|FTX.009.337|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(30)|20|583|612|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
FTX337|FTX.009.337|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00009|FQHC-WRAP-PAYMENT|X(30)|19|533|562|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.009.343 | Coding Requirement; Definition; VVL | UPDATE | FTX343|FTX.009.343|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00009| FQHC-WRAP-PAYMENT|X(5)|26|733|737|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX343|FTX.009.343|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00009|FQHC-WRAP-PAYMENT|X(5)|27|734|738|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.009.344 | Coding Requirement; Definition | UPDATE | FTX344|FTX.009.344|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00009| FQHC-WRAP-PAYMENT|X(50)|27|738|787|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX344|FTX.009.344|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00009|FQHC-WRAP-PAYMENT|X(50)|26|684|733|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.009.346 | Coding Requirement | UPDATE | FTX346|FTX.009.346|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00009| FQHC-WRAP-PAYMENT|X(20)|29|789|808|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
FTX346|FTX.009.346|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00009|FQHC-WRAP-PAYMENT|X(20)|28|739|758|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | RECORD-ID/FTX.095.357 | Coding Requirement | UPDATE | FTX357|FTX.095.357|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00095 |MISCELLANEOUS-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Value must be in RECORD-ID list (VVL) 3. Value must equal "FTX00095" 4. Mandatory |
FTX357|FTX.095.357|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|FTX00095 |MISCELLANEOUS-PAYMENT|X(8)|1|1|8|1. Value must be exactly 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "FTX00095" |
| 2024-04-12 | ICN-ORIG/FTX.095.360 | Coding Requirement; Necessity | UPDATE | FTX360|FTX.095.360|ICN-ORIG|ICN Orig|Conditional|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ORIG must not be populated 4. Conditional |
FTX360|FTX.095.360|ICN-ORIG|Original ICN|Mandatory|A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|4|22|71|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory |
| 2024-04-12 | ICN-ADJ/FTX.095.361 | Coding Requirement | UPDATE | FTX361|FTX.095.361|ICN-ADJ|ICN Adj|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If UNIQUE-TRANSACTION-ID is populated, ICN-ADJ must not be populated 4. Conditional |
FTX361|FTX.095.361|ICN-ADJ|Adjustment ICN|Conditional|A unique claim/transaction number assigned by the state’s payment system that identifies the adjustment claim/transaction for an original item control number.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|5|72|121|1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value equals "0", then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value equals "4", then value must be populated |
| 2024-04-12 | UNIQUE-TRANSACTION-ID/FTX.095.362 | All Data Element Attributes | DELETE | FTX362|FTX.095.362|UNIQUE-TRANSACTION-ID|Unique Transaction ID|Conditional|For transactions that are not assigned an ICN-ORIG or ICN-ADJ in the MMIS, this unique transaction ID distinguishes this transaction from all other transactions in T-MSIS.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|6|122|171|1. Value must be 50 characters or less 2. If ICN-ORIG or ICN-ADJ are populated, UNIQUE-TRANSACTION-ID must not be populated 3. Conditional |
N/A |
| 2024-04-12 | ADJUSTMENT-IND/FTX.095.363 | Coding Requirement | UPDATE | FTX363|FTX.095.363|ADJUSTMENT-IND|Adjustment Ind|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|7|172|172|1. Value must be 1 character 2. Value must be in ADJUSTMENT-IND list (VVL) 3. If UNIQUE-TRANSACTION-ID is populated, ADJUSTMENT-IND must not be populated 4. Conditional |
FTX363|FTX.095.363|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
| 2024-04-12 | PAYER-ID/FTX.095.368 | Coding Requirement; Definition | UPDATE | FTX368|FTX.095.368|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|12|217|246|1. Value must be 30 characters or less 2. If PAYER-ID-TYPE = '01' then PAYER-ID = SUBMITTING-STATE (FTX00001) 3. If PAYER-ID-TYPE = '02' then PAYER-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYER-ID-TYPE = '04' then PAYER-ID = SUBMITTING-STATE-PROV-ID (PRV00002) 5. Mandatory |
FTX368|FTX.095.368|PAYER-ID|Payer ID|Mandatory|This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|11|167|196|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYER-ID-TYPE/FTX.095.369 | Coding Requirement | UPDATE | FTX369|FTX.095.369|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|13|247|248|1. Value must be 2 characters 2. Value must be in PAYER-ID-TYPE list (VVL) 3. Mandatory |
FTX369|FTX.095.369|PAYER-ID-TYPE|Payer ID Type|Mandatory|This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code.|PAYER-ID-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|12|197|198|1. Value must be 2 characters 2. Value must be in Payer ID Type List (VVL) 3. Mandatory 4. When value equals "01" then Payer ID must equal Submitting State (FTX.001.007) 5. When value equals "02" then Payer ID must equal State Plan Identification Number (MCR.002.019) 6. When value equals "04" then Payer ID must equal must equal Submitting State Provider Identifier (PRV.002.019) |
| 2024-04-12 | PAYEE-ID/FTX.095.373 | Coding Requirement | UPDATE | FTX373|FTX.095.373|PAYEE-ID|Payee ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|17|451|480|1. Value must be 30 characters or less 2. If PAYEE-ID-TYPE = '01' then PAYEE-ID = SUBMITTING-STATE (FTX00001) 3. If PAYEE-ID-TYPE = '02' then PAYEE-ID = STATE-PLAN-ID-NUM (MCR00002) 4. If PAYEE-ID-TYPE = '04' or '05' then PAYEE-ID = SUBMITTING-STATE-PROV-ID (PRV0002) 6. If PAYEE-ID-TYPE = '06' then PAYEE-ID = PROV-IDENTIFIER where PROV-IDENTIFIER-TYPE = 2 (PRV00005) 7. If PAYEE-ID-TYPE = '07' then PAYEE-ID = INSURANCE-CARRIER-ID-NUM (TPL00006) 8. If PAYER-ID-TYPE = '08' then PAYEE-ID = MSIS-IDENTIFICATION-NUM (ELG00002) 9. Mandatory |
FTX373|FTX.095.373|PAYEE-ID|Payee Identfier|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|16|401|430|1. Value must be 30 characters or less 2. Mandatory |
| 2024-04-12 | PAYEE-ID-TYPE /FTX.095.374 | Coding Requirement | UPDATE | FTX374|FTX.095.374|PAYEE-ID-TYPE |Payee ID Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|18|481|482|1. Value must be 2 characters 2. Value must be in PAYEE-ID-TYPE list (VVL) 3. Mandatory |
FTX374|FTX.095.374|PAYEE-ID-TYPE |Payee Identifier Type|Mandatory|This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID.|PAYEE-ID-TYPE |FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|17|431|432|1. Value must be 2 characters 2. Value must be in Payee Identifier Type List (VVL) 3. If value equals "01", then Payee Identifier must equal Submitting State (FTX.001.007) 4. If value equals "02", then Payee Identifier must equal State Plan Identification Number (MCR.002.019) 5. If value in [04,05], then Payee Identifier must equal Submitting State Provider Identifier (PRV.002.019) 6. If value equals "06", then Payee Identifier must equal Provider Identifier (PRV.005.081) where Provider Identifier Type (PRV.005.077) equals "2" 7. If value equals "07", then Payee Identifier must equal Insurance Carrier Identification Number (TPL.006.075) 8. If value equals "08", then Payee Identifier must equal MSIS Identification Number (ELG.002.019) 9. Mandatory |
| 2024-04-12 | PAYEE-TAX-ID/FTX.095.378 | Coding Requirement; Definition | UPDATE | FTX378|FTX.095.378|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|22|685|714|1. Value must be 12 characters or less 2. Mandatory 3. Value must meet requirements of SSN if PAYEE-ID-TYPE = '01' |
FTX378|FTX.095.378|PAYEE-TAX-ID|Payee Tax ID|Mandatory|This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(30)|21|635|664|1. Value must be 30 characters or less 2. Mandatory 3. If Payee Tax ID Type equals "01", then value must be 9-digits and meet the requirements of a valid SSN per SSA requirements |
| 2024-04-12 | INSURANCE-CARRIER-ID-NUM/FTX.095.382 | Coding Requirement | UPDATE | FTX382|FTX.095.382|INSURANCE-CARRIER-ID-NUM|Insurance Carrier ID Num|Conditional| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(12)|26|917|928|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
FTX382|FTX.095.382|INSURANCE-CARRIER-ID-NUM|Insurance Carrier Identification Number|Conditional| The state-assigned identification number of the Third Party Liability (TPL) Entity.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(12)|25|867|878|1. Value must be 12 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Conditional |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/FTX.095.383 | Definition, Coding Requirement | UPDATE | FTX383|FTX.095.383|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(20)|27|929|948|1. Value must be 20 characters or less 2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN 3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN 4. Conditional |
FTX383|FTX.095.383|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Conditional|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique “key” value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(20)|26|879|898|1. Value must be 20 characters or less 2. Conditional 3. When populated, value must match MSIS Identification Number (ELG.002.019) 4. When Adjustment Indicator does not equal 1, there must be a valid record of type Enrollment Time Span where the Payment Period Start Date is equal to or greater than Enrollment Start Date and Period Period End Date is less than or equal to Enrollment End Date |
| 2024-04-12 | PAYMENT-PERIOD-TYPE/FTX.095.386 | Coding Requirement; Necessity | UPDATE | FTX386|FTX.095.386|PAYMENT-PERIOD-TYPE|Payment Period Type|Conditional|A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment.|PAYMENT-PERIOD-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|30|965|966|1. Value must be 2 characters 2. Value must be in PAYMENT-PERIOD-TYPE list 3. Conditional |
FTX386|FTX.095.386|PAYMENT-PERIOD-TYPE|Payment Period Type|Mandatory|A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment.|PAYMENT-PERIOD-TYPE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|29|915|916|1. Value must be 2 characters 2. Value must be in Payment Period Type List (VVL) 3. Mandatory |
| 2024-04-12 | MBESCBES-CATEGORY-OF-SERVICE/FTX.095.391 | Coding Requirement; Definition; VVL | UPDATE | FTX391|FTX.095.391|MBESCBES-CATEGORY-OF-SERVICE|MBES or CBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS) that states use to report their expenditures and request federal financial participation.|MBESCBES-CATEGORY-OF-SERVICE (XIX), MBESCBES-CATEGORY-OF-SERVICE (XXI)|FTX00095 |MISCELLANEOUS-PAYMENT|X(5)|35|1171|1175|1. Value must be in XIX-MBESCBES-CATEGORY-OF-SERVICE or XXI-MBESCBES-CATEGORY-OF-SERVICE lists (VVLs) 2. Value must be 5 characters or less 3. Mandatory |
FTX391|FTX.095.391|MBESCBES-CATEGORY-OF-SERVICE|MBESCBES Category of Service|Mandatory|A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.|21.P-FORM, 21BASE-FORM, 64.21U-FORM, 64.10BASE-FORM, 64.9P-FORM, 64.9A-FORM, 64.9BASE-FORM, 64.21UP-FORM|FTX00095 |MISCELLANEOUS-PAYMENT|X(5)|36|1172|1176|1. Value must be 5 characters or less 2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL) 3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL) 4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL) 5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL) 6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL) 7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL) 8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL) 9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL) 10. Mandatory |
| 2024-04-12 | MBESCBES-FORM/FTX.095.392 | Coding Requirement; Definition | UPDATE | FTX392|FTX.095.392|MBESCBES-FORM|MBES or CBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, 64.9 WAIVER OTHER ARP 9815 URBAN INDIAN HEALTH ORGS). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|36|1176|1225|1. Value must be 50 characters or less 2. Value must be in MBES or CBES Form list (VVL) 3. Mandatory |
FTX392|FTX.095.392|MBESCBES-FORM|MBESCBES Form|Mandatory|The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.|MBESCBES-FORM|FTX00095 |MISCELLANEOUS-PAYMENT|X(50)|35|1122|1171|1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 List (VVL) 5. Mandatory |
| 2024-04-12 | WAIVER-ID/FTX.095.394 | Coding Requirement | UPDATE | FTX394|FTX.095.394|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(20)|38|1227|1246|1. Value must be associated with a populated WAIVER-TYPE 2. Value must be 20 characters or less 3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33] 5. Conditional |
FTX394|FTX.095.394|WAIVER-ID|Waiver ID|Conditional|Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(20)|37|1177|1196|1. Value must be 20 characters or less 2. Value must be associated with a populated Waiver Type 3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30] 4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Waiver Type value must be in [02-20,32,33] 6. Conditional |
| 2024-04-12 | SPA-NUMBER/FTX.095.400 | Definition | UPDATE | FTX400|FTX.095.400|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an optional entry for specific SPA types|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(15)|44|1256|1270|1. Value must be 15 characters or less 2. Conditional |
FTX400|FTX.095.400|SPA-NUMBER|SPA Number|Conditional|State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. The system will not permit reuse of a previously used SPA ID for a package that has been formally submitted; xxxx = an Situational entry for specific SPA types|N/A|FTX00095 |MISCELLANEOUS-PAYMENT|X(15)|43|1206|1220|1. Value must be 15 characters or less 2. Conditional |
| 2024-04-12 | DATA-DICTIONARY-VERSION/MCR.001.002 | Coding Requirement | UPDATE | MCR002|MCR.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|DATA-DICTIONARY-VERSION|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
MCR002|MCR.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | FILE-NAME/MCR.001.006 | Definition | UPDATE | MCR006|MCR.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(8)|6|32|39|1. Value must equal 'MNGDCARE' 2. Mandatory |
