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T-MSIS Data Dictionary - Changes Between Versions 2.4.0 and 4.0.1 Redline

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	T-MSIS Data Dictionary - Changes Between Versions 2.4.0 and 4.0.1 Redline
Subject	T-MSIS Data Dictionary - Changes Between Versions 2.4.0 and 4.0.1 Redline
Author	CMS
Last Modified By	Johnston, Brian (CMS/CMCS)
File Modified	2026-05-14
File Created	2026-05-14
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Centers for Medicaid and CHIP Services (CMCS)

T-MSIS Data Dictionary - Changes Between Versions 4.0.0 and 4.1.0 Redline
Last Updated: 2026-04-29

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: 11/30/2027). 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 21244-1850.388

Color Coding Key:
• Black indicates no change
• Red with strike-out indicates content has been removed
• Red indicates content changed and/or added

Table of Contents
T-MSIS Data Dictionary – CIP File (No Changes Between Versions 4.0.0 and 4.1.0) 3
T-MSIS Data Dictionary – CLT File (No Changes Between Versions 4.0.0 and 4.1.0) 72
T-MSIS Data Dictionary – COT File (No Changes Between Versions 4.0.0 and 4.1.0) 142
T-MSIS Data Dictionary – CRX File (No Changes Between Versions 4.0.0 and 4.1.0) 237
T-MSIS Data Dictionary – ELG File Changes Between Versions 4.0.0 and 4.1.0 297
T-MSIS Data Dictionary – MCR File (No Changes Between Versions 4.0.0 and 4.1.0) 392
T-MSIS Data Dictionary – PRV File (No Changes Between Versions 4.0.0 and 4.1.0) 423
T-MSIS Data Dictionary – TPL File (No Changes Between Versions 4.0.0 and 4.1.0) 461
T-MSIS Data Dictionary – FTX File (No Changes Between Versions 4.0.0 and 4.1.0) 487

T-MSIS Data Dictionary – CIP File (No Changes Between Versions 4.0.0 and 4.1.0)

Data Element Number

System Data Element Number

Data Element

Data Element Name Text

Data Element Necessity

Definition

Valid Value List (VVL)

File Segment Number

File Segment Name

Size

Pipe Separated Value Segment Data Element Order
Fixed Length Field Start Position

Fixed Length Field Stop Position

Coding Requirements

CIP001
CIP.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
CIP00001
FILE-HEADER-RECORD-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 "CIP00001"
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
CIP003
CIP.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
CIP00001
FILE-HEADER-RECORD-IP
X(1)
3
19
19
1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory
CIP004
CIP.001.004
FILE-ENCODING-SPECIFICATION
File Encoding Specification
Mandatory
Denotes which supported file encoding standard was used to create the file.
FILE-ENCODING-SPECIFICATION
CIP00001
FILE-HEADER-RECORD-IP
X(3)
4
20
22
1. Value must be 3 characters
2. Value must be in File Encoding Specification List (VVL)
3. Mandatory
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
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
CIP007
CIP.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
CIP00001
FILE-HEADER-RECORD-IP
X(2)
7
40
41
1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
CIP008
CIP.001.008
DATE-FILE-CREATED
Date File Created
Mandatory
The date on which the file was created.
N/A
CIP00001
FILE-HEADER-RECORD-IP
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
CIP009
CIP.001.009
START-OF-TIME-PERIOD
Start of Time Period
Mandatory
This value must be the first day of the reporting month, regardless of the actual date span of the data in the file.
N/A
CIP00001
FILE-HEADER-RECORD-IP
9(8)
9
50
57
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be equal to or earlier than associated Date File Created
3. Value must be before associated End of Time Period
4. Mandatory
5. Value of the CC component must be "20"
CIP010
CIP.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
CIP00001
FILE-HEADER-RECORD-IP
9(8)
10
58
65
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be equal to or earlier than associated Date File Created
4. Value must be equal to or after associated Start of Time Period
5. Mandatory
CIP011
CIP.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
CIP00001
FILE-HEADER-RECORD-IP
X(1)
11
66
66
1. Value must be 1 character
2. For production files, value must be equal to "P"
3. Value must be in File Status Indicator List (VVL)
4. Mandatory
CIP012
CIP.001.012
SSN-INDICATOR
SSN Indicator
Mandatory
Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability files.
SSN-INDICATOR
CIP00001
FILE-HEADER-RECORD-IP
X(1)
12
67
67
1. Value must be 1 character
2. Value must be in SSN Indicator List (VVL)
3. Mandatory
CIP013
CIP.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
CIP00001
FILE-HEADER-RECORD-IP
9(11)
13
68
78
1. Value must be 11 digits or less
2. Value must be a positive integer
3. Value must be between 0:99999999999 (inclusive)
4. Value must equal the number of records included in the file submission except for the file header record.
5. Mandatory
CIP275
CIP.001.275
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
CIP00001
FILE-HEADER-RECORD-IP
X(4)
14
79
82
1. Value must be 4 characters or less
2. Value must between 1 and 9999
3. Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1)
4. Value must not contain a pipe symbol
5. Mandatory
CIP014
CIP.001.014
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CIP00001
FILE-HEADER-RECORD-IP
X(500)
15
83
582
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
CIP016
CIP.002.016
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
CIP00002
CLAIM-HEADER-RECORD-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 "CIP00002"
CIP017
CIP.002.017
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
CIP00002
CLAIM-HEADER-RECORD-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)
CIP018
CIP.002.018
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
CIP00002
CLAIM-HEADER-RECORD-IP
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
CIP019
CIP.002.019
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
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
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
CIP021
CIP.002.021
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(12)
6
122
133
1. Value must be 12 characters or less
2. Mandatory
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)
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
CIP024
CIP.002.024
TYPE-OF-HOSPITAL
Type of Hospital
Mandatory
This code denotes the type of hospital on the claim (servicing facility).
TYPE-OF-HOSPITAL
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
9
155
156
1. Value must be 2 characters
2. Value must be in Type of Hospital List (VVL)
3. Mandatory
CIP025
CIP.002.025
1115A-DEMONSTRATION-IND
1115A Demonstration Indicator
Conditional
In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration.
1115A-DEMONSTRATION-IND
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
10
157
157
1. Value must be 1 character
2. Value must be in 1115A Demonstration Indicator List (VVL)
3. Conditional
4. 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
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"
CIP027
CIP.002.027
ADJUSTMENT-REASON-CODE
Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a claim was paid differently than it was billed.
ADJUSTMENT-REASON-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(3)
12
159
161
1. Value must be 3 characters or less
2. Value must be in Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
CIP028
CIP.002.028
ADMISSION-TYPE
Admission Type
Mandatory
The basic types of admission for Inpatient hospital stays and a code indicating the priority of this admission.
ADMISSION-TYPE
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
13
162
162
1. Value must be 1 character
2. Value must be in Admission Type List (VVL)
3. Mandatory
CIP029
CIP.002.029
DRG-DESCRIPTION
DRG Description
Conditional
Description of the associated state-specific DRG code. If using standard MS-DRG classification system, leave blank.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(20)
14
163
182
1. Value must be 20 characters or less
2. Conditional
CIP068
CIP.002.068
DIAGNOSIS-RELATED-GROUP
Diagnosis Related Group
Conditional
A code representing the Diagnosis Related Group (DRG) that is applicable for the inpatient services being rendered. This field is required on FFS claims and encounters records in which diagnosis related groups are used to determine paid amounts.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(4)
15
183
186
1. Value must be 4 characters or less
2. Conditional
CIP069
CIP.002.069
DIAGNOSIS-RELATED-GROUP-IND
Diagnosis Related Group Indicator
Conditional
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' would represent CMS Grouper version 15. If version is unknown, fill with '99'.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(4)
16
187
190
1. Value must be 4 characters or less
2. The right-most 2 positions must be found in [01-99]
3. Conditional
4. Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated
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
CIP072
CIP.002.072
PROCEDURE-CODE-FLAG-1
Procedure Code Flag 1
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
18
199
200
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. Conditional
4. When populated, there must be a corresponding Procedure Code
5. If Procedure Code 1 (CIP.002.070) is populated, Procedure Code Flag 1 (CIP.002.072) must be "02" (ICD-9 CM) or "07" (ICD-10 - CM PCS)
CIP073
CIP.002.073
PROCEDURE-CODE-DATE-1
Procedure Code Date 1
Conditional
The date upon which a reported medical procedure was performed.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
19
201
208
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
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
CIP076
CIP.002.076
PROCEDURE-CODE-FLAG-2
Procedure Code Flag 2
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
21
217
218
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. Conditional
4. When populated, there must be a corresponding Procedure Code
CIP077
CIP.002.077
PROCEDURE-CODE-DATE-2
Procedure Code Date 2
Conditional
The date upon which a reported medical procedure was performed.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
22
219
226
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
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
CIP080
CIP.002.080
PROCEDURE-CODE-FLAG-3
Procedure Code Flag 3
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
24
235
236
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. Conditional
4. When populated, there must be a corresponding Procedure Code
CIP081
CIP.002.081
PROCEDURE-CODE-DATE-3
Procedure Code Date 3
Conditional
The date upon which a reported medical procedure was performed.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
25
237
244
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
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
CIP084
CIP.002.084
PROCEDURE-CODE-FLAG-4
Procedure Code Flag 4
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
27
253
254
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. Conditional
4. When populated, there must be a corresponding Procedure Code
CIP085
CIP.002.085
PROCEDURE-CODE-DATE-4
Procedure Code Date 4
Conditional
The date upon which a reported medical procedure was performed.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
28
255
262
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
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
CIP088
CIP.002.088
PROCEDURE-CODE-FLAG-5
Procedure Code Flag 5
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
30
271
272
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. Conditional
4. When populated, there must be a corresponding Procedure Code
CIP089
CIP.002.089
PROCEDURE-CODE-DATE-5
Procedure Code Date 5
Conditional
The date upon which a reported medical procedure was performed.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
31
273
280
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
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
CIP092
CIP.002.092
PROCEDURE-CODE-FLAG-6
Procedure Code Flag 6
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
33
289
290
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. Conditional
4. When populated, there must be a corresponding Procedure Code
CIP093
CIP.002.093
PROCEDURE-CODE-DATE-6
Procedure Code Date 6
Conditional
The date upon which a reported medical procedure was performed.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
34
291
298
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
7. Conditional
CIP094
CIP.002.094
ADMISSION-DATE
Admission Date
Mandatory
The date on which the recipient was admitted to a hospital.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
35
299
306
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated Discharge Date value in the claim header
3. Value must be greater than or equal to associated eligible Date of Birth value
4. Value must be less than or equal to associated eligible Date of Death value
5. Mandatory
6. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)
7. Value must be before Adjudication Date (CIP.003.286)
CIP095
CIP.002.095
ADMISSION-HOUR
Admission Hour
Conditional
The hour of admission to a hospital.
HOUR
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
36
307
308
1. Value must be 2 characters
2. Value must be in Hour List (VVL)
3. Conditional
CIP096
CIP.002.096
DISCHARGE-DATE
Discharge Date
Conditional
The date on which the recipient was discharged from a hospital.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
37
309
316
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated Adjudication Date value.
3. Value must be greater than or equal to associated Admission Date value.
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. Conditional
7. 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.
8. When populated, Discharge Hour (CIP.002.097) must be populated
CIP097
CIP.002.097
DISCHARGE-HOUR
Discharge Hour
Conditional
The hour of discharge from a hospital.
HOUR
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
38
317
318
1. Value must be 2 characters
2. Value must be in Hour List (VVL)
3. Conditional
4. When populated, Discharge Date (CIP.002.096) must be populated
CIP098
CIP.002.098
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
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
39
319
326
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CIP.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CIP099
CIP.002.099
MEDICAID-PAID-DATE
Medicaid Paid Date
Mandatory
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
40
327
334
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Total Medicaid Paid Amount
3. Mandatory
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
CIP101
CIP.002.101
TYPE-OF-BILL
Type of Bill
Mandatory
A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.)
TYPE-OF-BILL
CIP00002
CLAIM-HEADER-RECORD-IP
X(4)
42
336
339
1. Value must be 4 characters
2. Value must be in Type of Bill List (VVL)
3. First character must be a "0"
4. Mandatory
CIP102
CIP.002.102
CLAIM-STATUS
Claim Status
Conditional
The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim.
CLAIM-STATUS
CIP00002
CLAIM-HEADER-RECORD-IP
X(3)
43
340
342
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2"
CIP103
CIP.002.103
CLAIM-STATUS-CATEGORY
Claim Status Category
Mandatory
The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.), which is then further detailed in the companion data element claim status.
CLAIM-STATUS-CATEGORY
CIP00002
CLAIM-HEADER-RECORD-IP
X(3)
44
343
345
1. Value must be 3 characters or less
2. Value must be in Claim Status Category List (VVL)
3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"
4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"
5. 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
CIP105
CIP.002.105
CHECK-NUM
Check Number
Conditional
The check or electronic funds transfer number.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(15)
46
348
362
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
CIP106
CIP.002.106
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
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
47
363
370
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Check Number
3. Conditional
CIP108
CIP.002.108
CLAIM-PYMT-REM-CODE-1
Remittance Advice Remark Code 1
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(5)
48
371
375
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
CIP109
CIP.002.109
CLAIM-PYMT-REM-CODE-2
Remittance Advice Remark Code 2
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(5)
49
376
380
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 1 (CIP.002.108) is not populated
CIP110
CIP.002.110
CLAIM-PYMT-REM-CODE-3
Remittance Advice Remark Code 3
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(5)
50
381
385
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 2 (CIP.002.109) is not populated
CIP111
CIP.002.111
CLAIM-PYMT-REM-CODE-4
Remittance Advice Remark Code 4
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(5)
51
386
390
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 3 (CIP.002.110) is not populated
CIP112
CIP.002.112
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
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
52
391
403
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 (CIP.002.132) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251)
CIP113
CIP.002.113
TOT-ALLOWED-AMT
Total Allowed Amount
Conditional
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 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 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.
PAYMENT-LEVEL-IND
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
67
506
506
1. Value must be 1 character
2. Value must be in Payment Level Indicator List (VVL)
3. Mandatory
CIP133
CIP.002.133
MEDICARE-REIM-TYPE
Medicare Reimbursement Type
Conditional
A code to indicate the type of Medicare reimbursement.
MEDICARE-REIM-TYPE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
68
507
508
1. Value must be 2 characters
2. Value must be in Medicare Reimbursement Type List (VVL)
3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)
4. Conditional
CIP134
CIP.002.134
NON-COV-DAYS
Non-Covered Days
Conditional
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-covered days does not refer to days not covered for any other service.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(5)
69
509
513
1. Value must be 5 digits or less
2. Conditional
CIP135
CIP.002.135
NON-COV-CHARGES
Non-Covered Charges
Conditional
The charges for inpatient care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
70
514
526
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
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]
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
CIP138
CIP.002.138
FORCED-CLAIM-IND
Forced Claim Indicator
Conditional
Indicates if the claim was processed by forcing it through a manual override process.
FORCED-CLAIM-IND
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
73
538
538