MCR006|MCR.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(8)|6|32|39|1. Value must equal "MNGDCARE" 2. Mandatory |
| 2024-04-12 | DATE-FILE-CREATED/MCR.001.008 | Coding Requirement | UPDATE | MCR008|MCR.001.008|DATE-FILE-CREATED|Date File Created|Mandatory|The date on which the file was created.|N/A|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|9(8)|8|42|49|1. Value of the CC component must be "20" 2. Value must be 8 characters in the form "CCYYMMDD" 3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 4. Value must be less than current date 5. Value must be equal to or after the value of associated End of Time Period 6. Mandatory |
MCR008|MCR.001.008|DATE-FILE-CREATED|Date File Created|Mandatory|The date on which the file was created.|N/A|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|9(8)|8|42|49|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 2024-04-12 | MANAGED-CARE-CONTRACT-EFF-DATE/MCR.002.020 | Coding Requirement | UPDATE | MCR020|MCR.002.020|MANAGED-CARE-CONTRACT-EFF-DATE|Managed Care Contract Effective Date|Mandatory|The start date of the managed care contract period with the state. |N/A|MCR00002|MANAGED-CARE-MAIN|9(8)|5|34|41|1. Value must be 8 characters in the form 'CCYYMMDD' 2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 3. Value must be before or the same as the associated Segment End Date value 4. Mandatory 5. Value of the CC component must be in ['18','19,'20'] 6. Mandatory 7. Value must occur before Managed Care Contract End Date (MCR.002.021) |
MCR020|MCR.002.020|MANAGED-CARE-CONTRACT-EFF-DATE|Managed Care Contract Effective Date|Mandatory|The start date of the managed care contract period with the state.|N/A|MCR00002|MANAGED-CARE-MAIN|9(8)|5|34|41|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value must occur before Managed Care Contract End Date (MCR.002.021) |
| 2024-04-12 | MANAGED-CARE-PLAN-TYPE/MCR.002.024 | Definition | UPDATE | MCR024|MCR.002.024|MANAGED-CARE-PLAN-TYPE|Managed Care Plan Type|Mandatory|The type of managed care plan that corresponds to the State Plan Identification Number. The value reported in this data element should match the Managed Care Plan Type value reported on the Eligible file for the corresponding managed care plan number. Assign plan type value "15" for plans that primarily cover non-emergency medical transportation (NEMT). See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47540 See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47564|MANAGED-CARE-PLAN-TYPE|MCR00002|MANAGED-CARE-MAIN|X(2)|9|106|107|1. Value must be in Managed Care Plan Type List (VVL) 2. Value must be 2 characters 3. Mandatory |
MCR024|MCR.002.024|MANAGED-CARE-PLAN-TYPE|Managed Care Plan Type|Mandatory|The type of managed care plan that corresponds to the State Plan Identification Number. The value reported in this data element should match the Managed Care Plan Type value reported on the Eligible file for the corresponding managed care plan number. Assign plan type value "15" for plans that primarily cover non-emergency medical transportation (NEMT). See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/|MANAGED-CARE-PLAN-TYPE|MCR00002|MANAGED-CARE-MAIN|X(2)|9|106|107|1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. Mandatory |
| 2024-04-12 | PERCENT-BUSINESS/MCR.002.028 | Coding Requirement | UPDATE | MCR028|MCR.002.028|PERCENT-BUSINESS|Percent Business|Mandatory|The percentage of the managed care entity's total revenue that is derived from contracts with Medicare (Part C and D) in the state and State Medicaid agency contract(s) prior calendar year. Include Medicaid and Medicare in calculation of percentage of business in public programs for IRS health insurer tax exemption as required in ACA.|N/A|MCR00002|MANAGED-CARE-MAIN|9(3)|13|113|115|1. Value must be between 0 and 100 inclusively 2. Mandatory |
MCR028|MCR.002.028|PERCENT-BUSINESS|Percent Business|Mandatory|The percentage of the managed care entity's total revenue that is derived from contracts with Medicare (Part C and D) in the state and State Medicaid agency contract(s) prior calendar year. Include Medicaid and Medicare in calculation of percentage of business in public programs for IRS health insurer tax exemption as required in ACA.|N/A|MCR00002|MANAGED-CARE-MAIN|9(3)|13|113|115|1. Value must be between 000 and 100 inclusively 2. Mandatory |
| 2024-04-12 | MANAGED-CARE-SERVICE-AREA/MCR.002.029 | Definition | UPDATE | MCR029|MCR.002.029|MANAGED-CARE-SERVICE-AREA|Managed Care Service Area|Mandatory|Identifies the geographic unit under which the managed care entity is under contract to provide services. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47542|MANAGED-CARE-SERVICE-AREA|MCR00002|MANAGED-CARE-MAIN|X(1)|14|116|116|1. Value must be in Managed Care Service Area List (VVL) 2. Value must be 1 character 3. Mandatory 4. When value equals '2', the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
MCR029|MCR.002.029|MANAGED-CARE-SERVICE-AREA|Managed Care Service Area|Mandatory|Identifies the geographic unit under which the managed care entity is under contract to provide services. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareservicearea-in-the-managed-care-file-managed-care/|MANAGED-CARE-SERVICE-AREA|MCR00002|MANAGED-CARE-MAIN|X(1)|14|116|116|1. Value must be 1 character 2. Value must be in Managed Care Service Area List (VVL) 3. Mandatory 4. When value equals "2", the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
| 2024-04-12 | MANAGED-CARE-ZIP-CODE/MCR.003.047 | Coding Requirement | UPDATE | MCR047|MCR.003.047|MANAGED-CARE-ZIP-CODE|Managed Care ZIP Code|Mandatory|U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)|N/A|MCR00003|MANAGED-CARE-LOCATION-AND-CONTACT-INFO|X(9)|14|276|284|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Mandatory |
MCR047|MCR.003.047|MANAGED-CARE-ZIP-CODE|Managed Care ZIP Code|Mandatory|U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)|ZIP-CODE|MCR00003|MANAGED-CARE-LOCATION-AND-CONTACT-INFO|X(9)|14|276|284|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 2024-04-12 | MANAGED-CARE-FAX-NUMBER/MCR.003.051 | Coding Requirement | UPDATE | MCR051|MCR.003.051|MANAGED-CARE-FAX-NUMBER|Managed Care Fax Number|Optional|A fax number, including area code, as listed on the contract with the state.|N/A|MCR00003|MANAGED-CARE-LOCATION-AND-CONTACT-INFO|X(10)|18|358|367|Optional | MCR051|MCR.003.051|MANAGED-CARE-FAX-NUMBER|Managed Care Fax Number|Conditional|A fax number, including area code, as listed on the contract with the state.|N/A|MCR00003|MANAGED-CARE-LOCATION-AND-CONTACT-INFO|X(10)|18|358|367|1. Value must be 10-digit number 2. Conditional |
| 2024-04-12 | MANAGED-CARE-SERVICE-AREA-NAME/MCR.004.058 | Definition | UPDATE | MCR058|MCR.004.058|MANAGED-CARE-SERVICE-AREA-NAME|Managed Care Service Area Name|Conditional|The specific identifiers for the counties, cities, regions, ZIP Codes and/or other geographic areas that the managed care entity serves. Put each zip code, city, county, region, or other area descriptor on a separate record. Use 5 digit zip codes when service area definition is zip code based. Use ANSI codes when service area is defined by counties or cities The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47542|MANAGED-CARE-SERVICE-AREA-NAME|MCR00004|MANAGED-CARE-SERVICE-AREA|X(30)|5|34|63|1. Value must be in Managed Care Service Area Name List (VVL) 2. If associated Managed Care Service Area (MCR.002.029) is in [ 2, 3, 4, 5, 6 ], then value is mandatory and must be provided 3. Value must not contain a pipe or asterisk symbol 4. Value must be 30 characters or less 5. Conditional 6. If associated Managed Care Service Area (MCR.002.029) equals '5' (zipcode), then value must be a 5-digit zipcode 7. If associated Managed Care Service Area (MCR.002.029) equals '2' (county code), then value must be a 3-digit number |
MCR058|MCR.004.058|MANAGED-CARE-SERVICE-AREA-NAME|Managed Care Service Area Name|Conditional|The specific identifiers for the counties, cities, regions, ZIP Codes and/or other geographic areas that the managed care entity serves. Put each zip code, city, county, region, or other area descriptor on a separate record. Use 5 digit zip codes when service area definition is zip code based. Use ANSI codes when service area is defined by counties or cities. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareservicearea-in-the-managed-care-file-managed-care/|MANAGED-CARE-SERVICE-AREA-NAME|MCR00004|MANAGED-CARE-SERVICE-AREA|X(30)|5|34|63|1. Value must be 30 characters or less 2. Value must be in Managed Care Service Area Name List (VVL) 3. If associated Managed Care Service Area (MCR.002.029) is in [2,3,4,5,6], then value is mandatory and must be provided 4. Value must not contain a pipe or asterisk symbol 5. Conditional 6. If associated Managed Care Service Area (MCR.002.029) equals "5" (zipcode), then value must be a 5-digit zipcode 7. If associated Managed Care Service Area (MCR.002.029) equals "2" (county code), then value must be a 3-digit number |
| 2024-04-12 | OPERATING-AUTHORITY/MCR.005.067 | Definition | UPDATE | MCR067|MCR.005.067|OPERATING-AUTHORITY|Operating Authority|Mandatory|The type of operating authority through which the managed care entity receives its contract authority. The Managed Care Plan Type assigned to the manage care plan in the Managed Care Main segment should be consistent with the Operating Authority value reported. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47566|OPERATING-AUTHORITY|MCR00005|MANAGED-CARE-OPERATING-AUTHORITY|X(2)|5|34|35|1. Value must be in Operating Authority List (VVL) 2. Value must be 2 characters or less 3. Mandatory |
MCR067|MCR.005.067|OPERATING-AUTHORITY|Operating Authority|Mandatory|The type of operating authority through which the managed care entity receives its contract authority. The Managed Care Plan Type assigned to the manage care plan in the Managed Care Main segment should be consistent with the Operating Authority value reported. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/|OPERATING-AUTHORITY|MCR00005|MANAGED-CARE-OPERATING-AUTHORITY|X(2)|5|34|35|1. Value must be 2 characters 2. Value must be in Operating Authority List (VVL) 3. Mandatory |
| 2024-04-12 | RECORD-ID/MCR.010.114 | Coding Requirement; VVL | UPDATE | MCR114|MCR.010.114|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|N/A|MCR00010|MANAGED-CARE-ID|X(8)|1|1|8|1. Mandatory 2. Value must be 8 characters 3. Value must be in Record ID List (VVL) |
MCR114|MCR.010.114|RECORD-ID|Record ID|Mandatory|The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.).|RECORD-ID|MCR00010|MANAGED-CARE-ID|X(8)|1|1|8|1. Value must be 8 characters 2. Mandatory 3. Value must be in Record ID List (VVL) 4. Value must equal "MCR00010" |
| 2024-04-12 | MANAGED-CARE-PLAN-ID/MCR.010.119 | Coding Requirement | UPDATE | MCR119|MCR.010.119|MANAGED-CARE-PLAN-ID|Managed Care Plan ID|Mandatory|A data element to capture the various IDs used to identify a managed care plan. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Identifier Type data element.|N/A|MCR00010|MANAGED-CARE-ID|X(30)|6|36|65|1. Value must be 2 characters 3. Mandatory |
MCR119|MCR.010.119|MANAGED-CARE-PLAN-ID|Managed Care Plan ID|Mandatory|A data element to capture the various IDs used to identify a managed care plan. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Identifier Type data element.|N/A|MCR00010|MANAGED-CARE-ID|X(30)|6|36|65|1. Value must be 30 characters 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 2024-04-12 | DATA-DICTIONARY-VERSION/PRV.001.002 | Coding Requirement | UPDATE | PRV002|PRV.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|DATA-DICTIONARY-VERSION|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
PRV002|PRV.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | FILE-NAME/PRV.001.006 | Definition | UPDATE | PRV006|PRV.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(8)|6|32|39|1. Value must equal 'PROVIDER' 2. Mandatory |
PRV006|PRV.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(8)|6|32|39|1. Value must equal "PROVIDER" 2. Mandatory |
| 2024-04-12 | FACILITY-GROUP-INDIVIDUAL-CODE/PRV.002.026 | Coding Requirement | UPDATE | PRV026|PRV.002.026|FACILITY-GROUP-INDIVIDUAL-CODE|Facility Group Individual Code|Mandatory|A code to identify whether the Submitting State Provider Identifier is assigned to an individual, group, or a facility.|FACILITY-GROUP-INDIVIDUAL-CODE|PRV00002|PROV-ATTRIBUTES-MAIN|X(2)|11|428|429|1. Value must be in Facility Group Individual Code List (VVL) 2. Value must be 2 characters 3. Mandatory 4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated 5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated 6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated 7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated 8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated 9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated |
PRV026|PRV.002.026|FACILITY-GROUP-INDIVIDUAL-CODE|Facility Group Individual Code|Mandatory|A code to identify whether the Submitting State Provider Identifier is assigned to an individual, group, or a facility.|FACILITY-GROUP-INDIVIDUAL-CODE|PRV00002|PROV-ATTRIBUTES-MAIN|X(2)|11|428|429|1. Value must be in Facility Group Individual Code List (VVL) 2. Value must be 2 characters 3. Mandatory 4. (Individual) If value equals "03", then Provider First Name (PRV.002.028) must be populated 5. (Individual) NPPES Entity Type Code associate with this NPI must equal "1" (Individual) 6. (Individual) If value equals "03", then Provider Last Name (PRV.002.030) must be populated 7. (Individual) If value equals "03", then Provider Sex (PRV.002.031) must be populated 8. (Individual) If value equals "03", then Provider Date of Birth (PRV.002.034) must be populated 9. (Organization) If value equals "01" or "02", then Provider Date of Death (PRV.002.035) must not be populated 10. (Organization) If value does not equal "03", then Provider Middle Initial (PRV.002.029) must not be populated 11. (Organization) NPPES Entity Type Code associate with this NPI must equal "2" (Organization) |
| 2024-04-12 | ADDR-ZIP-CODE/PRV.003.052 | Coding Requirement; VVL | UPDATE | PRV052|PRV.003.052|ADDR-ZIP-CODE|Provider ZIP Code|Mandatory|U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|X(9)|14|284|292|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Mandatory |