1. Value must be 1 character
2. Value must be in Forced Claim Indicator List (VVL)
3. Conditional
CIP139
CIP.002.139
HEALTH-CARE-ACQUIRED-CONDITION-IND
Healthcare Acquired Condition Indicator
Conditional
This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage
HEALTH-CARE-ACQUIRED-CONDITION-IND
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
74
539
539
1. Value must be 1 character
2. Value must be in Healthcare Acquired Condition Indicator List (VVL)
3. Conditional
CIP140
CIP.002.140
OCCURRENCE-CODE-01
Occurrence Code 1
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
75
540
541
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP141
CIP.002.141
OCCURRENCE-CODE-02
Occurrence Code 2
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
76
542
543
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP142
CIP.002.142
OCCURRENCE-CODE-03
Occurrence Code 3
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
77
544
545
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP143
CIP.002.143
OCCURRENCE-CODE-04
Occurrence Code 4
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
78
546
547
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP144
CIP.002.144
OCCURRENCE-CODE-05
Occurrence Code 5
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
79
548
549
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP145
CIP.002.145
OCCURRENCE-CODE-06
Occurrence Code 6
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
80
550
551
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP146
CIP.002.146
OCCURRENCE-CODE-07
Occurrence Code 7
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
81
552
553
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP147
CIP.002.147
OCCURRENCE-CODE-08
Occurrence Code 8
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
82
554
555
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP148
CIP.002.148
OCCURRENCE-CODE-09
Occurrence Code 9
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
83
556
557
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP149
CIP.002.149
OCCURRENCE-CODE-10
Occurrence Code 10
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
84
558
559
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CIP150
CIP.002.150
OCCURRENCE-CODE-EFF-DATE-01
Occurrence Code Effective Date 1
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
85
560
567
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP151
CIP.002.151
OCCURRENCE-CODE-EFF-DATE-02
Occurrence Code Effective Date 2
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
86
568
575
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP152
CIP.002.152
OCCURRENCE-CODE-EFF-DATE-03
Occurrence Code Effective Date 3
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
87
576
583
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP153
CIP.002.153
OCCURRENCE-CODE-EFF-DATE-04
Occurrence Code Effective Date 4
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
88
584
591
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP154
CIP.002.154
OCCURRENCE-CODE-EFF-DATE-05
Occurrence Code Effective Date 5
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
89
592
599
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP155
CIP.002.155
OCCURRENCE-CODE-EFF-DATE-06
Occurrence Code Effective Date 6
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
90
600
607
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP156
CIP.002.156
OCCURRENCE-CODE-EFF-DATE-07
Occurrence Code Effective Date 7
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
91
608
615
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP157
CIP.002.157
OCCURRENCE-CODE-EFF-DATE-08
Occurrence Code Effective Date 8
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
92
616
623
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP158
CIP.002.158
OCCURRENCE-CODE-EFF-DATE-09
Occurrence Code Effective Date 9
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
93
624
631
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP159
CIP.002.159
OCCURRENCE-CODE-EFF-DATE-10
Occurrence Code Effective Date 10
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
94
632
639
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CIP160
CIP.002.160
OCCURRENCE-CODE-END-DATE-01
Occurrence Code End Date 1
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
95
640
647
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP161
CIP.002.161
OCCURRENCE-CODE-END-DATE-02
Occurrence Code End Date 2
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
96
648
655
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP162
CIP.002.162
OCCURRENCE-CODE-END-DATE-03
Occurrence Code End Date 3
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
97
656
663
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP163
CIP.002.163
OCCURRENCE-CODE-END-DATE-04
Occurrence Code End Date 4
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
98
664
671
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP164
CIP.002.164
OCCURRENCE-CODE-END-DATE-05
Occurrence Code End Date 5
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
99
672
679
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP165
CIP.002.165
OCCURRENCE-CODE-END-DATE-06
Occurrence Code End Date 6
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
100
680
687
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP166
CIP.002.166
OCCURRENCE-CODE-END-DATE-07
Occurrence Code End Date 7
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
101
688
695
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP167
CIP.002.167
OCCURRENCE-CODE-END-DATE-08
Occurrence Code End Date 8
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
102
696
703
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP168
CIP.002.168
OCCURRENCE-CODE-END-DATE-09
Occurrence Code End Date 9
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
103
704
711
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP169
CIP.002.169
OCCURRENCE-CODE-END-DATE-10
Occurrence Code End Date 10
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
104
712
719
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CIP170
CIP.002.170
BIRTH-WEIGHT-GRAMS
Birth Weight Grams
Conditional
The weight of a newborn at time of birth in grams (applicable to newborns only). The field is required when a claim involves a child birth.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(6)V999
105
720
728
1. Value must not be greater than 6 digits to the left of the decimal and have no more than 3 digits to the right of the decimal (i.e. 999999.999)
2. Conditional
CIP171
CIP.002.171
PATIENT-CONTROL-NUM
Patient Control Number
Conditional
A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(20)
106
729
748
1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk symbol
3. Conditional
CIP172
CIP.002.172
ELIGIBLE-LAST-NAME
Eligible Last Name
Conditional
The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(30)
107
749
778
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CIP173
CIP.002.173
ELIGIBLE-FIRST-NAME
Eligible First Name
Conditional
The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(30)
108
779
808
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CIP174
CIP.002.174
ELIGIBLE-MIDDLE-INIT
Eligible Middle Initial
Conditional
Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name).
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
109
809
809
1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CIP175
CIP.002.175
DATE-OF-BIRTH
Date of Birth
Mandatory
Date of birth of the individual to whom the services were provided. A patient's age should not be greater than 112 years.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
110
810
817
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Mandatory
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
CIP177
CIP.002.177
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 claim is submitted.
WAIVER-TYPE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
112
819
820
1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)
4. Value must have a corresponding value in Waiver ID (CIP.002.178)
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
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)
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)
CIP181
CIP.002.181
BILLING-PROV-TAXONOMY
Billing Provider Taxonomy
Conditional
The taxonomy code for the institution billing for the beneficiary.
PROV-TAXONOMY
CIP00002
CLAIM-HEADER-RECORD-IP
X(12)
116
881
892
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CIP182
CIP.002.182
BILLING-PROV-TYPE
Billing Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
117
893
894
1. Value must be 2 characters
2. Value must be in Provider Type Code List (VVL)
3. Conditional
CIP183
CIP.002.183
BILLING-PROV-SPECIALTY
Billing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
118
895
896
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional
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
CIP185
CIP.002.185
ADMITTING-PROV-NUM
Admitting Provider Number
Conditional
The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(30)
120
907
936
1. Value must be 30 characters or less
2. Conditional
CIP186
CIP.002.186
ADMITTING-PROV-SPECIALTY
Admitting Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
121
937
938
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional
CIP187
CIP.002.187
ADMITTING-PROV-TAXONOMY
Admitting Provider Taxonomy
Conditional
Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee.
PROV-TAXONOMY
CIP00002
CLAIM-HEADER-RECORD-IP
X(12)
122
939
950
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CIP188
CIP.002.188
ADMITTING-PROV-TYPE
Admitting Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
123
951
952
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CIP189
CIP.002.189
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(30)
124
953
982
1. Value must be 30 characters or less
2. 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
CIP194
CIP.002.194
DRG-OUTLIER-AMT
DRG Outlier Amount
Conditional
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
126
993
1005
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Value must be populated when Outlier Code (CIP.002.197) is in [01,02,10]
4. Conditional
CIP195
CIP.002.195
DRG-REL-WEIGHT
DRG Relative Weight
Conditional
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 0.5000 was 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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(3)V99999
127
1006
1013
1. Value may include up to 3 digits to the left of the decimal point, and 5 digits to the right e.g. 123.45678
2. Conditional
3. When populated value must be zero or greater
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
CIP197
CIP.002.197
OUTLIER-CODE
Outlier Code
Conditional
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 the source for developing the DRG.
https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code
OUTLIER-CODE
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
129
1026
1027
1. Value must be 2 characters
2. Value must be in Outlier Code List (VVL)
3. Value is mandatory if either DRG Outlier Amount (CIP.002.194) or Outlier Days (CIP.002.198) are populated
4. Conditional
CIP198
CIP.002.198
OUTLIER-DAYS
Outlier Days
Conditional
This field specifies the number of days paid as outliers under Prospective Payment System (PPS) and the days over the threshold for the DRG.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(5)
130
1028
1032
1. Value must be 5 digits or less
2. Value must be numeric
3. Value must be populated, if Outlier Code (CIP.002.197) equals "01"
4. Conditional
CIP199
CIP.002.199
PATIENT-STATUS
Patient Status
Mandatory
A code indicating the patient's status as of the last day the claim covers. Values used are from UB-04. This is also referred to as patient discharge status. A valid list of codes can be purchased at:
https://www.nubc.org/license
PATIENT-STATUS
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
131
1033
1034
1. Value must be 2 characters
2. Value must be in Patient Status List (VVL)
3. Mandatory
4. When value in [20,40,41,42], then associated Discharge Date (CIP.002.096) must be less than or equal to Date of Death (ELG.002.025)
CIP202
CIP.002.202
REMITTANCE-NUM
Remittance Number
Mandatory
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(30)
132
1035
1064
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
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
CIP204
CIP.002.204
BORDER-STATE-IND
Border State Indicator
Conditional
A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)
BORDER-STATE-IND
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
134
1066
1066
1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional
CIP206
CIP.002.206
TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
Beneficiary Coinsurance Paid Amount
Conditional
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
135
1067
1079
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
CIP207
CIP.002.207
BENEFICIARY-COINSURANCE-DATE-PAID
Beneficiary Coinsurance Date Paid
Conditional
The date the beneficiary paid the coinsurance amount.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
136
1080
1087
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Coinsurance Amount
3. Conditional
CIP208
CIP.002.208
TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
Total Beneficiary Copayment Paid Amount
Conditional
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
137
1088
1100
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
CIP209
CIP.002.209
BENEFICIARY-COPAYMENT-DATE-PAID
Beneficiary Copayment Date Paid
Conditional
The date the beneficiary paid the copayment amount.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
138
1101
1108
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Copayment Amount
3. Conditional
CIP210
CIP.002.210
TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
Total Beneficiary Deductible Paid Amount
Conditional
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
139
1109
1121
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
CIP211
CIP.002.211
BENEFICIARY-DEDUCTIBLE-DATE-PAID
Beneficiary Deductible Date Paid
Conditional
The date the beneficiary paid the deductible amount.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
140
1122
1129
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Deductible Amount
3. Conditional
CIP212
CIP.002.212
CLAIM-DENIED-INDICATOR
Claim Denied Indicator
Mandatory
An indicator to identify a claim that the state refused pay in its entirety.
CLAIM-DENIED-INDICATOR
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
141
1130
1130
1. Value must be 1 character
2. Value must be in Claim Denied Indicator List (VVL)
3. If value equals "0", then Claim Status Category must equal "F2"
4. Mandatory
CIP213
CIP.002.213
COPAY-WAIVED-IND
Copayment Waived Indicator
Situational
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.
COPAY-WAIVED-IND
CIP00002
CLAIM-HEADER-RECORD-IP
X(1)
142
1131
1131
1. Value must be 1 character
2. Value must be in Copay Waived Indicator List (VVL)
3. Situational
CIP214
CIP.002.214
HEALTH-HOME-ENTITY-NAME
Health Home Entity Name
Conditional
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(50)
143
1132
1181
1. Value must not contain a pipe or asterisk symbols
2. Value must 50 characters or less
3. Conditional
CIP216
CIP.002.216
THIRD-PARTY-COINSURANCE-AMOUNT-PAID
Third Party Coinsurance Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
144
1182
1194
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. Situational
CIP217
CIP.002.217
THIRD-PARTY-COINSURANCE-DATE-PAID
Third Party Coinsurance Date Paid
Conditional
The date the third party paid the coinsurance amount
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
145
1195
1202
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Coinsurance Amount
3. Conditional
CIP218
CIP.002.218
THIRD-PARTY-COPAYMENT-AMOUNT-PAID
Third Party Copayment Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards copayment.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
146
1203
1215
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. Situational
CIP219
CIP.002.219
THIRD-PARTY-COPAYMENT-DATE-PAID
Third Party Copayment Date Paid
Situational
The date the third party paid the copayment amount.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
147
1216
1223
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Copayment Amount
3. Situational
CIP220
CIP.002.220
MEDICAID-AMOUNT-PAID-DSH
Medicaid Amount Paid DSH
Conditional
The amount included in the Total Medicaid Amount (CIP.002.114) that is attributable to a Disproportionate Share Hospital (DSH) payment, when the state makes DSH payments by claim.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
148
1224
1236
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
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
CIP222
CIP.002.222
MEDICARE-BENEFICIARY-IDENTIFIER
Medicare Beneficiary Identifier
Conditional
The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(12)
150
1247
1258
1. Conditional