PRV052|PRV.003.052|ADDR-ZIP-CODE|Provider ZIP Code|Mandatory|U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)|ZIP-CODE|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|X(9)|14|284|292|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Mandatory |
| 2024-04-12 | ADDR-BORDER-STATE-IND/PRV.003.056 | Coding Requirement | UPDATE | PRV056|PRV.003.056|ADDR-BORDER-STATE-IND|Address Border State Indicator|Mandatory|A code identify an out of state provider enrolled with the state (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)|ADDR-BORDER-STATE-IND|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|X(1)|18|373|373|1. Value must be in Address Border State Indicator List (VVL) 2. Mandatory |
PRV056|PRV.003.056|ADDR-BORDER-STATE-IND|Address Border State Indicator|Mandatory|A code identify an out of state provider enrolled with the state (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)|ADDR-BORDER-STATE-IND|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|X(1)|18|373|373|1. Value must be 1 character 2. Value must be in Address Border State Indicator List (VVL) 3. Mandatory |
| 2024-04-12 | LICENSE-ISSUING-ENTITY-ID/PRV.004.068 | Coding Requirement | UPDATE | PRV068|PRV.004.068|LICENSE-ISSUING-ENTITY-ID|License Issuing Entity ID|Mandatory|A free text field to capture the identity of the entity issuing the license or accreditation. Enter the applicable state code, county code, municipality name, "DEA", professional society's name, or the CLIA accreditation body's name. -If associated License Type is equal to 1 and issuing authority is a State, then value must be ANSI State abbreviation code. - If associated License Type is equal to 1 and issuing authority is a county, then value must be a 5-digit, concatenated code consisting of the ANSI state code plus the ANSI county code.A list of codes can be found here: https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/home/?cid=nrcs143_013697 - If associated License Type is equal to 1 and issuing authority is a municipality, then enter a text string with the name of the municipality. -If associated License Type is equal to 3, then enter the text string identifying the professional society issuing the accreditation. -If associated License Type is equal to 4, then value must be the text string identifying the CLIA accreditation body's name.|N/A|PRV00004|PROV-LICENSING-INFO|X(60)|9|74|133|1. Value must not contain a pipe or asterisk symbol 2. Value must be 60 characters or less 3. (required) if associated License or Accreditation Number (PRV.004.069) value is populated, then value is mandatory and must be provided 4. Mandatory 5. Value must equal 'DEA' when associated License Type equals '2' |
PRV068|PRV.004.068|LICENSE-ISSUING-ENTITY-ID|License Issuing Entity ID|Mandatory|A free text field to capture the identity of the entity issuing the license or accreditation. Enter the applicable state code, county code, municipality name, "DEA", professional society's name, or the CLIA accreditation body's name. -If associated License Type is equal to 1 and issuing authority is a State, then value must be ANSI State abbreviation code.- If associated License Type is equal to 1 and issuing authority is a county, then value must be a 5-digit, concatenated code consisting of the ANSI state code plus the ANSI county code.A list of codes can be found here: https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/home/?cid=nrcs143_013697 - If associated License Type is equal to 1 and issuing authority is a municipality, then enter a text string with the name of the municipality. -If associated License Type is equal to 3, then enter the text string identifying the professional society issuing the accreditation. -If associated License Type is equal to 4, then value must be the text string identifying the CLIA accreditation body's name.|N/A|PRV00004|PROV-LICENSING-INFO|X(60)|9|74|133|1. Value must be 60 characters or less 2. Value must not contain a pipe or asterisk symbol 3. Mandatory 4. If associated License Type equals "2", then value must equal "DEA" |
| 2024-04-12 | PROV-CLASSIFICATION-TYPE/PRV.006.088 | Definition | UPDATE | PRV088|PRV.006.088|PROV-CLASSIFICATION-TYPE|Provider Classification Type|Mandatory|A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, 'CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File' https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |PROV-CLASSIFICATION-TYPE|PRV00006|PROV-TAXONOMY-CLASSIFICATION|X(1)|5|52|52|1. Value must be in Provider Classification Type List (VVL) 2. Value must be 1 character 3. Mandatory |
PRV088|PRV.006.088|PROV-CLASSIFICATION-TYPE|Provider Classification Type|Mandatory|A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-technical-instructions-provider-classification-requirements-in-tmsis/ A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply.|PROV-CLASSIFICATION-TYPE|PRV00006|PROV-TAXONOMY-CLASSIFICATION|X(1)|5|52|52|1. Value must be 1 character 2. Value must be in Provider Classification Type List (VVL) 3. Mandatory |
| 2024-04-12 | BED-COUNT/PRV.010.135 | Definition | UPDATE | PRV135|PRV.010.135|BED-COUNT|Bed Count|Mandatory|A count of the number of beds available at the facility for the category of bed identified in the Bed Type Code data element. Beds should not be counted twice under different bed types. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47561|N/A|PRV00010|PROV-BED-TYPE-INFO|9(5)|9|74|78|1. Value must be 5 digits or less 2. Mandatory |
PRV135|PRV.010.135|BED-COUNT|Bed Count|Mandatory|A count of the number of beds available at the facility for the category of bed identified in the Bed Type Code data element. Beds should not be counted twice under different bed types. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T-MSIS Provider File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-provider-bed-information-in-the-tmsis-provider-file-provider/|N/A|PRV00010|PROV-BED-TYPE-INFO|9(5)|9|74|78|1. Value must be 5 digits or less 2. Mandatory |
| 2024-04-12 | DATA-DICTIONARY-VERSION/TPL.001.002 | Coding Requirement | UPDATE | TPL002|TPL.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary".|DATA-DICTIONARY-VERSION|TPL00001|FILE-HEADER-RECORD-TPL|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must not include the pipe ("|") symbol 3. Mandatory |
TPL002|TPL.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|TPL00001|FILE-HEADER-RECORD-TPL|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-04-12 | FILE-NAME/TPL.001.006 | Definition | UPDATE | TPL006|TPL.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, and Pharmacy Claim).|FILE-NAME|TPL00001|FILE-HEADER-RECORD-TPL|X(8)|6|32|39|1. Value must equal 'TPL-FILE' 2. Mandatory |
TPL006|TPL.001.006|FILE-NAME|File Name|Mandatory|A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions).|N/A|TPL00001|FILE-HEADER-RECORD-TPL|X(8)|6|32|39|1. Value must equal "TPL-FILE" 2. Mandatory |
| 2024-04-12 | DATE-FILE-CREATED/TPL.001.008 | Coding Requirement | UPDATE | TPL008|TPL.001.008|DATE-FILE-CREATED|Date File Created|Mandatory|The date on which the file was created.|N/A|TPL00001|FILE-HEADER-RECORD-TPL|9(8)|8|42|49|1. Value of the CC component must be "20" 2. Value must be 8 characters in the form "CCYYMMDD" 3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st) 4. Value must be less than current date 5. Value must be equal to or after the value of associated End of Time Period 6. Mandatory |
TPL008|TPL.001.008|DATE-FILE-CREATED|Date File Created|Mandatory|The date on which the file was created.|N/A|TPL00001|FILE-HEADER-RECORD-TPL|9(8)|8|42|49|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value of the CC component must be "20" 3. Value must be less than current date 4. Value must be equal to or after the value of associated End of Time Period 5. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/TPL.002.019 | Definition | UPDATE | TPL019|TPL.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
TPL019|TPL.002.019|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | TPL-HEALTH-INSURANCE-COVERAGE-IND/TPL.002.020 | Coding Requirement | UPDATE | TPL020|TPL.002.020|TPL-HEALTH-INSURANCE-COVERAGE-IND|TPL Health Insurance Coverage Indicator|Mandatory|A flag to indicate that the Medicaid/CHIP eligible person has some form of third party insurance coverage.|TPL-HEALTH-INSURANCE-COVERAGE-IND|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|X(1)|5|42|42|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in TPL Health Insurance Coverage Indicator List (VVL) 4. Value must be 1 character 5. Mandatory 6. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
TPL020|TPL.002.020|TPL-HEALTH-INSURANCE-COVERAGE-IND|TPL Health Insurance Coverage Indicator|Mandatory|A flag to indicate that the Medicaid/CHIP eligible person has some form of third party insurance coverage.|TPL-HEALTH-INSURANCE-COVERAGE-IND|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|X(1)|5|42|42|1. Value must be 1 character 2. Value must be in [0, 1] or not populated 3. Value must be in TPL Health Insurance Coverage Indicator List (VVL) 4. Mandatory 5. When value equals "1", there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/TPL.003.032 | Definition | UPDATE | TPL032|TPL.003.032|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00003|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
TPL032|TPL.003.032|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|TPL00003|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | MSIS-IDENTIFICATION-NUM/TPL.005.066 | Definition | UPDATE | TPL066|TPL.005.066|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, 'CMS Guidance: Reporting Shared MSIS Identification Numbers' for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |N/A|TPL00005|TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION|X(20)|4|22|41|1. Mandatory 2. Value must be 20 characters or less |
TPL066|TPL.005.066|MSIS-IDENTIFICATION-NUM|MSIS Identification Number|Mandatory|A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/|N/A|TPL00005|TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION|X(20)|4|22|41|1. Value must be 20 characters or less 2. Mandatory |
| 2024-04-12 | INSURANCE-CARRIER-ZIP-CODE/TPL.006.082 | Coding Requirement; Necessity; VVL | UPDATE | TPL082|TPL.006.082|INSURANCE-CARRIER-ZIP-CODE|Insurance Carrier ZIP Code|Optional|The ZIP Code for the location being captured on the TPL Entity Contact Information record.|N/A|TPL00006|TPL-ENTITY-CONTACT-INFORMATION|X(9)|11|246|254|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Optional |
TPL082|TPL.006.082|INSURANCE-CARRIER-ZIP-CODE|Insurance Carrier ZIP Code|Situational|The ZIP Code for the location being captured on the TPL Entity Contact Information record.|ZIP-CODE|TPL00006|TPL-ENTITY-CONTACT-INFORMATION|X(9)|11|246|254|1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011) 2. Value must be in ZIP Code List (VVL) 3. Situational |
| 2024-06-03 | DATA-DICTIONARY-VERSION/CIP.001.002 | Definition | UPDATE | 2|CIP002|CIP.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|CIP00001|FILE-HEADER-RECORD-IP|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
2|CIP002|CIP.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|CIP00001|FILE-HEADER-RECORD-IP|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/CIP.001.005 | Definition | UPDATE | 5|CIP005|CIP.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|CIP00001|FILE-HEADER-RECORD-IP|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
5|CIP005|CIP.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|CIP00001|FILE-HEADER-RECORD-IP|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | FUNDING-CODE/CIP.002.126 | Coding Requirement(s) | UPDATE | 77|CIP126|CIP.002.126|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|62|487|488|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
77|CIP126|CIP.002.126|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CIP00002|CLAIM-HEADER-RECORD-IP|X(2)|62|487|488|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 2024-06-03 | MEDICAID-COV-INPATIENT-DAYS/CIP.002.136 | Coding Requirement(s) | UPDATE | 86|CIP136|CIP.002.136|MEDICAID-COV-INPATIENT-DAYS|Medicaid Covered Inpatient Days|Conditional|The number of days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(7)|71|527|533|1. Value must be a positive integer 2. Value must be between 0000000:9999999 (inclusive) 3. Conditional 4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day 5. Value must be 7 digits or less 6. Value is required if the associated Type of Service (CIP.002.257) in [001,058,060,084,086,090,091,092,093,123,132] 7. Value is required if at least one associated Revenue Code (CIP.003.245) in [100-219] |
86|CIP136|CIP.002.136|MEDICAID-COV-INPATIENT-DAYS|Medicaid Covered Inpatient Days|Conditional|The number of days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field.|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|S9(7)|71|527|533|1. Value must be a positive integer 2. Value must be between 0000000:9999999 (inclusive) 3. Conditional 4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day 5. Value must be 7 digits or less 6. Value is required if the associated Type of Service (CIP.002.257) in [001,058,060,084,086,090,091,092,093] 7. Value is required if at least one associated Revenue Code (CIP.003.245) in [100-219] |
| 2024-06-03 | MEDICARE-HIC-NUM/CIP.002.196 | Definition | UPDATE | 143|CIP196|CIP.002.196|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based)|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(12)|128|1014|1025|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CIP.002.023) equals "1" and Medicare Beneficiary Identifier (CIP.002.222) is not populated |
143|CIP196|CIP.002.196|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based).|N/A|CIP00002|CLAIM-HEADER-RECORD-IP|X(12)|128|1014|1025|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CIP.002.023) equals "1" and Medicare Beneficiary Identifier (CIP.002.222) is not populated |
| 2024-06-03 | LINE-NUM-ORIG/CIP.003.237 | Coding Requirement(s) | UPDATE | 199|CIP237|CIP.003.237|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. When populated, value must be one or greater |
199|CIP237|CIP.003.237|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 2024-06-03 | REVENUE-CENTER-QUANTITY-ACTUAL/CIP.003.249 | Definition | UPDATE | 208|CIP249|CIP.003.249|REVENUE-CENTER-QUANTITY-ACTUAL|Revenue Center Quantity Actual|Mandatory|On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(6)V999|16|187|195|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 3. Mandatory |
208|CIP249|CIP.003.249|REVENUE-CENTER-QUANTITY-ACTUAL|Revenue Center Quantity Actual|Mandatory|On facility claims/encounters, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounters use Service Quantity Actual and CLAIMRX claims/encounters use the Prescription Quantity Actual field|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(6)V999|16|187|195|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 3. Mandatory |
| 2024-06-03 | REVENUE-CENTER-QUANTITY-ALLOWED/CIP.003.250 | Definition | UPDATE | 209|CIP250|CIP.003.250|REVENUE-CENTER-QUANTITY-ALLOWED|Revenue Center Quantity Allowed|Conditional|On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(6)V999|17|196|204|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 3. Conditional |
209|CIP250|CIP.003.250|REVENUE-CENTER-QUANTITY-ALLOWED|Revenue Center Quantity Allowed|Conditional|On facility claims/encounters, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was allowed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounters use Service Quantity Allowed and CLAIMRX claims/encounters use the Prescription Quantity Allowed field.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(6)V999|17|196|204|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 3. Conditional |
| 2024-06-03 | TYPE-OF-SERVICE/CIP.003.257 | Valid Value List; Coding Requirement(s) |
UPDATE | 215|CIP257|CIP.003.257|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|23|259|261|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. If Sex (ELG.002.023) equals "M", then value must not equal "086" 5. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
215|CIP257|CIP.003.257|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE-IP|CIP00003|CLAIM-LINE-RECORD-IP|X(3)|23|259|261|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service IP List (VVL) 4. If Sex (ELG.002.023) equals "M", then value must not equal "086" |
| 2024-06-03 | NDC-QUANTITY/CIP.003.278 | Definition | UPDATE | 225|CIP278|CIP.003.278|NDC-QUANTITY|NDC Quantity|Conditional|This field is to capture the actual quantity of the National Drug Code being prescribed on the claim.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(9)V(9)|33|343|360|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
225|CIP278|CIP.003.278|NDC-QUANTITY|NDC Quantity|Conditional|This field is to capture the actual quantity of the National Drug Code being prescribed on the claim/encounter.|N/A|CIP00003|CLAIM-LINE-RECORD-IP|S9(9)V(9)|33|343|360|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 2024-06-03 | DATA-DICTIONARY-VERSION/CLT.001.002 | Definition | UPDATE | 256|CLT002|CLT.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|CLT00001|FILE-HEADER-RECORD-LT|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
256|CLT002|CLT.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|CLT00001|FILE-HEADER-RECORD-LT|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/CLT.001.005 | Definition | UPDATE | 259|CLT005|CLT.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|CLT00001|FILE-HEADER-RECORD-LT|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
259|CLT005|CLT.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|CLT00001|FILE-HEADER-RECORD-LT|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | FUNDING-CODE/CLT.002.076 | Coding Requirement(s) | UPDATE | 310|CLT076|CLT.002.076|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|41|364|365|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
310|CLT076|CLT.002.076|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CLT00002|CLAIM-HEADER-RECORD-LT|X(2)|41|364|365|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 2024-06-03 | MEDICARE-HIC-NUM/CLT.002.140 | Definition | UPDATE | 368|CLT140|CLT.002.140|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based)|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(12)|99|803|814|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CLT.002.023) equals "1" and Medicare Beneficiary Identifier (CLT.002.168) is not populated |
368|CLT140|CLT.002.140|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based).|N/A|CLT00002|CLAIM-HEADER-RECORD-LT|X(12)|99|803|814|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CLT.002.023) equals "1" and Medicare Beneficiary Identifier (CLT.002.168) is not populated |
| 2024-06-03 | LINE-NUM-ORIG/CLT.003.190 | Coding Requirement(s) | UPDATE | 426|CLT190|CLT.003.190|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. When populated, value must be one or greater |
426|CLT190|CLT.003.190|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 2024-06-03 | REVENUE-CENTER-QUANTITY-ACTUAL/CLT.003.202 | Definition | UPDATE | 435|CLT202|CLT.003.202|REVENUE-CENTER-QUANTITY-ACTUAL|Revenue Center Quantity Actual|Mandatory|On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(6)V999|16|187|195|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 3. Mandatory |
435|CLT202|CLT.003.202|REVENUE-CENTER-QUANTITY-ACTUAL|Revenue Center Quantity Actual|Mandatory|On facility claims/encounters, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(6)V999|16|187|195|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789 3. Mandatory |
| 2024-06-03 | REVENUE-CENTER-QUANTITY-ALLOWED/CLT.003.203 | Definition | UPDATE | 436|CLT203|CLT.003.203|REVENUE-CENTER-QUANTITY-ALLOWED|Revenue Center Quantity Allowed|Conditional|On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(6)V999|17|196|204|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 3. Conditional |
436|CLT203|CLT.003.203|REVENUE-CENTER-QUANTITY-ALLOWED|Revenue Center Quantity Allowed|Conditional|On facility claims/encounters, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was allowed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounters use Service Quantity Allowed and CLAIMRX claims/encounters use the Prescription Quantity Allowed field.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(6)V999|17|196|204|1. Value must be numeric 2. Value may include up to 6 digits to the left of the decimal point, and 3 digits to the right, e.g. 123456.789 3. Conditional |
| 2024-06-03 | TYPE-OF-SERVICE/CLT.003.211 | Valid Value List; Coding Requirement(s) |
UPDATE | 444|CLT211|CLT.003.211|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|CLT00003|CLAIM-LINE-RECORD-LT|X(3)|25|285|287|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. Value must be in [009,044,045,046,047,048,050,059,133,136,137,146,147] |
444|CLT211|CLT.003.211|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE-LT|CLT00003|CLAIM-LINE-RECORD-LT|X(3)|25|285|287|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service LT List (VVL) |
| 2024-06-03 | NDC-QUANTITY/CLT.003.230 | Definition | UPDATE | 454|CLT230|CLT.003.230|NDC-QUANTITY|NDC Quantity|Conditional|This field is to capture the actual quantity of the National Drug Code being prescribed on the claim.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(9)V(9)|35|360|377|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
454|CLT230|CLT.003.230|NDC-QUANTITY|NDC Quantity|Conditional|This field is to capture the actual quantity of the National Drug Code being prescribed on the claim/encounters.|N/A|CLT00003|CLAIM-LINE-RECORD-LT|S9(9)V(9)|35|360|377|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 2024-06-03 | DATA-DICTIONARY-VERSION/COT.001.002 | Definition | UPDATE | 483|COT002|COT.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|COT00001|FILE-HEADER-RECORD-OT|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
483|COT002|COT.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|COT00001|FILE-HEADER-RECORD-OT|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/COT.001.005 | Definition | UPDATE | 486|COT005|COT.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|COT00001|FILE-HEADER-RECORD-OT|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
486|COT005|COT.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|COT00001|FILE-HEADER-RECORD-OT|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | FUNDING-CODE/COT.002.062 | Coding Requirement(s) | UPDATE | 533|COT062|COT.002.062|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|37|344|345|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
533|COT062|COT.002.062|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|COT00002|CLAIM-HEADER-RECORD-OT|X(2)|37|344|345|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 2024-06-03 | BILLING-PROV-TAXONOMY/COT.002.114 | Coding Requirement(s) | UPDATE | 583|COT114|COT.002.114|BILLING-PROV-TAXONOMY|Billing Provider Taxonomy|Conditional|The taxonomy code for the provider billing for the service.|PROV-TAXONOMY|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|87|704|715|1. Value must be in Provider Taxonomy List (VVL) 2. Value must be 12 characters or less 3. Conditional 4. If associated Type of Service value is in [119,120,121,122], then value should not be populated |
583|COT114|COT.002.114|BILLING-PROV-TAXONOMY|Billing Provider Taxonomy|Conditional|The taxonomy code for the provider billing for the service.|PROV-TAXONOMY|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|87|704|715|1. Value must be in Provider Taxonomy List (VVL) 2. Value must be 12 characters or less 3. Conditional |
| 2024-06-03 | MEDICARE-HIC-NUM/COT.002.122 | Definition | UPDATE | 588|COT122|COT.002.122|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based)|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|92|760|771|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (COT.002.023) equals "1" and Medicare Beneficiary Identifier (COT.002.147) is not populated |
588|COT122|COT.002.122|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based).|N/A|COT00002|CLAIM-HEADER-RECORD-OT|X(12)|92|760|771|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (COT.002.023) equals "1" and Medicare Beneficiary Identifier (COT.002.147) is not populated |
| 2024-06-03 | LINE-NUM-ORIG/COT.003.160 | Coding Requirement(s) | UPDATE | 639|COT160|COT.003.160|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. When populated, value must be one or greater |
639|COT160|COT.003.160|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 2024-06-03 | SERVICE-QUANTITY-ACTUAL/COT.003.183 | Definition; Coding Requirement(s) |
UPDATE | 659|COT183|COT.003.183|SERVICE-QUANTITY-ACTUAL|Service Quantity Actual|Mandatory|The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(8)V999|27|298|308|1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Mandatory 3. When populated, corresponding Unit of Measure must be populated |
659|COT183|COT.003.183|SERVICE-QUANTITY-ACTUAL|Service Quantity Actual|Mandatory|The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim/encounter line. For use with CLAIMOT claims. For CLAIMRX claims/encounters, use the Prescription Quantity Actual field. For CLAIMIP and CLAIMLT claims/encounters, use the Revenue Center Quantity Actual field.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(8)V999|27|298|308|1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Mandatory |
| 2024-06-03 | SERVICE-QUANTITY-ALLOWED/COT.003.184 | Definition | UPDATE | 660|COT184|COT.003.184|SERVICE-QUANTITY-ALLOWED|Service Quantity Allowed|Conditional|The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(8)V999|28|309|319|1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Conditional |
660|COT184|COT.003.184|SERVICE-QUANTITY-ALLOWED|Service Quantity Allowed|Conditional|The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT claims/encounters. For CLAIMIP and CLAIMLT claims/encounters, use the Revenue Center Quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Service Quantity Allowed = 100. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(8)V999|28|309|319|1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.999 2. Conditional |
| 2024-06-03 | TYPE-OF-SERVICE/COT.003.186 | Valid Value List; Coding Requirement(s) |
UPDATE | 661|COT186|COT.003.186|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|COT00003|CLAIM-LINE-RECORD-OT|X(3)|29|320|322|1. Value must be 3 characters. 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020, 021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066, 067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085, 086,087,088,089,115,127,136,137,144,145,147] 5. When value is not in [025,085], Sex (ELG.002.023) equals "M" |
661|COT186|COT.003.186|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE-OT|COT00003|CLAIM-LINE-RECORD-OT|X(3)|29|320|322|1. Value must be 3 characters. 2. Mandatory 3. Value must be in Type of Service OT List (VVL) 4. When value is not in [025,085], Sex (ELG.002.023) equals "M" |
| 2024-06-03 | HCBS-TAXONOMY/COT.003.188 | Definition | UPDATE | 663|COT188|COT.003.188|HCBS-TAXONOMY|HCBS Taxonomy|Conditional|A code to classify the home and community based services listed on the claim into the HCBS taxonomy.|HCBS-TAXONOMY|COT00003|CLAIM-LINE-RECORD-OT|X(5)|31|324|328|1. Value must be 5 characters or less 2. Value must be in HCBS Taxonomy Code List (VVL) 3. Conditional |
663|COT188|COT.003.188|HCBS-TAXONOMY|HCBS Taxonomy|Conditional|A code to classify the home and community based services listed on the claim into the HCBS taxonomy. The HCBS Taxonomic classification system was adopted by CMS in August 2012. To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting. Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as “extended state plan” services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment. The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state’s service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc. Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf.|HCBS-TAXONOMY|COT00003|CLAIM-LINE-RECORD-OT|X(5)|31|324|328|1. Value must be 5 characters or less 2. Value must be in HCBS Taxonomy Code List (VVL) 3. Conditional |
| 2024-06-03 | NDC-QUANTITY/COT.003.225 | Definition | UPDATE | 694|COT225|COT.003.225|NDC-QUANTITY|NDC Quantity|Conditional|This field is to capture the actual quantity of the National Drug Code being prescribed on the claim.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(9)V(9)|62|777|794|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