2. Value must be an 11-character string
3. Character 1 must be numeric values 1 thru 9
4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
6. Character 4 must be numeric values 0 thru 9
7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
9. Character 7 must be numeric values 0 thru 9
10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
12. Character 10 must be numeric values 0 thru 9
13. Character 11 must be numeric values 0 thru 9
14. Value must not contain a pipe or asterisk symbols
CIP223
CIP.002.223
OPERATING-PROV-TAXONOMY
Operating Provider Taxonomy
Conditional
Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee.
PROV-TAXONOMY
CIP00002
CLAIM-HEADER-RECORD-IP
X(12)
151
1259
1270
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CIP228
CIP.002.228
MEDICARE-PAID-AMT
Medicare Paid Amount
Conditional
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
152
1271
1283
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value equals "0", then the value must not be populated
4. Conditional
5. If value is populated, Crossover Indicator must be equal to "1"
CIP289
CIP.002.289
PROV-LOCATION-ID
Provider Location ID
Mandatory
A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(5)
153
1284
1288
1. Value must be 5 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
CIP290
CIP.002.290
BEGINNING-DATE-OF-SERVICE
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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
154
1289
1296
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be less than or equal to associated Ending Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
7. Mandatory
CIP291
CIP.002.291
ENDING-DATE-OF-SERVICE
Ending Date of Service
Mandatory
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving 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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
9(8)
155
1297
1304
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be greater than or equal to associated Beginning Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value
7. Mandatory
CIP292
CIP.002.292
TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
Total 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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
156
1305
1317
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP293
CIP.002.293
TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
Total 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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
157
1318
1330
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP294
CIP.002.294
TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
Total 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 minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
158
1331
1343
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP295
CIP.002.295
COMBINED-BENE-COST-SHARING-PAID-AMOUNT
Combined Beneficiary 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.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
159
1344
1356
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP297
CIP.002.297
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
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
160
1357
1369
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
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
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
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
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
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
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)
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
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
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
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
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
CIP309
CIP.002.309
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
CIP00002
CLAIM-HEADER-RECORD-IP
X(2)
172
1698
1699
1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code List (VVL)
3. Mandatory
CIP310
CIP.002.310
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
CIP00002
CLAIM-HEADER-RECORD-IP
X(50)
173
1700
1749
1. Value must not be more than 50 characters long
2. Conditional
3. Value must be provided when corresponding Provider Claim Form Code is "Other"
CIP311
CIP.002.311
TOT-GME-AMOUNT-PAID
Total GME Amount Paid
Conditional
The amount included in the Total Medicaid Amount (CIP.002.114) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
174
1750
1762
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP338
CIP.002.338
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
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
175
1763
1775
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP339
CIP.002.339
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
CIP00002
CLAIM-HEADER-RECORD-IP
S9(11)V99
176
1776
1788
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP229
CIP.002.229
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CIP00002
CLAIM-HEADER-RECORD-IP
X(500)
177
1789
2288
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
CIP231
CIP.003.231
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
CIP00003
CLAIM-LINE-RECORD-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 "CIP00003"
CIP232
CIP.003.232
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
CIP00003
CLAIM-LINE-RECORD-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)
CIP233
CIP.003.233
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
CIP00003
CLAIM-LINE-RECORD-IP
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
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
CIP235
CIP.003.235
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(50)
5
42
91
1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
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
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
CIP238
CIP.003.238
LINE-NUM-ADJ
Adjustment Line Number
Conditional
A unique number to identify the transaction line number that identifies the line number on the adjustment claim.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(3)
8
145
147
1. Value must be 3 characters or less
2. If associated Line Adjustment Indicator value equals "0", then value must not be populated
3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided
4. Conditional
5. When populated, value must be one or greater
CIP239
CIP.003.239
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
CIP00003
CLAIM-LINE-RECORD-IP
X(1)
9
148
148
1. Value must be 1 character
2. Value must be in Line Adjustment Indicator List (VVL)
3. Value must be in [0,1,4]
4. Conditional
5. If associated Line Adjustment Number is populated, then value must be populated
CIP240
CIP.003.240
LINE-ADJUSTMENT-REASON-CODE
Line Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a service line was paid differently than it was billed.
LINE-ADJUSTMENT-REASON-CODE
CIP00003
CLAIM-LINE-RECORD-IP
X(3)
10
149
151
1. Value must be 3 characters or less
2. Value must be in Line Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
CIP241
CIP.003.241
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(12)
11
152
163
1. Value must be 12 characters or less
2. Mandatory
CIP242
CIP.003.242
CLAIM-LINE-STATUS
Claim Line Status
Conditional
The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim.
CLAIM-STATUS
CIP00003
CLAIM-LINE-RECORD-IP
X(3)
12
164
166
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2"
CIP243
CIP.003.243
BEGINNING-DATE-OF-SERVICE
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.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
9(8)
13
167
174
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be less than or equal to associated Ending Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
7. Mandatory
CIP244
CIP.003.244
ENDING-DATE-OF-SERVICE
Ending Date of Service
Mandatory
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving 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.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
9(8)
14
175
182
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be greater than or equal to associated Beginning Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value
7. Mandatory
CIP245
CIP.003.245
REVENUE-CODE
Revenue Code
Mandatory
A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims.
REVENUE-CODE
CIP00003
CLAIM-LINE-RECORD-IP
X(4)
15
183
186
1. Value must be 4 characters or less
2. Value must be in Revenue Code List (VVL)
3. A Revenue Code value requires an associated Revenue Charge
4. Mandatory
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
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
CIP251
CIP.003.251
REVENUE-CHARGE
Revenue Charge
Conditional
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.
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]
CIP255
CIP.003.255
MEDICAID-FFS-EQUIVALENT-AMT
Medicaid FFS Equivalent Amount
Conditional
The amount that would have been paid had the services been provided on a Fee for Service basis.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
S9(11)V99
21
244
256
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 in [3,C,W], then value is mandatory and must be provided
4. Conditional
CIP256
CIP.003.256
BILLING-UNIT
Billing Unit
Conditional
Unit of billing that is used for billing services by the facility.
BILLING-UNIT
CIP00003
CLAIM-LINE-RECORD-IP
X(2)
22
257
258
1. Value must be 2 characters
2. Value must be in Billing Unit List (VVL)
3. Conditional
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"
CIP260
CIP.003.260
SERVICING-PROV-NUM
Servicing Provider Number
Conditional
A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The value is conditional as its usage varies by state.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(30)
24
262
291
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.005.081) Provider Identifier or
4. When Type of Claim not in [3,C,W], then value may match (PRV.002.019) Submitting State Provider ID
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
CIP263
CIP.003.263
SERVICING-PROV-TYPE
Servicing Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
CIP00003
CLAIM-LINE-RECORD-IP
X(2)
26
302
303
1. Value must be 2 characters
2. Value must be in Provider Type Code List (VVL)
3. Conditional
CIP264
CIP.003.264
SERVICING-PROV-SPECIALTY
Servicing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CIP00003
CLAIM-LINE-RECORD-IP
X(2)
27
304
305
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
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
CIP266
CIP.003.266
OTHER-TPL-COLLECTION
Other TPL Collection
Mandatory
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.
OTHER-TPL-COLLECTION
CIP00003
CLAIM-LINE-RECORD-IP
X(3)
29
316
318
1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory
CIP267
CIP.003.267
PROV-FACILITY-TYPE
Provider Facility Type
Mandatory
The type of facility in which services on the claim were rendered. The Provider Facility Type code set is based on corresponding groups of HIPAA provider taxonomy codes.
PROV-FACILITY-TYPE
CIP00003
CLAIM-LINE-RECORD-IP
X(9)
30
319
327
1. Value must be 9 characters or less
2. Value must be in Provider Facility Type List (VVL)
3. Mandatory
CIP269
CIP.003.269
CATEGORY-FOR-FEDERAL-REIMBURSEMENT
Category for Federal Reimbursement
Conditional
A code to indicate the Federal funding source for the payment.
CATEGORY-FOR-FEDERAL-REIMBURSEMENT
CIP00003
CLAIM-LINE-RECORD-IP
X(2)
31
328
329
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
CIP272
CIP.003.272
OTHER-INSURANCE-AMT
Other Insurance Amount
Conditional
The amount paid by insurance other than Medicare or Medicaid on this claim.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
S9(11)V99
32
330
342
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
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
CIP284
CIP.003.284
NATIONAL-DRUG-CODE
National Drug Code
Conditional
A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(12)
34
361
372
1. Value must be 12 digits or less
2. Value must be a valid National Drug Code
3. Conditional
CIP285
CIP.003.285
NDC-UNIT-OF-MEASURE
NDC Unit of Measure
Conditional
A code to indicate the basis by which the quantity of the National Drug Code is expressed.
NDC-UNIT-OF-MEASURE
CIP00003
CLAIM-LINE-RECORD-IP
X(2)
35
373
374
1. Value must be 2 characters
2. Value must be in NDC Unit of Measure List (VVL)
3. Conditional
CIP286
CIP.003.286
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
CIP00003
CLAIM-LINE-RECORD-IP
9(8)
36
375
382
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CRX.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CIP287
CIP.003.287
SELF-DIRECTION-TYPE
Self Direction Type
Mandatory
This data element is not applicable to this file type.
SELF-DIRECTION-TYPE
CIP00003
CLAIM-LINE-RECORD-IP
X(3)
37
383
385
1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory
CIP288
CIP.003.288
PRE-AUTHORIZATION-NUM
Preauthorization Number
Conditional
A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number).
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(18)
38
386
403
1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
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
CIP314
CIP.003.314
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
CIP00003
CLAIM-LINE-RECORD-IP
X(76)
40
405
480
1. Value must not be more than 76 characters long
2. Conditional
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
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-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3
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
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
CIP317
CIP.003.317
GME-AMOUNT-PAID
GME Amount Paid
Conditional
The amount included in the Medicaid Amount (CIP.003.254) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
S9(11)V99
44
537
549
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP318
CIP.003.318
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.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(30)
45
550
579
1. Value must be 30 characters or less
2. 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
CIP336
CIP.003.336
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
CIP00003
CLAIM-LINE-RECORD-IP
S9(11)V99
47
590
602
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP337
CIP.003.337
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
CIP00003
CLAIM-LINE-RECORD-IP
S9(11)V99
48
603
615
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CIP273
CIP.003.273
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CIP00003
CLAIM-LINE-RECORD-IP
X(500)
49
616
1115
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
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"
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)
CIP324
CIP.004.324
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
CIP00004
CLAIM-DX-IP
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
CIP325
CIP.004.325
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CIP00004
CLAIM-DX-IP
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
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
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)
CIP328
CIP.004.328
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
CIP00004
CLAIM-DX-IP
9(8)
7
123
130
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CIP.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CIP329
CIP.004.329
DIAGNOSIS-TYPE
Diagnosis Type
Mandatory
Indicates the context of the diagnosis code from the provider's claim (i.e., an 837I claim can have one principal diagnosis code, one admitting diagnosis code, up to 12 external cause of injury diagnosis codes, and up to 24 other diagnosis codes; a UB-04 claim can have one principal diagnosis code, one admitting diagnosis code, and up to 17 other 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
CIP00004
CLAIM-DX-IP
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 [P,A,E,O]
4. 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
CIP331
CIP.004.331
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
CIP00004
CLAIM-DX-IP
X(1)
10
134
134
1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List (VVL)
3. Mandatory
CIP332
CIP.004.332
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 '21051'.
DIAGNOSIS-CODE
CIP00004
CLAIM-DX-IP
X(7)
11
135
141
1. Value must be a minimum of 3 characters
2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)
3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)
4. Value must not contain a decimal point
5. Mandatory
CIP333
CIP.004.333
DIAGNOSIS-POA-FLAG
Diagnosis POA Flag
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.
DIAGNOSIS-POA-FLAG
CIP00004
CLAIM-DX-IP
X(1)
12
142
142
1. Value must be 1 character
2. Value must be in Diagnosis POA Flag List (VVL)
3. Conditional
CIP334
CIP.004.334
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CIP00004
CLAIM-DX-IP
X(500)
13
143
642
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational

T-MSIS Data Dictionary – CLT File (No Changes Between Versions 4.0.0 and 4.1.0)

Data Element Number

System Data Element Number

Data Element

Data Element Name Text

Data Element Necessity

Definition

Valid Value List (VVL)

File Segment Number

File Segment Name

Size

Pipe Separated Value Segment Data Element Order
Fixed Length Field Start Position

Fixed Length Field Stop Position

Coding Requirements

CLT001
CLT.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
CLT00001
FILE-HEADER-RECORD-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 "CLT00001"
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
CLT003
CLT.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
CLT00001
FILE-HEADER-RECORD-LT
X(1)
3
19
19
1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory
CLT004
CLT.001.004
FILE-ENCODING-SPECIFICATION
File Encoding Specification
Mandatory
Denotes which supported file encoding standard was used to create the file.
FILE-ENCODING-SPECIFICATION
CLT00001
FILE-HEADER-RECORD-LT
X(3)
4
20
22
1. Value must be 3 characters
2. Value must be in File Encoding Specification List (VVL)
3. Mandatory
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
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
CLT007
CLT.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
CLT00001
FILE-HEADER-RECORD-LT
X(2)
7
40
41
1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
CLT008
CLT.001.008
DATE-FILE-CREATED
Date File Created
Mandatory
The date on which the file was created.
N/A
CLT00001
FILE-HEADER-RECORD-LT
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
CLT009
CLT.001.009
START-OF-TIME-PERIOD
Start of Time Period
Mandatory
This value must be the first day of the reporting month, regardless of the actual date span of the data in the file.
N/A
CLT00001
FILE-HEADER-RECORD-LT
9(8)
9
50
57
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be equal to or earlier than associated Date File Created
3. Value must be before associated End of Time Period
4. Mandatory
5. Value of the CC component must be "20"
CLT010
CLT.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
CLT00001
FILE-HEADER-RECORD-LT
9(8)
10
58
65
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be equal to or earlier than associated Date File Created
4. Value must be equal to or after associated Start of Time Period
5. Mandatory
CLT011
CLT.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
CLT00001
FILE-HEADER-RECORD-LT
X(1)
11
66
66
1. Value must be 1 character
2. For production files, value must be equal to "P"
3. Value must be in File Status Indicator List (VVL)
4. Mandatory
CLT012
CLT.001.012
SSN-INDICATOR
SSN Indicator
Mandatory
Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability files.
SSN-INDICATOR
CLT00001
FILE-HEADER-RECORD-LT
X(1)
12
67
67
1. Value must be 1 character
2. Value must be in SSN Indicator List (VVL)
3. Mandatory
CLT013
CLT.001.013
TOT-REC-CNT
Total Record Count
Mandatory
A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission.
N/A
CLT00001
FILE-HEADER-RECORD-LT
9(11)
13
68
78
1. Value must be 11 digits or less
2. Value must be a positive integer
3. Value must be between 0:99999999999 (inclusive)
4. Value must equal the number of records included in the file submission except for the file header record.
5. Mandatory
CLT227
CLT.001.227
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
CLT00001
FILE-HEADER-RECORD-LT
X(4)
14
79
82
1. Value must be 4 characters or less
2. Value must between 1 and 9999
3. Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1)
4. Value must not contain a pipe symbol
5. Mandatory
CLT014
CLT.001.014
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CLT00001
FILE-HEADER-RECORD-LT
X(500)
15
83
582
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
CLT016
CLT.002.016
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
CLT00002
CLAIM-HEADER-RECORD-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 "CLT00002"
CLT017
CLT.002.017
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
CLT00002
CLAIM-HEADER-RECORD-LT
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 (CLT.001.007)
CLT018
CLT.002.018
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
CLT00002
CLAIM-HEADER-RECORD-LT
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
CLT019
CLT.002.019
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
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
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
CLT021
CLT.002.021
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(12)
6
122
133
1. Value must be 12 characters or less
2. Mandatory
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
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
CLT024
CLT.002.024
1115A-DEMONSTRATION-IND
1115A Demonstration Indicator
Conditional
In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration.
1115A-DEMONSTRATION-IND
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
9
155
155
1. Value must be 1 character
2. Value must be in 1115A Demonstration Indicator List (VVL)
3. Conditional
4. 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
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)
CLT026
CLT.002.026
ADJUSTMENT-REASON-CODE
Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a claim was paid differently than it was billed.
ADJUSTMENT-REASON-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(3)
11
157
159
1. Value must be 3 characters or less
2. Value must be in Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
CLT044
CLT.002.044
ADMISSION-DATE
Admission Date
Mandatory
The date on which the recipient was admitted to a psychiatric or long-term care facility.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
12
160
167
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated Discharge Date value in the claim header
3. Value must be greater than or equal to associated eligible Date of Birth value
4. Value must be less than or equal to associated eligible Date of Death value
5. Mandatory
6. Value must be before Adjudication Date (CLT.002.050)
CLT045
CLT.002.045
ADMISSION-HOUR
Admission Hour
Conditional
The time of admission to a psychiatric or long-term care facility.
HOUR
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
13
168
169
1. Value must be 2 characters
2. Value must be in Hour List (VVL)
3. Conditional
CLT046
CLT.002.046
DISCHARGE-DATE
Discharge Date
Conditional
The date on which the recipient was discharged from a psychiatric or long-term care facility.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
14
170
177
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated Adjudication Date value.
3. Value must be greater than or equal to associated Admission Date value.
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. Conditional
7. When populated, Discharge Hour (CLT.002.047) must be populated
CLT047
CLT.002.047
DISCHARGE-HOUR
Discharge Hour
Conditional
The time of discharge from a psychiatric or long-term care facility.
HOUR
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
15
178
179
1. Value must be 2 characters
2. Value must be in Hour List (VVL)
3. Conditional
4. When populated, Discharge Date (CLT.002.046) must be populated
CLT048
CLT.002.048
BEGINNING-DATE-OF-SERVICE
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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
16
180
187
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be less than or equal to associated Ending Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
7. Mandatory
CLT049
CLT.002.049
ENDING-DATE-OF-SERVICE
Ending Date of Service
Mandatory
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving 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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
17
188
195
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be greater than or equal to associated Beginning Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value
7. Mandatory
CLT050
CLT.002.050
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
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
18
196
203
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CIP.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CLT051
CLT.002.051
MEDICAID-PAID-DATE
Medicaid Paid Date
Mandatory
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
19
204
211
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Total Medicaid Paid Amount
3. Mandatory
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
CLT053
CLT.002.053
TYPE-OF-BILL
Type of Bill
Mandatory
A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.)
TYPE-OF-BILL
CLT00002
CLAIM-HEADER-RECORD-LT
X(4)
21
213
216
1. Value must be 4 characters
2. Value must be in Type of Bill List (VVL)
3. First character must be a "0"
4. Mandatory
CLT054
CLT.002.054
CLAIM-STATUS
Claim Status
Conditional
The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim.
CLAIM-STATUS
CLT00002
CLAIM-HEADER-RECORD-LT
X(3)
22
217
219
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2"
CLT055
CLT.002.055
CLAIM-STATUS-CATEGORY
Claim Status Category
Mandatory
The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status.
CLAIM-STATUS-CATEGORY
CLT00002
CLAIM-HEADER-RECORD-LT
X(3)
23
220
222
1. Value must be 3 characters or less
2. Value must be in Claim Status Category List (VVL)
3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"
4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"
5. Mandatory
CLT056
CLT.002.056
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 network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee.
SOURCE-LOCATION
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
24
223
224
1. Value must be 2 characters
2. Value must be in Source Location List (VVL)
3. Mandatory
CLT057
CLT.002.057
CHECK-NUM
Check Number
Conditional
The check or electronic funds transfer number.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(15)
25
225
239
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
CLT058
CLT.002.058
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
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
26
240
247
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Check Number
3. Conditional
CLT059
CLT.002.059
CLAIM-PYMT-REM-CODE-1
Remittance Advice Remark Code 1
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(5)
27
248
252
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
CLT060
CLT.002.060
CLAIM-PYMT-REM-CODE-2
Remittance Advice Remark Code 2
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(5)
28
253
257
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 1 (CLT.002.059) is not populated
CLT061
CLT.002.061
CLAIM-PYMT-REM-CODE-3
Remittance Advice Remark Code 3
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(5)
29
258
262
1. Value must be in Claim Payment Remittance Code List (VVL)
2. Value must be 5 characters or less
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 2 (CLT.002.060) is not populated
CLT062
CLT.002.062
CLAIM-PYMT-REM-CODE-4
Remittance Advice Remark Code 4
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(5)
30
263
267
1. Value must be in Claim Payment Remittance Code List (VVL)
2. Value must be 5 characters or less
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 3 (CLT.002.061) is not populated
CLT063
CLT.002.063
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
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
31
268
280
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 (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204).
CLT064
CLT.002.064
TOT-ALLOWED-AMT
Total Allowed Amount
Conditional
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 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.
PAYMENT-LEVEL-IND
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
46
383
383
1. Value must be 1 character
2. Value must be in Payment Level Indicator List (VVL)
3. Mandatory
CLT083
CLT.002.083
MEDICARE-REIM-TYPE
Medicare Reimbursement Type
Conditional
A code to indicate the type of Medicare reimbursement.
MEDICARE-REIM-TYPE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
47
384
385
1. Value must be 2 characters
2. Value must be in Medicare Reimbursement Type List (VVL)
3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)
4. Conditional
CLT084
CLT.002.084
NON-COV-DAYS
Non-Covered Days
Conditional
The number of days of institutional long-term care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(5)
48
386
390
1. Value must be 5 digits or less
2. Conditional
CLT085
CLT.002.085
NON-COV-CHARGES
Non-Covered Charges
Conditional
The charges for institutional long-term care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
49
391
403
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
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
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
CLT090
CLT.002.090
FORCED-CLAIM-IND
Forced Claim Indicator
Conditional
Indicates if the claim was processed by forcing it through a manual override process.
FORCED-CLAIM-IND
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
52
413
413
1. Value must be 1 character
2. Value must be in Forced Claim Indicator List (VVL)
3. Conditional
CLT091
CLT.002.091
HEALTH-CARE-ACQUIRED-CONDITION-IND
Healthcare Acquired Condition Indicator
Conditional
This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage
HEALTH-CARE-ACQUIRED-CONDITION-IND
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
53
414
414
1. Value must be 1 character
2. Value must be in Healthcare Acquired Condition Indicator List (VVL)
3. Conditional
CLT092
CLT.002.092
OCCURRENCE-CODE-01
Occurrence Code 1
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
54
415
416
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT093
CLT.002.093
OCCURRENCE-CODE-02
Occurrence Code 2
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
55
417
418
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT094
CLT.002.094
OCCURRENCE-CODE-03
Occurrence Code 3
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
56
419
420
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT095
CLT.002.095
OCCURRENCE-CODE-04
Occurrence Code 4
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
57
421
422
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT096
CLT.002.096
OCCURRENCE-CODE-05
Occurrence Code 5
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
58
423
424
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT097
CLT.002.097
OCCURRENCE-CODE-06
Occurrence Code 6
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
59
425
426
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT098
CLT.002.098
OCCURRENCE-CODE-07
Occurrence Code 7
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
60
427
428
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT099
CLT.002.099
OCCURRENCE-CODE-08
Occurrence Code 8
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
61
429
430
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT100
CLT.002.100
OCCURRENCE-CODE-09
Occurrence Code 9
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
62
431
432
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT101
CLT.002.101
OCCURRENCE-CODE-10
Occurrence Code 10
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
63
433
434
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
CLT102
CLT.002.102
OCCURRENCE-CODE-EFF-DATE-01
Occurrence Code Effective Date 1
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
64
435
442
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT103
CLT.002.103
OCCURRENCE-CODE-EFF-DATE-02
Occurrence Code Effective Date 2
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
65
443
450
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT104
CLT.002.104
OCCURRENCE-CODE-EFF-DATE-03
Occurrence Code Effective Date 3
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
66
451
458
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT105
CLT.002.105
OCCURRENCE-CODE-EFF-DATE-04
Occurrence Code Effective Date 4
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
67
459
466
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT106
CLT.002.106
OCCURRENCE-CODE-EFF-DATE-05
Occurrence Code Effective Date 5
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
68
467
474
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT107
CLT.002.107
OCCURRENCE-CODE-EFF-DATE-06
Occurrence Code Effective Date 6
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
69
475
482
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT108
CLT.002.108
OCCURRENCE-CODE-EFF-DATE-07
Occurrence Code Effective Date 7
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
70
483
490
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT109
CLT.002.109
OCCURRENCE-CODE-EFF-DATE-08
Occurrence Code Effective Date 8
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
71
491
498
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT110
CLT.002.110
OCCURRENCE-CODE-EFF-DATE-09
Occurrence Code Effective Date 9
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
72
499
506
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT111
CLT.002.111
OCCURRENCE-CODE-EFF-DATE-10
Occurrence Code Effective Date 10
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
73
507
514
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
CLT112
CLT.002.112
OCCURRENCE-CODE-END-DATE-01
Occurrence Code End Date 1
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
74
515
522
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT113
CLT.002.113
OCCURRENCE-CODE-END-DATE-02
Occurrence Code End Date 2
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
75
523
530
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT114
CLT.002.114
OCCURRENCE-CODE-END-DATE-03
Occurrence Code End Date 3
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
76
531
538
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT115
CLT.002.115
OCCURRENCE-CODE-END-DATE-04
Occurrence Code End Date 4
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
77
539
546
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT116
CLT.002.116
OCCURRENCE-CODE-END-DATE-05
Occurrence Code End Date 5
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
78
547
554
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT117
CLT.002.117
OCCURRENCE-CODE-END-DATE-06
Occurrence Code End Date 6
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
79
555
562
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT118
CLT.002.118
OCCURRENCE-CODE-END-DATE-07
Occurrence Code End Date 7
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
80
563
570
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT119
CLT.002.119
OCCURRENCE-CODE-END-DATE-08
Occurrence Code End Date 8
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
81
571
578
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT120
CLT.002.120
OCCURRENCE-CODE-END-DATE-09
Occurrence Code End Date 9
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
82
579
586
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT121
CLT.002.121
OCCURRENCE-CODE-END-DATE-10
Occurrence Code End Date 10
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
83
587
594
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
CLT122
CLT.002.122
PATIENT-CONTROL-NUM
Patient Control Number
Conditional
A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(20)
84
595
614
1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk symbol
3. Conditional
CLT123
CLT.002.123
ELIGIBLE-LAST-NAME
Eligible Last Name
Conditional
The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(30)
85
615
644
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CLT124
CLT.002.124
ELIGIBLE-FIRST-NAME
Eligible First Name
Conditional
The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(30)
86
645
674
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CLT125
CLT.002.125
ELIGIBLE-MIDDLE-INIT
Eligible Middle Initial
Conditional
Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name).
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
87
675
675
1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CLT126
CLT.002.126
DATE-OF-BIRTH
Date of Birth
Mandatory
An individual's date of birth.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
88
676
683
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Mandatory
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
CLT128
CLT.002.128
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 claim is submitted.
WAIVER-TYPE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
90
685
686
1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)
4. Value must have a corresponding value in Waiver ID (CLT.002.129)
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
CLT130
CLT.002.130
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
CLT00002
CLAIM-HEADER-RECORD-LT
X(30)
92
707
736
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)
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)
CLT132
CLT.002.132
BILLING-PROV-TAXONOMY
Billing Provider Taxonomy
Conditional
The taxonomy code for the institution billing for the beneficiary.
PROV-TAXONOMY
CLT00002
CLAIM-HEADER-RECORD-LT
X(12)
94
747
758
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CLT133
CLT.002.133
BILLING-PROV-TYPE
Billing Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
95
759
760
1. Value must be 2 characters
2. Value must be in Provider Type Code List (VVL)
3. Conditional
CLT134
CLT.002.134
BILLING-PROV-SPECIALTY
Billing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
96
761
762
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional
CLT135
CLT.002.135
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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(30)
97
763
792
1. Value must be 30 characters or less
2. 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
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
CLT141
CLT.002.141
PATIENT-STATUS
Patient Status
Mandatory
A code indicating the patient's status as of the last day the claim covers. Values used are from UB-04. This is also referred to as patient discharge status. A valid list of codes can be purchased at:
https://www.nubc.org/license
PATIENT-STATUS
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
100
815
816
1. Value must be 2 characters
2. Value must be in Patient Status List (VVL)
3. Mandatory
CLT144
CLT.002.144
REMITTANCE-NUM
Remittance Number
Mandatory
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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(30)
101
817
846
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
CLT145
CLT.002.145
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
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