694|COT225|COT.003.225|NDC-QUANTITY|NDC Quantity|Conditional|This field is to capture the actual quantity of the National Drug Code being prescribed on the claim/encounters.|N/A|COT00003|CLAIM-LINE-RECORD-OT|S9(9)V(9)|62|777|794|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Conditional |
| 2024-06-03 | DATA-DICTIONARY-VERSION/CRX.001.002 | Definition | UPDATE | 734|CRX002|CRX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|CRX00001|FILE-HEADER-RECORD-RX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
734|CRX002|CRX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|CRX00001|FILE-HEADER-RECORD-RX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/CRX.001.005 | Definition | UPDATE | 737|CRX005|CRX.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|CRX00001|FILE-HEADER-RECORD-RX|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
737|CRX005|CRX.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|CRX00001|FILE-HEADER-RECORD-RX|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | FUNDING-CODE/CRX.002.053 | Coding Requirement(s) | UPDATE | 781|CRX053|CRX.002.053|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|34|324|325|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
781|CRX053|CRX.002.053|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|CRX00002|CLAIM-HEADER-RECORD-RX|X(2)|34|324|325|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is not in [3,C,W], then value must be populated 4. Conditional |
| 2024-06-03 | MEDICARE-HIC-NUM/CRX.002.079 | Definition | UPDATE | 803|CRX079|CRX.002.079|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based)|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(12)|56|556|567|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CRX.002.023) equals "1" and Medicare Beneficiary Identifier (CRX.002.105) is not populated |
803|CRX079|CRX.002.079|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based).|N/A|CRX00002|CLAIM-HEADER-RECORD-RX|X(12)|56|556|567|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated 5. Value must be populated when Crossover Indicator (CRX.002.023) equals "1" and Medicare Beneficiary Identifier (CRX.002.105) is not populated |
| 2024-06-03 | LINE-NUM-ORIG/CRX.003.114 | Coding Requirement(s) | UPDATE | 846|CRX114|CRX.003.114|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. When populated, value must be one or greater |
846|CRX114|CRX.003.114|LINE-NUM-ORIG|Original Line Number|Mandatory|A unique number to identify the transaction line number that is being reported on the original claim.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|7|142|144|1. Value must be 3 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory 4. Value must be one or greater |
| 2024-06-03 | PRESCRIPTION-QUANTITY-ALLOWED/CRX.003.131 | Definition | UPDATE | 862|CRX131|CRX.003.131|PRESCRIPTION-QUANTITY-ALLOWED|Prescription Quantity Allowed|Conditional|The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|23|290|307|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. When populated, corresponding Unit of Measure must be populated 3. Conditional |
862|CRX131|CRX.003.131|PRESCRIPTION-QUANTITY-ALLOWED|Prescription Quantity Allowed|Conditional|The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMRX claims/encounters. For CLAIMOT claims/encounters, use the Service Quantity Allowed field. For CLAIMIP and CLAIMLT claims/encounters, use the Revenue Center Quantity Actual field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|23|290|307|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. When populated, corresponding Unit of Measure must be populated 3. Conditional |
| 2024-06-03 | PRESCRIPTION-QUANTITY-ACTUAL/CRX.003.132 | Definition | UPDATE | 863|CRX132|CRX.003.132|PRESCRIPTION-QUANTITY-ACTUAL|Prescription Quantity Actual|Mandatory|The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|24|308|325|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Mandatory |
863|CRX132|CRX.003.132|PRESCRIPTION-QUANTITY-ACTUAL|Prescription Quantity Actual|Mandatory|The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line. For use with CLAIMRX claims/encounters. For CLAIMOT claims/encounters, use the Service Quantity Actual field. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field.|N/A|CRX00003|CLAIM-LINE-RECORD-RX|S9(9)V(9)|24|308|325|1. Value may include up to 9 digits to the left of the decimal point, and 9 digits to the right e.g. 123456789.123456789 2. Mandatory |
| 2024-06-03 | TYPE-OF-SERVICE/CRX.003.134 | Valid Value List; Coding Requirement(s) |
UPDATE | 865|CRX134|CRX.003.134|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|26|328|330|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service List (VVL) 4. Value must be in [011,018,033,034,036,085,089,127,131,136,137,145] |
865|CRX134|CRX.003.134|TYPE-OF-SERVICE|Type of Service|Mandatory|A code to categorize the services provided to a Medicaid or CHIP enrollee.|TYPE-OF-SERVICE-RX|CRX00003|CLAIM-LINE-RECORD-RX|X(3)|26|328|330|1. Value must be 3 characters 2. Mandatory 3. Value must be in Type of Service RX List (VVL) |
| 2024-06-03 | HCBS-TAXONOMY/CRX.003.136 | Definition | UPDATE | 867|CRX136|CRX.003.136|HCBS-TAXONOMY|HCBS Taxonomy|Conditional|A code to classify the home and community based services listed on the claim into the HCBS taxonomy.|HCBS-TAXONOMY|CRX00003|CLAIM-LINE-RECORD-RX|X(5)|28|332|336|1. Value must be 5 characters or less 2. Value must be in HCBS Taxonomy Code List (VVL) 3. Conditional |
867|CRX136|CRX.003.136|HCBS-TAXONOMY|HCBS Taxonomy|Conditional|A code to classify the home and community based services listed on the claim into the HCBS taxonomy. The HCBS Taxonomic classification system was adopted by CMS in August 2012. To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting. Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as “extended state plan” services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment. The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state’s service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc. Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf.|HCBS-TAXONOMY|CRX00003|CLAIM-LINE-RECORD-RX|X(5)|28|332|336|1. Value must be 5 characters or less 2. Value must be in HCBS Taxonomy Code List (VVL) 3. Conditional |
| 2024-06-03 | DRUG-UTILIZATION-CODE/CRX.003.143 | Definition | UPDATE | 874|CRX143|CRX.003.143|DRUG-UTILIZATION-CODE|Drug Utilization Code|Mandatory|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: 'Reason for Service Code' (439-E4); 'Professional Service Code' (440-E5); and 'Result of Service Code' (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP 'Reasons of Service Code' (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP 'Professional Service Code' (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP 'Result of Service Code' (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.|DRUG-UTILIZATION-CODE-E4, DRUG-UTILIZATION-CODE-E5, DRUG-UTILIZATION-CODE-E6|CRX00003|CLAIM-LINE-RECORD-RX|X(6)|35|368|373|1. Value must be 6 characters or less 2. Characters 1 and 2 (2-character string) must be in Drug Utilization Reason for Service Code List (VVL) 3. Characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL) 4. Characters 5 and 6 (2-character string) must be in Drug Utilization Result of Service Code List (VVL) 5. Mandatory |
874|CRX143|CRX.003.143|DRUG-UTILIZATION-CODE|Drug Utilization Code|Mandatory|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: 'Reason for Service Code' (439-E4); 'Professional Service Code' (440-E5); and 'Result of Service Code' (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP 'Reasons of Service Code' (bytes 1 and 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP 'Professional Service Code' (bytes 3 and 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP 'Result of Service Code' (bytes 5 and 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.|DRUG-UTILIZATION-CODE-E4, DRUG-UTILIZATION-CODE-E5, DRUG-UTILIZATION-CODE-E6|CRX00003|CLAIM-LINE-RECORD-RX|X(6)|35|368|373|1. Value must be 6 characters or less 2. Characters 1 and 2 (2-character string) must be in Drug Utilization Reason for Service Code List (VVL) 3. Characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL) 4. Characters 5 and 6 (2-character string) must be in Drug Utilization Result of Service Code List (VVL) 5. Mandatory |
| 2024-06-03 | DATA-DICTIONARY-VERSION/ELG.001.002 | Definition | UPDATE | 921|ELG002|ELG.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
921|ELG002|ELG.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/ELG.001.005 | Definition | UPDATE | 924|ELG005|ELG.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
924|ELG005|ELG.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|ELG00001|FILE-HEADER-RECORD-ELIGIBILITY|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | MEDICARE-HIC-NUM/ELG.003.050 | Definition | UPDATE | 968|ELG050|ELG.003.050|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based)|N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(12)|20|126|137|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value is "00", then value must not be populated. 5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value for either HICN or MBI is mandatory and must be provided |
968|ELG050|ELG.003.050|MEDICARE-HIC-NUM|Medicare HIC Number|Conditional|The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN and alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based).|N/A|ELG00003|VARIABLE-DEMOGRAPHICS-ELIGIBILITY|X(12)|20|126|137|1. Value must be 12 characters or less 2. Conditional 3. Value must not contain a pipe or asterisk symbols 4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value is "00", then value must not be populated. 5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value for either HICN or MBI is mandatory and must be provided |
| 2024-06-03 | ELIGIBLE-ADDR-LN1/ELG.004.066 | Coding Requirement(s) | UPDATE | 981|ELG066|ELG.004.066|ELIGIBLE-ADDR-LN1|Eligible Address Line 1|Mandatory|The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.).|N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(60)|6|44|103|1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory 5. When populated, the associated Address Type is required |
981|ELG066|ELG.004.066|ELIGIBLE-ADDR-LN1|Eligible Address Line 1|Mandatory|The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.).|N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|X(60)|6|44|103|1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory |
| 2024-06-03 | ELIGIBLE-ADDR-END-DATE/ELG.004.076 | Coding Requirement(s) | UPDATE | 991|ELG076|ELG.004.076|ELIGIBLE-ADDR-END-DATE|Eligible Address End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|9(8)|16|384|391|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
991|ELG076|ELG.004.076|ELIGIBLE-ADDR-END-DATE|Eligible Address End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00004|ELIGIBLE-CONTACT-INFORMATION|9(8)|16|384|391|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | DUAL-ELIGIBLE-CODE/ELG.005.085 | Coding Requirement(s) | UPDATE | 998|ELG085|ELG.005.085|DUAL-ELIGIBLE-CODE|Dual Eligible Code|Mandatory|Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits.|DUAL-ELIGIBLE-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(2)|6|54|55|1. Value must be 2 characters 2. Value must be in Dual Eligible Code List (VVL) 3. If value equals "05", then Eligibility Group (ELG.005.087) must be "24" 3. If value equals "06", then Eligibility Group (ELG.005.087) must be "26" 4. If Dual Eligible Code (ELG.005.085) is in [01,02,03,04,05,06,08,09,10], then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes) 5. Mandatory 6. A partial dual eligible (values="01", "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3" 7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated. 8. Value must be 2 characters 9. If value is in [08,10] then Restricted Benefits Code (ELG.005.097) must be "1" 10. If value equals "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated 11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated 12. If value equals "01", then Eligibility Group (ELG.005.087) must be "23" 13. If value equals "03", then Eligibility Group (ELG.005.087) must be "25" |
998|ELG085|ELG.005.085|DUAL-ELIGIBLE-CODE|Dual Eligible Code|Mandatory|Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits.|DUAL-ELIGIBLE-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(2)|6|54|55|1. Value must be 2 characters 2. Value must be in Dual Eligible Code List (VVL) 3. If value equals "05", then Eligibility Group (ELG.005.087) must be "24" 4. If value equals "06", then Eligibility Group (ELG.005.087) must be "26" 5. If Dual Eligible Code (ELG.005.085) is in [01,02,03,04,05,06,08,09,10], then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes) 6. Mandatory 7. A partial dual eligible (values="01", "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3" 8. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated. 9. Value must be 2 characters 10. If value is in [08,10] then Restricted Benefits Code (ELG.005.097) must be "1" 11. If value equals "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated 12. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated 13. If value equals "01", then Eligibility Group (ELG.005.087) must be "23" 14. If value equals "03", then Eligibility Group (ELG.005.087) must be "25" |
| 2024-06-03 | RESTRICTED-BENEFITS-CODE/ELG.005.097 | Coding Requirement(s) | UPDATE | 1009|ELG097|ELG.005.097|RESTRICTED-BENEFITS-CODE|Restricted Benefits Code|Mandatory|A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to.|RESTRICTED-BENEFITS-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|17|79|79|1. Value must be 1 character 2. Value must be in Restricted Benefits Code List (VVL) 3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24" 4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26" 5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23" 6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25" 7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00" 8. Mandatory 9. If value is populated, then Eligibility Group (ELG.005.087) must be populated. 10. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70] 11. If value is in [1,7] then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06" 11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F" 12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1" 13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment 14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23" 16. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25" 17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