102
847
859
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
CLT147
CLT.002.147
ICF-IID-DAYS
ICF IID Days
Conditional
The number of days of intermediate care for individuals with an intellectual disability that were paid for in whole or in part by Medicaid. If value exceeds 99998 days, code as 99998. (e.g., code 100023 as 99998).
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(5)
103
860
864
1. Value must be 5 digits or less
2. Conditional
3. Value is mandatory when associated Type of Service (CLT.003.211) equals "046"
4. Value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day
5. When populated, if value is greater than 0 and less than 99998, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal "004" (ICF/IID) for the same month as the begin and end date of service
CLT148
CLT.002.148
LEAVE-DAYS
Leave Days
Conditional
The number of days, during the period covered by Medicaid, on which the patient did not reside in the long term care facility.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(5)
104
865
869
1. Value must be numeric
2. Value must be 5 digits or less
3. Conditional
4. (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009,045,046,047,059]
CLT149
CLT.002.149
NURSING-FACILITY-DAYS
Nursing Facility Days
Conditional
The number of days of nursing care included in this claim that were paid for, in whole or in part, by Medicaid. Includes days during which nursing facility received partial payment for holding a bed during patient leave days. If value exceeds 99998 days, code as 99998.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(5)
105
870
874
1. Value must be 5 digits or less
2. Value must be numeric
3. Conditional
4. When populated, value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day
5. (nursing facility) value is required when the Type of Service in [009,045,047,059]
6. When populated, if value is greater than zero, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal "003" (Nursing Facility) for the same month as the beginning and ending date of service
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
CLT151
CLT.002.151
BORDER-STATE-IND
Border State Indicator
Conditional
A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)
BORDER-STATE-IND
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
107
876
876
1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional
CLT153
CLT.002.153
TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
Total Beneficiary Coinsurance Paid Amount
Conditional
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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
108
877
889
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
CLT154
CLT.002.154
BENEFICIARY-COINSURANCE-DATE-PAID
Beneficiary Coinsurance Date Paid
Conditional
The date the beneficiary paid the coinsurance amount.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
109
890
897
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Coinsurance Amount
3. Conditional
CLT155
CLT.002.155
TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
Total Beneficiary Copayment Paid Amount
Conditional
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..
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
110
898
910
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
CLT156
CLT.002.156
BENEFICIARY-COPAYMENT-DATE-PAID
Beneficiary Copayment Date Paid
Conditional
The date the beneficiary paid the copayment amount.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
111
911
918
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Copayment Amount
3. Conditional
CLT157
CLT.002.157
TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
Total Beneficiary Deductible Paid Amount
Conditional
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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
112
919
931
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
CLT158
CLT.002.158
BENEFICIARY-DEDUCTIBLE-DATE-PAID
Beneficiary Deductible Date Paid
Conditional
The date the beneficiary paid the deductible amount.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
113
932
939
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Deductible Amount
3. Conditional
CLT159
CLT.002.159
CLAIM-DENIED-INDICATOR
Claim Denied Indicator
Mandatory
An indicator to identify a claim that the state refused pay in its entirety.
CLAIM-DENIED-INDICATOR
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
114
940
940
1. Value must be 1 character
2. Value must be in Claim Denied Indicator List (VVL)
3. If value equals "0", then Claim Status Category must equal "F2"
4. Mandatory
CLT160
CLT.002.160
COPAY-WAIVED-IND
Copayment Waived Indicator
Situational
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.
COPAY-WAIVED-IND
CLT00002
CLAIM-HEADER-RECORD-LT
X(1)
115
941
941
1. Value must be 1 character
2. Value must be in Copay Waived Indicator List (VVL)
3. Situational
CLT161
CLT.002.161
HEALTH-HOME-ENTITY-NAME
Health Home Entity Name
Conditional
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(50)
116
942
991
1. Value must not contain a pipe or asterisk symbols
2. Value must 50 characters or less
3. Conditional
CLT163
CLT.002.163
THIRD-PARTY-COINSURANCE-AMOUNT-PAID
Third Party Coinsurance Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
117
992
1004
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. Situational
CLT164
CLT.002.164
THIRD-PARTY-COINSURANCE-DATE-PAID
Third Party Coinsurance Date Paid
Conditional
The date the third party paid the coinsurance amount
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
118
1005
1012
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Coinsurance Amount
3. Conditional
CLT165
CLT.002.165
THIRD-PARTY-COPAYMENT-AMOUNT-PAID
Third Party Copayment Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards copayment.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
119
1013
1025
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. Situational
CLT166
CLT.002.166
THIRD-PARTY-COPAYMENT-DATE-PAID
Third Party Copayment Date Paid
Situational
The date the third party paid the copayment amount.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
9(8)
120
1026
1033
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Copayment Amount
3. Situational
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
CLT168
CLT.002.168
MEDICARE-BENEFICIARY-IDENTIFIER
Medicare Beneficiary Identifier
Conditional
The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(12)
122
1046
1057
1. Conditional
2. Value must be an 11-character string
3. Character 1 must be numeric values 1 thru 9
4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
6. Character 4 must be numeric values 0 thru 9
7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
9. Character 7 must be numeric values 0 thru 9
10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
12. Character 10 must be numeric values 0 thru 9
13. Character 11 must be numeric values 0 thru 9
14. Value must not contain a pipe or asterisk symbols
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
CLT175
CLT.002.175
ADMITTING-PROV-NUM
Admitting Provider Number
Conditional
The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(30)
124
1068
1097
1. Value must be 30 characters or less
2. Conditional
CLT176
CLT.002.176
ADMITTING-PROV-SPECIALTY
Admitting Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
125
1098
1099
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional
CLT177
CLT.002.177
ADMITTING-PROV-TAXONOMY
Admitting Provider Taxonomy
Conditional
Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee.
PROV-TAXONOMY
CLT00002
CLAIM-HEADER-RECORD-LT
X(12)
126
1100
1111
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CLT178
CLT.002.178
ADMITTING-PROV-TYPE
Admitting Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
127
1112
1113
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional
CLT179
CLT.002.179
MEDICARE-PAID-AMT
Medicare Paid Amount
Conditional
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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
128
1114
1126
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. If associated Crossover Indicator value equals "0", then the value must not be populated
4. Conditional
5. If value is populated, Crossover Indicator must be equal to "1"
CLT237
CLT.002.237
PROV-LOCATION-ID
Provider Location ID
Mandatory
A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(5)
129
1127
1131
1. Value must be 5 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
CLT239
CLT.002.239
TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
Total 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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
130
1132
1144
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT240
CLT.002.240
TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
Total 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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
131
1145
1157
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT241
CLT.002.241
TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
Total 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 minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
132
1158
1170
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT242
CLT.002.242
COMBINED-BENE-COST-SHARING-PAID-AMOUNT
Combined Beneficiary 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.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
133
1171
1183
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
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
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
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
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
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
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)
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
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
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
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
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
CLT255
CLT.002.255
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
CLT00002
CLAIM-HEADER-RECORD-LT
X(2)
145
1512
1513
1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code List (VVL)
3. Mandatory
CLT256
CLT.002.256
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
CLT00002
CLAIM-HEADER-RECORD-LT
X(50)
146
1514
1563
1. Value must not be more than 50 characters long
2. Conditional
3. Value must be provided when corresponding Provider Claim Form Code is "Other"
CLT257
CLT.002.257
TOT-GME-AMOUNT-PAID
Total GME Amount Paid
Conditional
The amount included in the Total Medicaid Amount (CLT.002.065) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
147
1564
1576
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT258
CLT.002.258
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
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
148
1577
1589
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT259
CLT.002.259
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
CLT00002
CLAIM-HEADER-RECORD-LT
S9(11)V99
149
1590
1602
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT173
CLT.002.173
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CLT00002
CLAIM-HEADER-RECORD-LT
X(500)
150
1603
2102
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
CLT184
CLT.003.184
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
CLT00003
CLAIM-LINE-RECORD-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 "CLT00003"
CLT185
CLT.003.185
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
CLT00003
CLAIM-LINE-RECORD-LT
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 (CLT.001.007)
CLT186
CLT.003.186
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
CLT00003
CLAIM-LINE-RECORD-LT
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
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
CLT188
CLT.003.188
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(50)
5
42
91
1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
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
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
CLT191
CLT.003.191
LINE-NUM-ADJ
Adjustment Line Number
Conditional
A unique number to identify the transaction line number that identifies the line number on the adjustment claim.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(3)
8
145
147
1. Value must be 3 characters or less
2. If associated Line Adjustment Indicator value equals "0", then value must not be populated
3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided
4. Conditional
5. When populated, value must be one or greater
CLT192
CLT.003.192
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
CLT00003
CLAIM-LINE-RECORD-LT
X(1)
9
148
148
1. Value must be 1 character
2. Value must be in Line Adjustment Indicator List (VVL)
3. Value must be in [0,1,4]
4. Conditional
5. If associated Line Adjustment Number is populated, then value must be populated
CLT193
CLT.003.193
LINE-ADJUSTMENT-REASON-CODE
Line Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a service line was paid differently than it was billed.
LINE-ADJUSTMENT-REASON-CODE
CLT00003
CLAIM-LINE-RECORD-LT
X(3)
10
149
151
1. Value must be 3 characters or less
2. Value must be in Line Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
CLT194
CLT.003.194
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(12)
11
152
163
1. Value must be 12 characters or less
2. Mandatory
CLT195
CLT.003.195
CLAIM-LINE-STATUS
Claim Line Status
Conditional
The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim.
CLAIM-STATUS
CLT00003
CLAIM-LINE-RECORD-LT
X(3)
12
164
166
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2"
CLT196
CLT.003.196
BEGINNING-DATE-OF-SERVICE
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.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
9(8)
13
167
174
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be less than or equal to associated Ending Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
7. Mandatory
CLT197
CLT.003.197
ENDING-DATE-OF-SERVICE
Ending Date of Service
Mandatory
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving 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.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
9(8)
14
175
182
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be greater than or equal to associated Beginning Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value
7. Mandatory
CLT198
CLT.003.198
REVENUE-CODE
Revenue Code
Mandatory
A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims.
REVENUE-CODE
CLT00003
CLAIM-LINE-RECORD-LT
X(4)
15
183
186
1. Value must be 4 characters or less
2. Value must be in Revenue Code List (VVL)
3. A Revenue Code value requires an associated Revenue Charge
4. Mandatory
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
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
CLT204
CLT.003.204
REVENUE-CHARGE
Revenue Charge
Conditional
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 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]
CLT209
CLT.003.209
MEDICAID-FFS-EQUIVALENT-AMT
Medicaid FFS Equivalent Amount
Conditional
The amount that would have been paid had the services been provided on a Fee for Service basis.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
S9(11)V99
23
270
282
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 in [3,C,W], then value is mandatory and must be provided
4. Conditional
CLT210
CLT.003.210
BILLING-UNIT
Billing Unit
Conditional
Unit of billing that is used for billing services by the facility.
BILLING-UNIT
CLT00003
CLAIM-LINE-RECORD-LT
X(2)
24
283
284
1. Value must be 2 characters
2. Value must be in Billing Unit List (VVL)
3. Conditional
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)
CLT212
CLT.003.212
SERVICING-PROV-NUM
Servicing Provider Number
Conditional
A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The value is conditional as its usage varies by state.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(30)
26
288
317
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.005.081) Provider Identifier or
4. When Type of Claim not in [3,C,W], then value may match (PRV.002.019) Submitting State Provider ID
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
CLT215
CLT.003.215
SERVICING-PROV-TYPE
Servicing Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
CLT00003
CLAIM-LINE-RECORD-LT
X(2)
28
328
329
1. Value must be 2 characters
2. Value must be in Provider Type Code List (VVL).
3. Conditional
CLT216
CLT.003.216
SERVICING-PROV-SPECIALTY
Servicing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CLT00003
CLAIM-LINE-RECORD-LT
X(2)
29
330
331
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional
CLT217
CLT.003.217
OTHER-TPL-COLLECTION
Other TPL Collection
Mandatory
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.
OTHER-TPL-COLLECTION
CLT00003
CLAIM-LINE-RECORD-LT
X(3)
30
332
334
1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory
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
CLT221
CLT.003.221
PROV-FACILITY-TYPE
Provider Facility Type
Mandatory
The type of facility in which services on the claim were rendered. The Provider Facility Type code set is based on corresponding groups of HIPAA provider taxonomy codes.
PROV-FACILITY-TYPE
CLT00003
CLAIM-LINE-RECORD-LT
X(9)
32
337
345
1. Value must be 9 characters or less
2. Value must be in Provider Facility Type List (VVL)
3. Mandatory
CLT228
CLT.003.228
NATIONAL-DRUG-CODE
National Drug Code
Conditional
A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(12)
33
346
357
1. Value must be 12 digits or less
2. Value must be a valid National Drug Code
3. Conditional
CLT229
CLT.003.229
NDC-UNIT-OF-MEASURE
NDC Unit of Measure
Conditional
A code to indicate the basis by which the quantity of the National Drug Code is expressed.
NDC-UNIT-OF-MEASURE
CLT00003
CLAIM-LINE-RECORD-LT
X(2)
34
358
359
1. Value must be 2 characters
2. Value must be in NDC Unit of Measure List (VVL)
3. Conditional
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
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
CLT234
CLT.003.234
SELF-DIRECTION-TYPE
Self Direction Type
Mandatory
This data element is not applicable to this file type.
SELF-DIRECTION-TYPE
CLT00003
CLAIM-LINE-RECORD-LT
X(3)
37
386
388
1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory
CLT235
CLT.003.235
PRE-AUTHORIZATION-NUM
Preauthorization Number
Conditional
A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number).
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(18)
38
389
406
1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
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
CLT260
CLT.003.260
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
CLT00003
CLAIM-LINE-RECORD-LT
X(76)
40
408
483
1. Value must not be more than 76 characters long
2. Conditional
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
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-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3
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
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
CLT263
CLT.003.263
GME-AMOUNT-PAID
GME Amount Paid
Conditional
The amount included in the Medicaid Amount (CLT.003.208) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
S9(11)V99
44
540
552
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT264
CLT.003.264
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.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(30)
45
553
582
1. Value must be 30 characters or less
2. 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
CLT266
CLT.003.266
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
CLT00003
CLAIM-LINE-RECORD-LT
S9(11)V99
47
593
605
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT267
CLT.003.267
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
CLT00003
CLAIM-LINE-RECORD-LT
S9(11)V99
48
606
618
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CLT226
CLT.003.226
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CLT00003
CLAIM-LINE-RECORD-LT
X(500)
49
619
1118
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
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"
CLT269
CLT.004.269
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
CLT00004
CLAIM-DX-LT
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 (CLT.001.007)
CLT270
CLT.004.270
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
CLT00004
CLAIM-DX-LT
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
CLT271
CLT.004.271
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CLT00004
CLAIM-DX-LT
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
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
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)
CLT274
CLT.004.274
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
CLT00004
CLAIM-DX-LT
9(8)
7
123
130
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CLT.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CLT275
CLT.004.275
DIAGNOSIS-TYPE
Diagnosis Type
Mandatory
Indicates the context of the diagnosis code from the provider's claim (i.e., an 837I claim can have one principal diagnosis code, one admitting diagnosis code, up to 12 external cause of injury diagnosis codes, and up to 24 other diagnosis codes; a UB-04 claim can have one principal diagnosis code, one admitting diagnosis code, and up to 17 other 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
CLT00004
CLAIM-DX-LT
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 [P,A,E,O]
4. 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
CLT277
CLT.004.277
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
CLT00004
CLAIM-DX-LT
X(1)
10
134
134
1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List (VVL)
3. Mandatory
CLT278
CLT.004.278
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
CLT00004
CLAIM-DX-LT
X(7)
11
135
141
1. Value must be a minimum of 3 characters
2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)
3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)
4. Value must not contain a decimal point
5. Mandatory
CLT279
CLT.004.279
DIAGNOSIS-POA-FLAG
Diagnosis POA Flag
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.
DIAGNOSIS-POA-FLAG
CLT00004
CLAIM-DX-LT
X(1)
12
142
142
1. Value must be 1 character
2. Value must be in Diagnosis POA Flag List (VVL)
3. Conditional
CLT280
CLT.004.280
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CLT00004
CLAIM-DX-LT
X(500)
13
143
642
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational

T-MSIS Data Dictionary – COT File (No Changes Between Versions 4.0.0 and 4.1.0)

Data Element Number

System Data Element Number

Data Element

Data Element Name Text

Data Element Necessity

Definition

Valid Value List (VVL)

File Segment Number

File Segment Name

Size

Pipe Separated Value Segment Data Element Order
Fixed Length Field Start Position

Fixed Length Field Stop Position

Coding Requirements

COT001
COT.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
COT00001
FILE-HEADER-RECORD-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 "COT00001"
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
COT003
COT.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
COT00001
FILE-HEADER-RECORD-OT
X(1)
3
19
19
1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory
COT004
COT.001.004
FILE-ENCODING-SPECIFICATION
File Encoding Specification
Mandatory
Denotes which supported file encoding standard was used to create the file.
FILE-ENCODING-SPECIFICATION
COT00001
FILE-HEADER-RECORD-OT
X(3)
4
20
22
1. Value must be 3 characters
2. Value must be in File Encoding Specification List (VVL)
3. Mandatory
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
COT006
COT.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
COT00001
FILE-HEADER-RECORD-OT
X(8)
6
32
39
1. Value must equal "CLAIM-OT"
2. Mandatory
COT007
COT.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
COT00001
FILE-HEADER-RECORD-OT
X(2)
7
40
41
1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory
COT008
COT.001.008
DATE-FILE-CREATED
Date File Created
Mandatory
The date on which the file was created.
N/A
COT00001
FILE-HEADER-RECORD-OT
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
COT009
COT.001.009
START-OF-TIME-PERIOD
Start of Time Period
Mandatory
This value must be the first day of the reporting month, regardless of the actual date span of the data in the file.
N/A
COT00001
FILE-HEADER-RECORD-OT
9(8)
9
50
57
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be equal to or earlier than associated Date File Created
3. Value must be before associated End of Time Period
4. Mandatory
5. Value of the CC component must be "20"
COT010
COT.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
COT00001
FILE-HEADER-RECORD-OT
9(8)
10
58
65
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be equal to or earlier than associated Date File Created
4. Value must be equal to or after associated Start of Time Period
5. Mandatory
COT011
COT.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
COT00001
FILE-HEADER-RECORD-OT
X(1)
11
66
66
1. Value must be 1 character
2. For production files, value must be equal to "P"
3. Value must be in File Status Indicator List (VVL)
4. Mandatory
COT012
COT.001.012
SSN-INDICATOR
SSN Indicator
Mandatory
Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability files.
SSN-INDICATOR
COT00001
FILE-HEADER-RECORD-OT
X(1)
12
67
67
1. Value must be 1 character
2. Value must be in SSN Indicator List (VVL)
3. Mandatory
COT013
COT.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
COT00001
FILE-HEADER-RECORD-OT
9(11)
13
68
78
1. Value must be 11 digits or less
2. Value must be a positive integer
3. Value must be between 0:99999999999 (inclusive)
4. Value must equal the number of records included in the file submission except for the file header record.
5. Mandatory
COT216
COT.001.216
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
COT00001
FILE-HEADER-RECORD-OT
X(4)
14
79
82
1. Value must be 4 characters or less
2. Value must between 1 and 9999
3. Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1)
4. Value must not contain a pipe symbol
5. Mandatory
COT014
COT.001.014
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
COT00001
FILE-HEADER-RECORD-OT
X(500)
15
83
582
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
COT016
COT.002.016
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
COT00002
CLAIM-HEADER-RECORD-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 "COT00002"
COT017
COT.002.017
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
COT00002
CLAIM-HEADER-RECORD-OT
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 (COT.001.007)
COT018
COT.002.018
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
COT00002
CLAIM-HEADER-RECORD-OT
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
COT019
COT.002.019
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
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
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

COT021
COT.002.021
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(12)
6
122
133
1. Value must be 12 characters or less
2. Mandatory
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)

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
COT024
COT.002.024
1115A-DEMONSTRATION-IND
1115A Demonstration Indicator
Conditional
In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration.
1115A-DEMONSTRATION-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
9
155
155
1. Value must be 1 character
2. Value must be in 1115A Demonstration Indicator List (VVL)
3. Conditional
4. 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
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"

COT026
COT.002.026
ADJUSTMENT-REASON-CODE
Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a claim was paid differently than it was billed.
ADJUSTMENT-REASON-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(3)
11
157
159
1. Value must be 3 characters or less
2. Value must be in Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
COT033
COT.002.033
BEGINNING-DATE-OF-SERVICE
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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
12
160
167
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be less than or equal to associated Ending Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
7. Mandatory
COT034
COT.002.034
ENDING-DATE-OF-SERVICE
Ending Date of Service
Mandatory
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving 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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
13
168
175
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be greater than or equal to associated Beginning Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value
7. Mandatory
COT035
COT.002.035
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
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
14
176
183
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CIP.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
COT036
COT.002.036
MEDICAID-PAID-DATE
Medicaid Paid Date
Mandatory
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
15
184
191
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Total Medicaid Paid Amount
3. Mandatory

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

COT038
COT.002.038
TYPE-OF-BILL
Type of Bill
Conditional
A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.)
TYPE-OF-BILL
COT00002
CLAIM-HEADER-RECORD-OT
X(4)
17
193
196
1. Value must be 4 characters
2. Value must be in Type of Bill List (VVL)
3. First character must be a "0"
4. Conditional

COT039
COT.002.039
CLAIM-STATUS
Claim Status
Conditional
The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim.
CLAIM-STATUS
COT00002
CLAIM-HEADER-RECORD-OT
X(3)
18
197
199
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2"
COT040
COT.002.040
CLAIM-STATUS-CATEGORY
Claim Status Category
Mandatory
The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status.
CLAIM-STATUS-CATEGORY
COT00002
CLAIM-HEADER-RECORD-OT
X(3)
19
200
202
1. Value must be 3 characters or less
2. Value must be in Claim Status Category List (VVL)
3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"
4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"
5. Mandatory
COT041
COT.002.041
SOURCE-LOCATION
Source Location
Mandatory
The field denotes the claims payment system from which the claim was extracted.

COT042
COT.002.042
CHECK-NUM
Check Number
Conditional
The check or electronic funds transfer number.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(15)
21
205
219
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
COT043
COT.002.043
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
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
22
220
227
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Check Number
3. Conditional
COT044
COT.002.044
CLAIM-PYMT-REM-CODE-1
Remittance Advice Remark Code 1
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(5)
23
228
232
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
COT045
COT.002.045
CLAIM-PYMT-REM-CODE-2
Remittance Advice Remark Code 2
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(5)
24
233
237
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 1 (COT.002.044) is not populated
COT046
COT.002.046
CLAIM-PYMT-REM-CODE-3
Remittance Advice Remark Code 3
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(5)
25
238
242
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 2 (CLT.002.045) is not populated
COT047
COT.002.047
CLAIM-PYMT-REM-CODE-4
Remittance Advice Remark Code 4
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(5)
26
243
247
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 3 (COT.002.046) is not populated
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)
COT049
COT.002.049
TOT-ALLOWED-AMT
Total Allowed Amount
Conditional
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.