1009|ELG097|ELG.005.097|RESTRICTED-BENEFITS-CODE|Restricted Benefits Code|Mandatory|A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to.|RESTRICTED-BENEFITS-CODE|ELG00005|ELIGIBILITY-DETERMINANTS|X(1)|17|79|79|1. Value must be 1 character 2. Value must be in Restricted Benefits Code List (VVL) 3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24" 4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26" 5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23" 6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25" 7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00" 8. Mandatory 9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70] 10. If value is in [1,7] then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06" 11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F" 12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1" 13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment 14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23" 15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25" 16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
| 2024-06-03 | ELIGIBILITY-DETERMINANT-END-DATE/ELG.005.100 | Coding Requirement(s) | UPDATE | 1012|ELG100|ELG.005.100|ELIGIBILITY-DETERMINANT-END-DATE|Eligibility Determinant End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|20|89|96|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1012|ELG100|ELG.005.100|ELIGIBILITY-DETERMINANT-END-DATE|Eligibility Determinant End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|20|89|96|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | ELIGIBILITY-REDETERMINATION-DATE/ELG.005.274 | Data Element Name | UPDATE | 1013|ELG274|ELG.005.274|ELIGIBILITY-REDETERMINTATION-DATE|Eligibility Redetermination Date|Conditional|The date by which a person's Medicaid or CHIP eligibility must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|21|97|104|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. Value must be greater than the Eligibility Determinant Effective Date |
1013|ELG274|ELG.005.274|ELIGIBILITY-REDETERMINATION-DATE|Eligibility Redetermination Date|Conditional|The date by which a person's Medicaid or CHIP eligibility must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. |N/A|ELG00005|ELIGIBILITY-DETERMINANTS|9(8)|21|97|104|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Conditional 3. Value must be greater than the Eligibility Determinant Effective Date |
| 2024-06-03 | ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT/ELG.005.281 | Coding Requirement(s) | UPDATE | 1020|ELG281|ELG.005.281|ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT|Eligibility Termination Reason Other Type Text|Conditional|Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(100)|28|263|362|1. Value must be 100 characters or less 2. Value must not be populated when Eligibility Termination Reason equals "22" (Other) 3. Value must be populated when Eligibility Termination Reason does not equal "22" (Other) 4. Conditional |
1020|ELG281|ELG.005.281|ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT|Eligibility Termination Reason Other Type Text|Conditional|Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'.|N/A|ELG00005|ELIGIBILITY-DETERMINANTS|X(100)|28|263|362|1. Value must be 100 characters or less 2. Value must be populated when Eligibility Termination Reason equals "22" (Other) 3. Value must not be populated when Eligibility Termination Reason does not equal "22" (Other) 4. Conditional |
| 2024-06-03 | HEALTH-HOME-SPA-PARTICIPATION-END-DATE/ELG.006.110 | Coding Requirement(s) | UPDATE | 1029|ELG110|ELG.006.110|HEALTH-HOME-SPA-PARTICIPATION-END-DATE|Health Home SPA Participation End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00006|HEALTH-HOME-SPA-PARTICIPATION-INFORMATION|9(8)|8|250|257|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1029|ELG110|ELG.006.110|HEALTH-HOME-SPA-PARTICIPATION-END-DATE|Health Home SPA Participation End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00006|HEALTH-HOME-SPA-PARTICIPATION-INFORMATION|9(8)|8|250|257|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | HEALTH-HOME-SPA-PROVIDER-END-DATE/ELG.007.122 | Coding Requirement(s) | UPDATE | 1040|ELG122|ELG.007.122|HEALTH-HOME-SPA-PROVIDER-END-DATE|Health Home Spa Provider End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|9(8)|9|280|287|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1040|ELG122|ELG.007.122|HEALTH-HOME-SPA-PROVIDER-END-DATE|Health Home Spa Provider End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|9(8)|9|280|287|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | STATE-NOTATION/ELG.007.124 | Necessity | UPDATE | 1042|ELG124|ELG.007.124|STATE-NOTATION|State Notation|Situational|A free text field for the submitting state to enter whatever information it chooses.|N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|X(500)|11|296|795|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
1042|ELG124|ELG.007.124|STATE-NOTATION|State Notation|Situational|A free text field for the submitting state to enter whatever information it chooses.|N/A|ELG00007|HEALTH-HOME-SPA-PROVIDERS|X(500)|11|296|795|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 2024-06-03 | HEALTH-HOME-CHRONIC-CONDITION-END-DATE/ELG.008.133 | Coding Requirement(s) | UPDATE | 1050|ELG133|ELG.008.133|HEALTH-HOME-CHRONIC-CONDITION-END-DATE|Health Home Chronic Condition End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00008|HEALTH-HOME-CHRONIC-CONDITIONS|9(8)|8|101|108|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1050|ELG133|ELG.008.133|HEALTH-HOME-CHRONIC-CONDITION-END-DATE|Health Home Chronic Condition End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00008|HEALTH-HOME-CHRONIC-CONDITIONS|9(8)|8|101|108|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | LOCKIN-END-DATE/ELG.009.143 | Coding Requirement(s) | UPDATE | 1059|ELG143|ELG.009.143|LOCKIN-END-DATE|Lockin End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00009|LOCK-IN-INFORMATION|9(8)|8|82|89|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1059|ELG143|ELG.009.143|LOCKIN-END-DATE|Lockin End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00009|LOCK-IN-INFORMATION|9(8)|8|82|89|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | STATE-NOTATION/ELG.009.144 | Necessity | UPDATE | 1061|ELG144|ELG.009.144|STATE-NOTATION|State Notation|Situational|A free text field for the submitting state to enter whatever information it chooses.|N/A|ELG00009|LOCK-IN-INFORMATION|X(500)|10|93|592|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
1061|ELG144|ELG.009.144|STATE-NOTATION|State Notation|Situational|A free text field for the submitting state to enter whatever information it chooses.|N/A|ELG00009|LOCK-IN-INFORMATION|X(500)|10|93|592|1. Value must be 500 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Situational |
| 2024-06-03 | MFP-ENROLLMENT-END-DATE/ELG.010.156 | Coding Requirement(s) | UPDATE | 1072|ELG156|ELG.010.156|MFP-ENROLLMENT-END-DATE|MFP Enrollment End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00010|MFP-INFORMATION|9(8)|11|59|66|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1072|ELG156|ELG.010.156|MFP-ENROLLMENT-END-DATE|MFP Enrollment End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00010|MFP-INFORMATION|9(8)|11|59|66|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | STATE-PLAN-OPTION-TYPE/ELG.011.163 | Coding Requirement(s) | UPDATE | 1078|ELG163|ELG.011.163|STATE-PLAN-OPTION-TYPE|State Plan Option Type|Mandatory|This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment.|STATE-PLAN-OPTION-TYPE|ELG00011|STATE-PLAN-OPTION-PARTICIPATION|X(2)|5|42|43|1. Value must be 2 characters 2. Value must be in State Plan Option Type List (VVL) 3. If associated Eligibility Group (ELG.005.087) value is in [72,73,74, 75], and Restricted Benefits Code (ELG.DE.097) is in [1,7], then value must be "06" 4. Mandatory 5. Value must equal "02" when Program Type (CIP.002.129) equals "13" 6. Value must equal "02" when Program Type (COT.002.065) equals "13" |
1078|ELG163|ELG.011.163|STATE-PLAN-OPTION-TYPE|State Plan Option Type|Mandatory|This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment.|STATE-PLAN-OPTION-TYPE|ELG00011|STATE-PLAN-OPTION-PARTICIPATION|X(2)|5|42|43|1. Value must be 2 characters 2. Value must be in State Plan Option Type List (VVL) 3. If associated Eligibility Group (ELG.005.087) value is in [72,73,74, 75], and Restricted Benefits Code (ELG.DE.097) is in [1,7], then value must be "06" 4. Mandatory |
| 2024-06-03 | LTSS-ELIGIBILITY-END-DATE/ELG.013.185 | Coding Requirement(s) | UPDATE | 1098|ELG185|ELG.013.185|LTSS-ELIGIBILITY-END-DATE|LTSS Eligibility End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00013|LTSS-PARTICIPATION|9(8)|8|81|88|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1098|ELG185|ELG.013.185|LTSS-ELIGIBILITY-END-DATE|LTSS Eligibility End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00013|LTSS-PARTICIPATION|9(8)|8|81|88|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | MANAGED-CARE-PLAN-TYPE/ELG.014.193 | Coding Requirement(s) | UPDATE | 1105|ELG193|ELG.014.193|MANAGED-CARE-PLAN-TYPE|Managed Care Plan Type|Mandatory|A model of health care delivery organized to provide a defined set of services. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/|MANAGED-CARE-PLAN-TYPE|ELG00014|MANAGED-CARE-PARTICIPATION|X(2)|6|54|55|1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. Mandatory 4. Value must not be populated when Managed Care Plan ID (ELG.014.192) is not populated 5. Value must equal the Managed Care Plan Type (MCR.002.024) associated with the State Plan Identification Number (MCR.002.018) |
1105|ELG193|ELG.014.193|MANAGED-CARE-PLAN-TYPE|Managed Care Plan Type|Mandatory|A model of health care delivery organized to provide a defined set of services. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/|MANAGED-CARE-PLAN-TYPE|ELG00014|MANAGED-CARE-PARTICIPATION|X(2)|6|54|55|1. Value must be 2 characters 2. Value must be in Managed Care Plan Type List (VVL) 3. Mandatory 4. Value must equal the Managed Care Plan Type (MCR.002.024) associated with the State Plan Identification Number (MCR.002.018) |
| 2024-06-03 | MANAGED-CARE-PLAN-ENROLLMENT-END-DATE/ELG.014.197 | Coding Requirement(s) | UPDATE | 1107|ELG197|ELG.014.197|MANAGED-CARE-PLAN-ENROLLMENT-END-DATE|Managed Care Plan Enrollment End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00014|MANAGED-CARE-PARTICIPATION|9(8)|8|64|71|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1107|ELG197|ELG.014.197|MANAGED-CARE-PLAN-ENROLLMENT-END-DATE|Managed Care Plan Enrollment End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00014|MANAGED-CARE-PARTICIPATION|9(8)|8|64|71|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | ETHNICITY-DECLARATION-END-DATE/ELG.015.206 | Coding Requirement(s) | UPDATE | 1115|ELG206|ELG.015.206|ETHNICITY-DECLARATION-END-DATE|Ethnicity Declaration End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00015|ETHNICITY-INFORMATION|9(8)|7|51|58|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1115|ELG206|ELG.015.206|ETHNICITY-DECLARATION-END-DATE|Ethnicity Declaration End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00015|ETHNICITY-INFORMATION|9(8)|7|51|58|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | DISABILITY-TYPE-END-DATE/ELG.017.226 | Coding Requirement(s) | UPDATE | 1134|ELG226|ELG.017.226|DISABILITY-TYPE-END-DATE|Disability Type End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00017|DISABILITY-INFORMATION|9(8)|7|52|59|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1134|ELG226|ELG.017.226|DISABILITY-TYPE-END-DATE|Disability Type End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00017|DISABILITY-INFORMATION|9(8)|7|52|59|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | 1115A-END-DATE/ELG.018.235 | Coding Requirement(s) | UPDATE | 1142|ELG235|ELG.018.235|1115A-END-DATE|1115A End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00018|1115A-DEMONSTRATION-INFORMATION|9(8)|7|51|58|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1142|ELG235|ELG.018.235|1115A-END-DATE|1115A End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00018|1115A-DEMONSTRATION-INFORMATION|9(8)|7|51|58|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE/ELG.020.244 | Coding Requirement(s) | UPDATE | 1150|ELG244|ELG.020.244|HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE|HCBS Chronic Condition Non Health Home End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00020|HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME|9(8)|7|53|60|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1150|ELG244|ELG.020.244|HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE|HCBS Chronic Condition Non Health Home End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00020|HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME|9(8)|7|53|60|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | ENROLLMENT-END-DATE/ELG.021.254 | Coding Requirement(s) | UPDATE | 1158|ELG254|ELG.021.254|ENROLLMENT-END-DATE|Enrollment End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00021|ENROLLMENT-TIME-SPAN-SEGMENT|9(8)|7|51|58|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1158|ELG254|ELG.021.254|ENROLLMENT-END-DATE|Enrollment End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00021|ENROLLMENT-TIME-SPAN-SEGMENT|9(8)|7|51|58|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | ELG-IDENTIFIER-EFF-DATE/ELG.022.263 | Coding Requirement(s) | UPDATE | 1166|ELG263|ELG.022.263|ELG-IDENTIFIER-EFF-DATE|Eligible Identifier Effective Date|Mandatory|The first calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00022|ELG-IDENTIFIERS|9(8)|7|61|68|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1166|ELG263|ELG.022.263|ELG-IDENTIFIER-EFF-DATE|Eligible Identifier Effective Date|Mandatory|The first calendar day on which all of the other data elements in the same segment were effective.|N/A|ELG00022|ELG-IDENTIFIERS|9(8)|7|61|68|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | DATA-DICTIONARY-VERSION/FTX.001.002 | Definition | UPDATE | 1185|FTX002|FTX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|FTX00001|FILE-HEADER-RECORD-FTX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
1185|FTX002|FTX.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|FTX00001|FILE-HEADER-RECORD-FTX|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/FTX.001.005 | Definition | UPDATE | 1188|FTX005|FTX.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
1188|FTX005|FTX.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|FTX00001|FILE-HEADER-RECORD-FTX|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.002.023 | Necessity; Coding Requirement(s) |
UPDATE | 1204|FTX023|FTX.002.023|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1204|FTX023|FTX.002.023|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | PAYER-MCR-PLAN-TYPE-OTHER-TEXT/FTX.002.032 | Coding Requirement(s) | UPDATE | 1213|FTX032|FTX.002.032|PAYER-MCR-PLAN-TYPE-OTHER-TEXT|Payer MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|15|301|400|1. Value must be 100 characters or less 2. Value must be populated when Payee MCR Plan Type equals "95" 3. Conditional |
1213|FTX032|FTX.002.032|PAYER-MCR-PLAN-TYPE-OTHER-TEXT|Payer MCR Plan Type Other Text|Conditional|This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other".|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(100)|15|301|400|1. Value must be 100 characters or less 2. Value must be populated when Payer MCR Plan Type equals "95" 3. Conditional |
| 2024-06-03 | CAPITATION-PERIOD-START-DATE/FTX.002.043 | Coding Requirement(s) | UPDATE | 1224|FTX043|FTX.002.043|CAPITATION-PERIOD-START-DATE|Capitation Period Start Date|Mandatory|The date representing the beginning of the period covered by the capitation or sub-capitation payment or recoupment; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|26|887|894|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Capitation Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
1224|FTX043|FTX.002.043|CAPITATION-PERIOD-START-DATE|Capitation Period Start Date|Mandatory|The date representing the beginning of the period covered by the capitation or sub-capitation payment or recoupment; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).|N/A|FTX00002|INDIVIDUAL-CAPITATION-PMPM|9(8)|26|887|894|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Capitation Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.002.051 | Coding Requirement(s) | UPDATE | 1232|FTX051|FTX.002.051|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|34|983|984|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Type of Claim is in [3,C,W], then value must be populated 4. Conditional |
1232|FTX051|FTX.002.051|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|34|983|984|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 2024-06-03 | FUNDING-SOURCE-NONFEDERAL-SHARE/FTX.002.052 | Necessity; Coding Requirement(s) |
UPDATE | 1233|FTX052|FTX.002.052|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Mandatory|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|35|985|986|1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Mandatory |
1233|FTX052|FTX.002.052|FUNDING-SOURCE-NONFEDERAL-SHARE|Funding Source Nonfederal Share|Conditional|A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.|FUNDING-SOURCE-NONFEDERAL-SHARE|FTX00002|INDIVIDUAL-CAPITATION-PMPM|X(2)|35|985|986|1. Value must be 2 characters 2. Value must be in Funding Source Nonfederal Share List (VVL) 3. If Subcapitation Indicator equals "01", then value must be populated 4. Conditional |
| 2024-06-03 | ADJUSTMENT-IND/FTX.003.070 | Necessity; Coding Requirement(s) |
UPDATE | 1249|FTX070|FTX.003.070|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1249|FTX070|FTX.003.070|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.003.096 | Coding Requirement(s) | UPDATE | 1275|FTX096|FTX.003.096|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|32|731|732|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1275|FTX096|FTX.003.096|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00003|INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT|X(2)|32|731|732|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.004.111 | Necessity; Coding Requirement(s) |
UPDATE | 1288|FTX111|FTX.004.111|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1288|FTX111|FTX.004.111|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.004.140 | Coding Requirement(s) | UPDATE | 1317|FTX140|FTX.004.140|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|35|758|759|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. If Policy Owner Code equals"01", then value must be populated 4. Conditional |
1317|FTX140|FTX.004.140|FUNDING-CODE|Funding Code|Conditional|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00004|GROUP-INSURANCE-PREMIUM-PAYMENT|X(2)|35|758|759|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. If Policy Owner Code equals "01", then value must be populated 4. Conditional |
| 2024-06-03 | ADJUSTMENT-IND/FTX.005.155 | Necessity; Coding Requirement(s) |
UPDATE | 1330|FTX155|FTX.005.155|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00005|COST-SHARING-OFFSET|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1330|FTX155|FTX.005.155|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00005|COST-SHARING-OFFSET|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | COVERAGE-PERIOD-START-DATE/FTX.005.174 | Coding Requirement(s) | UPDATE | 1349|FTX174|FTX.005.174|COVERAGE-PERIOD-START-DATE|Coverage Period Start Date|Mandatory|The date representing the beginning of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the beginning of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them.|N/A|FTX00005|COST-SHARING-OFFSET|9(8)|25|805|812|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Cost Settlement Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
1349|FTX174|FTX.005.174|COVERAGE-PERIOD-START-DATE|Coverage Period Start Date|Mandatory|The date representing the beginning of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the beginning of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them.|N/A|FTX00005|COST-SHARING-OFFSET|9(8)|25|805|812|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Cost Settlement Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.005.182 | Coding Requirement(s) | UPDATE | 1357|FTX182|FTX.005.182|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00005|COST-SHARING-OFFSET|X(2)|33|901|902|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1357|FTX182|FTX.005.182|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00005|COST-SHARING-OFFSET|X(2)|33|901|902|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.006.198 | Necessity; Coding Requirement(s) |
UPDATE | 1371|FTX198|FTX.006.198|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00006|VALUE-BASED-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1371|FTX198|FTX.006.198|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00006|VALUE-BASED-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.006.224 | Coding Requirement(s) | UPDATE | 1397|FTX224|FTX.006.224|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00006|VALUE-BASED-PAYMENT|X(2)|32|881|882|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1397|FTX224|FTX.006.224|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00006|VALUE-BASED-PAYMENT|X(2)|32|881|882|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.007.242 | Necessity; Coding Requirement(s) |
UPDATE | 1413|FTX242|FTX.007.242|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1413|FTX242|FTX.007.242|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | PAYMENT-PERIOD-START-DATE/FTX.007.259 | Coding Requirement(s) | UPDATE | 1430|FTX259|FTX.007.259|PAYMENT-PERIOD-START-DATE|Payment Period Start Date|Mandatory|The date representing the start of the time period that the payment is expected to be used by the provider. |N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|23|765|772|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Mandatory 3. Value of the CC component must be equal to 20 |
1430|FTX259|FTX.007.259|PAYMENT-PERIOD-START-DATE|Payment Period Start Date|Mandatory|The date representing the start of the time period that the payment is expected to be used by the provider. |N/A|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|9(8)|23|765|772|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Payment Period End Date 3. Mandatory 4. Value of the CC component must be equal to "20" |
| 2024-06-03 | FUNDING-CODE/FTX.007.269 | Coding Requirement(s) | UPDATE | 1440|FTX269|FTX.007.269|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|33|963|964|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1440|FTX269|FTX.007.269|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00007|STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM|X(2)|33|963|964|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.008.285 | Necessity; Coding Requirement(s) |
UPDATE | 1454|FTX285|FTX.008.285|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00008|COST-SETTLEMENT-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1454|FTX285|FTX.008.285|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00008|COST-SETTLEMENT-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | COST-SETTLEMENT-PERIOD-START-DATE/FTX.008.301 | Coding Requirement(s) | Update | 1470|FTX301|FTX.008.301|COST-SETTLEMENT-PERIOD-START-DATE|Cost Settlement Period Start Date|Mandatory|The date representing the beginning of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement begin date would be March 1 of that year. |N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|22|665|672|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Cost Settlement Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
1470|FTX301|FTX.008.301|COST-SETTLEMENT-PERIOD-START-DATE|Cost Settlement Period Start Date|Mandatory|The date representing the beginning of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement begin date would be March 1 of that year. |N/A|FTX00008|COST-SETTLEMENT-PAYMENT|9(8)|22|665|672|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Cost Settlement Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.008.309 | Coding Requirement(s) | UPDATE | 1478|FTX309|FTX.008.309|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|30|761|762|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1478|FTX309|FTX.008.309|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00008|COST-SETTLEMENT-PAYMENT|X(2)|30|761|762|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.009.324 | Necessity; Coding Requirement(s) |
UPDATE | 1491|FTX324|FTX.009.324|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00009|FQHC-WRAP-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1491|FTX324|FTX.009.324|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00009|FQHC-WRAP-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | WRAP-PERIOD-START-DATE/FTX.009.340 | Coding Requirement(s) | UPDATE | 1507|FTX340|FTX.009.340|WRAP-PERIOD-START-DATE|Wrap Period Start Date|Mandatory|The date representing the beginning of the FQHC wrap payment or recoupment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment begin date would be March 1 of that year.|N/A|FTX00009|FQHC-WRAP-PAYMENT|9(8)|22|665|672|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Coverage Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
1507|FTX340|FTX.009.340|WRAP-PERIOD-START-DATE|Wrap Period Start Date|Mandatory|The date representing the beginning of the FQHC wrap payment or recoupment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment begin date would be March 1 of that year.|N/A|FTX00009|FQHC-WRAP-PAYMENT|9(8)|22|665|672|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Coverage Period End Date 3. Value of the CC component must be equal to "20" 4. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.009.348 | Coding Requirement(s) | UPDATE | 1515|FTX348|FTX.009.348|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00009|FQHC-WRAP-PAYMENT|X(2)|30|761|762|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1515|FTX348|FTX.009.348|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00009|FQHC-WRAP-PAYMENT|X(2)|30|761|762|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | ADJUSTMENT-IND/FTX.095.363 | Necessity; Coding Requirement(s) |
UPDATE | 1528|FTX363|FTX.095.363|ADJUSTMENT-IND|Adjustment Indicator|Conditional|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Conditional |
1528|FTX363|FTX.095.363|ADJUSTMENT-IND|Adjustment Indicator|Mandatory|Indicates the type of adjustment record.|ADJUSTMENT-IND|FTX00095 |MISCELLANEOUS-PAYMENT|X(1)|6|122|122|1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Mandatory |
| 2024-06-03 | FUNDING-CODE/FTX.095.396 | Coding Requirement(s) | UPDATE | 1561|FTX396|FTX.095.396|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|39|1199|1200|1. Value must be 2 characters 2. Value must be in Funding Code List (VVL) 3. Mandatory |
1561|FTX396|FTX.095.396|FUNDING-CODE|Funding Code|Mandatory|A code to indicate the source of non-federal share funds.|FUNDING-CODE|FTX00095 |MISCELLANEOUS-PAYMENT|X(2)|39|1199|1200|1. Value must be 1 character 2. Value must be in Funding Code List (VVL) 3. Mandatory |
| 2024-06-03 | DATA-DICTIONARY-VERSION/MCR.001.002 | Definition | UPDATE | 1572|MCR002|MCR.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
1572|MCR002|MCR.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/MCR.001.005 | Definition | UPDATE | 1575|MCR005|MCR.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
1575|MCR005|MCR.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|MCR00001|FILE-HEADER-RECORD-MANAGED-CARE|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | CORE-BASED-STATISTICAL-AREA-CODE/MCR.002.027 | Definition | UPDATE | 1597|MCR027|MCR.002.027|CORE-BASED-STATISTICAL-AREA-CODE|Core Based Statistical Area Code|Mandatory|A code signifying whether the Managed Care Organization's (MCO) service area falls into one or more metropolitan or micropolitan statistical areas. Whenever a service area straddles two types of areas (e.g., metropolitan & micropolitan, metropolitan & non-CBSA area) classify the service area based on the denser classification. Metropolitan and micropolitan statistical areas (metro and micro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB). The term "Core Based Statistical Area" (CBSA) is a collective term for both metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009. See the hyperlink below for further information. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf|CORE-BASED-STATISTICAL-AREA-CODE|MCR00002|MANAGED-CARE-MAIN|X(1)|12|112|112|1. Value must be 1 character 2. Value must be in Core Based Statistical Area Code List (VVL) 3. Mandatory |
1597|MCR027|MCR.002.027|CORE-BASED-STATISTICAL-AREA-CODE|Core Based Statistical Area Code|Mandatory|A code signifying whether the Managed Care Organization's (MCO) service area falls into one or more metropolitan or micropolitan statistical areas. Whenever a service area straddles two types of areas (e.g., metropolitan and micropolitan, metropolitan and non-CBSA area) classify the service area based on the denser classification. Metropolitan and micropolitan statistical areas (metro and micro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB). The term "Core Based Statistical Area" (CBSA) is a collective term for both metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009. See the hyperlink below for further information. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf|CORE-BASED-STATISTICAL-AREA-CODE|MCR00002|MANAGED-CARE-MAIN|X(1)|12|112|112|1. Value must be 1 character 2. Value must be in Core Based Statistical Area Code List (VVL) 3. Mandatory |
| 2024-06-03 | MANAGED-CARE-MAIN-REC-END-DATE/MCR.002.031 | Coding Requirement(s) | UPDATE | 1601|MCR031|MCR.002.031|MANAGED-CARE-MAIN-REC-END-DATE|Managed Care Main Record End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00002|MANAGED-CARE-MAIN|9(8)|16|125|132|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1601|MCR031|MCR.002.031|MANAGED-CARE-MAIN-REC-END-DATE|Managed Care Main Record End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00002|MANAGED-CARE-MAIN|9(8)|16|125|132|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE/MCR.003.040 | Coding Requirement(s) | UPDATE | 1609|MCR040|MCR.003.040|MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE|Managed Care Location and Contract End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00003|MANAGED-CARE-LOCATION-AND-CONTACT-INFO|9(8)|7|57|64|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1609|MCR040|MCR.003.040|MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE|Managed Care Location and Contract End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00003|MANAGED-CARE-LOCATION-AND-CONTACT-INFO|9(8)|7|57|64|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | MANAGED-CARE-SERVICE-AREA-END-DATE/MCR.004.060 | Coding Requirement(s) | UPDATE | 1628|MCR060|MCR.004.060|MANAGED-CARE-SERVICE-AREA-END-DATE|Managed Care Service Area End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00004|MANAGED-CARE-SERVICE-AREA|9(8)|7|72|79|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1628|MCR060|MCR.004.060|MANAGED-CARE-SERVICE-AREA-END-DATE|Managed Care Service Area End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00004|MANAGED-CARE-SERVICE-AREA|9(8)|7|72|79|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | MANAGED-CARE-OP-AUTHORITY-END-DATE/MCR.005.070 | Coding Requirement(s) | UPDATE | 1637|MCR070|MCR.005.070|MANAGED-CARE-OP-AUTHORITY-END-DATE|Managed Care Op Authority End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00005|MANAGED-CARE-OPERATING-AUTHORITY|9(8)|8|64|71|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1637|MCR070|MCR.005.070|MANAGED-CARE-OP-AUTHORITY-END-DATE|Managed Care Op Authority End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00005|MANAGED-CARE-OPERATING-AUTHORITY|9(8)|8|64|71|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | MANAGED-CARE-PLAN-POP-END-DATE/MCR.006.079 | Coding Requirement(s) | UPDATE | 1645|MCR079|MCR.006.079|MANAGED-CARE-PLAN-POP-END-DATE|Managed Care Plan Population End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00006|MANAGED-CARE-PLAN-POPULATION-ENROLLED|9(8)|7|44|51|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1645|MCR079|MCR.006.079|MANAGED-CARE-PLAN-POP-END-DATE|Managed Care Plan Population End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|MCR00006|MANAGED-CARE-PLAN-POPULATION-ENROLLED|9(8)|7|44|51|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | DATE-ACCREDITATION-END/MCR.007.088 | Coding Requirement(s) | UPDATE | 1653|MCR088|MCR.007.088|DATE-ACCREDITATION-END|Date Accreditation End|Mandatory|The date when organization's accreditation ends.|N/A|MCR00007|MANAGED-CARE-ACCREDITATION-ORGANIZATION|9(8)|7|44|51|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20] |
1653|MCR088|MCR.007.088|DATE-ACCREDITATION-END|Date Accreditation End|Mandatory|The date when organization's accreditation ends.|N/A|MCR00007|MANAGED-CARE-ACCREDITATION-ORGANIZATION|9(8)|7|44|51|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | MANAGED-CARE-PLAN-OTHER-ID-TYPE/MCR.010.118 | Data Element Name; Data Element Name Text; Valid Value List; Coding Requirement(s) |
UPDATE | 1659|MCR118|MCR.010.118|MANAGED-CARE-PLAN-ID-TYPE|Managed Care Plan ID Type|Mandatory|A code to identify the kind of managed care identifier that is captured in the Managed Care Identifier data element. The state should submit updates to T-MSIS whenever an identifier is retired or issued.|MANAGED-CARE-PLAN-ID-TYPE|MCR00010|MANAGED-CARE-ID|X(2)|5|34|35|1. Value must be 2 characters 2. Value must be in Managed Care Plan ID Type List (VVL) 3. Mandatory |
1659|MCR118|MCR.010.118|MANAGED-CARE-PLAN-OTHER-ID-TYPE|Managed Care Plan Other ID Type|Mandatory|A code to identify the kind of managed care identifier that is captured in the Managed Care Identifier data element. The state should submit updates to T-MSIS whenever an identifier is retired or issued.|MANAGED-CARE-PLAN-OTHER-ID-TYPE|MCR00010|MANAGED-CARE-ID|X(2)|5|34|35|1. Value must be 2 characters 2. Value must be in Managed Care Plan Other ID Type List (VVL) 3. Mandatory |
| 2024-06-03 | MANAGED-CARE-PLAN-OTHER-ID/MCR.010.119 | Data Element Name; Data Element Name Text; |
UPDATE | 1660|MCR119|MCR.010.119|MANAGED-CARE-PLAN-ID|Managed Care Plan ID|Mandatory|A data element to capture the various IDs used to identify a managed care plan. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Identifier Type data element.|N/A|MCR00010|MANAGED-CARE-ID|X(30)|6|36|65|1. Value must be 30 characters 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
1660|MCR119|MCR.010.119|MANAGED-CARE-PLAN-OTHER-ID|Managed Care Plan Other ID|Mandatory|A data element to capture the various IDs used to identify a managed care plan. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Identifier Type data element.|N/A|MCR00010|MANAGED-CARE-ID|X(30)|6|36|65|1. Value must be 30 characters 2. Value must not contain a pipe or asterisk symbol 3. Mandatory |
| 2024-06-03 | MANAGED-CARE-ID-END-DATE/MCR.010.121 | Coding Requirement(s) | UPDATE | 1662|MCR121|MCR.010.121|MANAGED-CARE-ID-END-DATE|Managed Care ID End Date|Mandatory|The date when organization's accreditation ends.|N/A|MCR00010|MANAGED-CARE-ID|9(8)|8|74|81|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1662|MCR121|MCR.010.121|MANAGED-CARE-ID-END-DATE|Managed Care ID End Date|Mandatory|The date when organization's accreditation ends.|N/A|MCR00010|MANAGED-CARE-ID|9(8)|8|74|81|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | DATA-DICTIONARY-VERSION/PRV.001.002 | Definition | UPDATE | 1665|PRV002|PRV.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
1665|PRV002|PRV.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/PRV.001.005 | Definition | UPDATE | 1668|PRV005|PRV.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
1668|PRV005|PRV.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|PRV00001|FILE-HEADER-RECORD-PROVIDER|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE/PRV.003.044 | Data Element Name Text | UPDATE | 1707|PRV044|PRV.003.044|PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE|Provider Location & Contact Info Effective Date|Mandatory|The first calendar day on which all of the other data elements in the same segment were effective.|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|9(8)|6|57|64|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20] |
1707|PRV044|PRV.003.044|PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE|Provider Location and Contact Info Effective Date|Mandatory|The first calendar day on which all of the other data elements in the same segment were effective.|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|9(8)|6|57|64|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [19,19,99] |
| 2024-06-03 | PROV-LOCATION-AND-CONTACT-INFO-END-DATE/PRV.003.045 | Data Element Name Text; Coding Requirement(s) |
UPDATE | 1708|PRV045|PRV.003.045|PROV-LOCATION-AND-CONTACT-INFO-END-DATE|Provider Location & Contact Info End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|9(8)|7|65|72|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1708|PRV045|PRV.003.045|PROV-LOCATION-AND-CONTACT-INFO-END-DATE|Provider Location and Contact Info End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|9(8)|7|65|72|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be greater than or equal to associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | ADDR-LN1/PRV.003.047 | Coding Requirement(s) | UPDATE | 1710|PRV047|PRV.003.047|ADDR-LN1|Provider Address Line 1|Mandatory|The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.).|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|X(60)|9|74|133|1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory 5. When populated, the associated Address Type is required |
1710|PRV047|PRV.003.047|ADDR-LN1|Provider Address Line 1|Mandatory|The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.).|N/A|PRV00003|PROV-LOCATION-AND-CONTACT-INFO|X(60)|9|74|133|1. Value must be 60 characters or less 2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s) 3. Value must not contain a pipe or asterisk symbols 4. Mandatory |
| 2024-06-03 | BED-TYPE-END-DATE/PRV.010.131 | Coding Requirement(s) | UPDATE | 1787|PRV131|PRV.010.131|BED-TYPE-END-DATE|Bed Type End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|PRV00010|PROV-BED-TYPE-INFO|9(8)|7|65|72|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1787|PRV131|PRV.010.131|BED-TYPE-END-DATE|Bed Type End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|PRV00010|PROV-BED-TYPE-INFO|9(8)|7|65|72|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | DATA-DICTIONARY-VERSION/TPL.001.002 | Definition | UPDATE | 1792|TPL002|TPL.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary.|DATA-DICTIONARY-VERSION|TPL00001|FILE-HEADER-RECORD-TPL|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
1792|TPL002|TPL.001.002|DATA-DICTIONARY-VERSION|Data Dictionary Version|Mandatory|A data element to capture the version of the T-MSIS data dictionary that was used to build the file.|DATA-DICTIONARY-VERSION|TPL00001|FILE-HEADER-RECORD-TPL|X(10)|2|9|18|1. Value must be 10 characters or less 2. Value must be in Data Dictionary Version List (VVL) 3. Value must not include the pipe ("|") symbol 4. Mandatory |
| 2024-06-03 | DATA-MAPPING-DOCUMENT-VERSION/TPL.001.005 | Definition | UPDATE | 1795|TPL005|TPL.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file. Use the version number specified on the title page of the data mapping document|N/A|TPL00001|FILE-HEADER-RECORD-TPL|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
1795|TPL005|TPL.001.005|DATA-MAPPING-DOCUMENT-VERSION|Data Mapping Document Version|Mandatory|Identifies the version of the T-MSIS data mapping document used to build a state submission file.|N/A|TPL00001|FILE-HEADER-RECORD-TPL|X(9)|5|23|31|1. Value must be 9 characters or less 2. Mandatory |
| 2024-06-03 | ELIG-PRSN-MAIN-END-DATE/TPL.002.026 | Coding Requirement(s) | UPDATE | 1817|TPL026|TPL.002.026|ELIG-PRSN-MAIN-END-DATE|Eligible Person Main End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|9(8)|11|113|120|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1817|TPL026|TPL.002.026|ELIG-PRSN-MAIN-END-DATE|Eligible Person Main End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|TPL00002|TPL-MEDICAID-ELIGIBLE-PERSON-MAIN|9(8)|11|113|120|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | INSURANCE-COVERAGE-END-DATE/TPL.003.049 | Coding Requirement(s) | UPDATE | 1834|TPL049|TPL.003.049|INSURANCE-COVERAGE-END-DATE|Insurance Coverage End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|TPL00003|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO|9(8)|16|204|211|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment End Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20] 5. When associated Date of Death (ELG.002.025) is populated, data element value must be less than or equal to Date of Death |
1834|TPL049|TPL.003.049|INSURANCE-COVERAGE-END-DATE|Insurance Coverage End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|TPL00003|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO|9(8)|16|204|211|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be after or the same as the associated Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| 2024-06-03 | INSURANCE-CATEGORIES-END-DATE/TPL.004.060 | Coding Requirement(s) | UPDATE | 1845|TPL060|TPL.004.060|INSURANCE-CATEGORIES-END-DATE|Insurance Categories End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|TPL00004|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES|9(8)|9|66|73|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be before or the same as the associated Segment Effective Date value 3. Mandatory 4. Value of the CC component must be in [18,19,20,99] |
1845|TPL060|TPL.004.060|INSURANCE-CATEGORIES-END-DATE|Insurance Categories End Date|Mandatory|The last calendar day on which all of the other data elements in the same segment were effective.|N/A|TPL00004|TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES|9(8)|9|66|73|1. The date must be a valid calendar date in the form "CCYYMMDD" 2. Value must be the after or the same as the associated Effective Date value 3. Mandatory 4. Value of the CC component must be in [19,20,99] |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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