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.

COT054
COT.002.054
TOT-TPL-AMT
Total TPL Amount
Conditional
Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
32
313
325
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)
4. Conditional
COT056
COT.002.056
TOT-OTHER-INSURANCE-AMT
Total Other Insurance Amount
Conditional
The amount paid by insurance other than Medicare or Medicaid on this claim.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
33
326
338
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

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

COT058
COT.002.058
OTHER-TPL-COLLECTION
Other TPL Collection
Mandatory
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.
OTHER-TPL-COLLECTION
COT00002
CLAIM-HEADER-RECORD-OT
X(3)
35
340
342
1. Value must be in Other TPL Collection List (VVL)
2. Value must be 3 characters
3. Mandatory
COT061
COT.002.061
FIXED-PAYMENT-IND
Fixed Payment Indicator
Conditional
This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review.
FIXED-PAYMENT-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
36
343
343
1. Value must be 1 character
2. Value must be in Fixed Payment Indicator List (VVL)
3. 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 not in [3,C,W], then value must be populated
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

COT064
COT.002.064
MEDICARE-COMB-DED-IND
Medicare Combined Deductible Indicator
Conditional
Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated.
MEDICARE-COMB-DED-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
39
348
348
1. Value must be 1 character
2. Value must be in Medicare Combined Deductible Indicator List (VVL)
3. If value equals "1", then Total Medicare Coinsurance amount must not be populated
4. If value equals "0", then Crossover Indicator must equals "0"
5. If value equals "1", then Crossover Indicator must equals "1"
6. Conditional
COT065
COT.002.065
PROGRAM-TYPE
Program Type
Mandatory
A code to indicate special Medicaid program under which the service was provided.
PROGRAM-TYPE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
40
349
350
1. Value must be 2 characters
2. Value must be in Program Type List (VVL)
3. Mandatory
4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period
5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period
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)
COT068
COT.002.068
PAYMENT-LEVEL-IND
Payment Level Indicator
Mandatory
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.

COT069
COT.002.069
MEDICARE-REIM-TYPE
Medicare Reimbursement Type
Conditional
A code to indicate the type of Medicare reimbursement.
MEDICARE-REIM-TYPE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
43
364
365
1. Value must be 2 characters
2. Value must be in Medicare Reimbursement Type List (VVL)
3. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)
4. Conditional
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
COT072
COT.002.072
FORCED-CLAIM-IND
Forced Claim Indicator
Conditional
Indicates if the claim was processed by forcing it through a manual override process.
FORCED-CLAIM-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
45
370
370
1. Value must be 1 character
2. Value must be in Forced Claim Indicator List (VVL)
3. Conditional

COT073
COT.002.073
HEALTH-CARE-ACQUIRED-CONDITION-IND
Healthcare Acquired Condition Indicator
Conditional
This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage
HEALTH-CARE-ACQUIRED-CONDITION-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
46
371
371
1. Value must be 1 character
2. Value must be in Healthcare Acquired Condition Indicator List (VVL)
3. Conditional

COT074
COT.002.074
OCCURRENCE-CODE-01
Occurrence Code 1
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
47
372
373
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT075
COT.002.075
OCCURRENCE-CODE-02
Occurrence Code 2
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
48
374
375
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT076
COT.002.076
OCCURRENCE-CODE-03
Occurrence Code 3
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
49
376
377
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT077
COT.002.077
OCCURRENCE-CODE-04
Occurrence Code 4
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
50
378
379
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT078
COT.002.078
OCCURRENCE-CODE-05
Occurrence Code 5
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
51
380
381
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT079
COT.002.079
OCCURRENCE-CODE-06
Occurrence Code 6
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
52
382
383
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT080
COT.002.080
OCCURRENCE-CODE-07
Occurrence Code 7
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
53
384
385
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT081
COT.002.081
OCCURRENCE-CODE-08
Occurrence Code 8
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
54
386
387
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT082
COT.002.082
OCCURRENCE-CODE-09
Occurrence Code 9
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
55
388
389
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT083
COT.002.083
OCCURRENCE-CODE-10
Occurrence Code 10
Conditional
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans.
OCCURRENCE-CODE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
56
390
391
1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional
COT084
COT.002.084
OCCURRENCE-CODE-EFF-DATE-01
Occurrence Code Effective Date 1
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
57
392
399
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT085
COT.002.085
OCCURRENCE-CODE-EFF-DATE-02
Occurrence Code Effective Date 2
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
58
400
407
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT086
COT.002.086
OCCURRENCE-CODE-EFF-DATE-03
Occurrence Code Effective Date 3
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
59
408
415
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT087
COT.002.087
OCCURRENCE-CODE-EFF-DATE-04
Occurrence Code Effective Date 4
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
60
416
423
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT088
COT.002.088
OCCURRENCE-CODE-EFF-DATE-05
Occurrence Code Effective Date 5
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
61
424
431
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT089
COT.002.089
OCCURRENCE-CODE-EFF-DATE-06
Occurrence Code Effective Date 6
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
62
432
439
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT090
COT.002.090
OCCURRENCE-CODE-EFF-DATE-07
Occurrence Code Effective Date 7
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
63
440
447
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT091
COT.002.091
OCCURRENCE-CODE-EFF-DATE-08
Occurrence Code Effective Date 8
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
64
448
455
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT092
COT.002.092
OCCURRENCE-CODE-EFF-DATE-09
Occurrence Code Effective Date 9
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
65
456
463
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT093
COT.002.093
OCCURRENCE-CODE-EFF-DATE-10
Occurrence Code Effective Date 10
Conditional
The start date of the corresponding occurrence code or occurrence span codes.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
66
464
471
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated populated Occurrence Code
3. Conditional
4. Value must be less than or equal to Occurrence Code End Date
COT094
COT.002.094
OCCURRENCE-CODE-END-DATE-01
Occurrence Code End Date 1
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
67
472
479
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT095
COT.002.095
OCCURRENCE-CODE-END-DATE-02
Occurrence Code End Date 2
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
68
480
487
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT096
COT.002.096
OCCURRENCE-CODE-END-DATE-03
Occurrence Code End Date 3
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
69
488
495
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT097
COT.002.097
OCCURRENCE-CODE-END-DATE-04
Occurrence Code End Date 4
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
70
496
503
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT098
COT.002.098
OCCURRENCE-CODE-END-DATE-05
Occurrence Code End Date 5
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
71
504
511
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT099
COT.002.099
OCCURRENCE-CODE-END-DATE-06
Occurrence Code End Date 6
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
72
512
519
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT100
COT.002.100
OCCURRENCE-CODE-END-DATE-07
Occurrence Code End Date 7
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
73
520
527
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT101
COT.002.101
OCCURRENCE-CODE-END-DATE-08
Occurrence Code End Date 8
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
74
528
535
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT102
COT.002.102
OCCURRENCE-CODE-END-DATE-09
Occurrence Code End Date 9
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
75
536
543
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT103
COT.002.103
OCCURRENCE-CODE-END-DATE-10
Occurrence Code End Date 10
Conditional
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
76
544
551
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Occurrence Code
3. Must be greater than or equal to Occurrence Code Effective Date
4. Conditional
COT104
COT.002.104
PATIENT-CONTROL-NUM
Patient Control Number
Conditional
A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(20)
77
552
571
1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk symbol
3. Conditional
COT105
COT.002.105
ELIGIBLE-LAST-NAME
Eligible Last Name
Conditional
The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(30)
78
572
601
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
COT106
COT.002.106
ELIGIBLE-FIRST-NAME
Eligible First Name
Conditional
The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(30)
79
602
631
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
COT107
COT.002.107
ELIGIBLE-MIDDLE-INIT
Eligible Middle Initial
Conditional
Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name).
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
80
632
632
1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional
COT108
COT.002.108
DATE-OF-BIRTH
Date of Birth
Mandatory
An individual's date of birth.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
81
633
640
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Mandatory
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
COT110
COT.002.110
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 claim is submitted.
WAIVER-TYPE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
83
642
643
1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)
4. When populated, Waiver ID (COT.002.111) must be populated
5. Conditional
6. Value must be in [06,07,08,09,10,11,12,13,14,15,16,17,18,19,20,33] when associated Program Type equals "07"
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
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'.
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)
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
COT115
COT.002.115
BILLING-PROV-TYPE
Billing Provider Type
Conditional
A code to describe the type of provider being reported.
PROV-TYPE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
88
716
717
1. Value must be 2 characters
2. Value must be in Provider Type Code List (VVL)
3. Conditional

COT116
COT.002.116
BILLING-PROV-SPECIALTY
Billing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
89
718
719
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional

COT117
COT.002.117
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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(30)
90
720
749
1. Value must be 30 characters or less
2. 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
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
COT123
COT.002.123
PLACE-OF-SERVICE
Place of Service
Conditional
A data element corresponding with line 24b on the CMS-1500 that indicates where the services took place. This is a pass-through data element that should not be modified or derived when missing unless otherwise specified.
PLACE-OF-SERVICE
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
93
772
773
1. Value must be 2 characters
2. Value must be in Place of Service Code List (VVL)
3. Conditional
4. If value is populated, then Type of Bill must not be populated
COT126
COT.002.126
REMITTANCE-NUM
Remittance Number
Mandatory
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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(30)
94
774
803
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory

COT127
COT.002.127
DAILY-RATE
Daily Rate
Conditional
The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as a flat rate.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(5)V99
95
804
810
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)
COT128
COT.002.128
BORDER-STATE-IND
Border State Indicator
Conditional
A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)
BORDER-STATE-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
96
811
811
1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional

COT130
COT.002.130
TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
Total Beneficiary Coinsurance Paid Amount
Conditional
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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
97
812
824
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
COT131
COT.002.131
BENEFICIARY-COINSURANCE-DATE-PAID
Beneficiary Coinsurance Date Paid
Conditional
The date the beneficiary paid the coinsurance amount.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
98
825
832
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Coinsurance Amount
3. Conditional
COT132
COT.002.132
TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
Total Beneficiary Copayment Paid Amount
Conditional
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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
99
833
845
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
COT133
COT.002.133
BENEFICIARY-COPAYMENT-DATE-PAID
Beneficiary Copayment Date Paid
Conditional
The date the beneficiary paid the copayment amount.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
100
846
853
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Copayment Amount
3. Conditional
COT134
COT.002.134
TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
Total Beneficiary Deductible Paid Amount
Conditional
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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
101
854
866
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
COT135
COT.002.135
BENEFICIARY-DEDUCTIBLE-DATE-PAID
Beneficiary Deductible Date Paid
Conditional
The date the beneficiary paid the deductible amount.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
102
867
874
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Deductible Amount
3. Conditional
COT136
COT.002.136
CLAIM-DENIED-INDICATOR
Claim Denied Indicator
Mandatory
An indicator to identify a claim that the state refused pay in its entirety.
CLAIM-DENIED-INDICATOR
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
103
875
875
1. Value must be 1 character
2. Value must be in Claim Denied Indicator List (VVL)
3. If value equals "0", then Claim Status Category must equal "F2"
4. Mandatory

COT137
COT.002.137
COPAY-WAIVED-IND
Copayment Waived Indicator
Situational
An indicator signifying that the copay was waived by the provider
COPAY-WAIVED-IND
COT00002
CLAIM-HEADER-RECORD-OT
X(1)
104
876
876
1. Value must be 1 character
2. Value must be in Copay Waived Indicator List (VVL)
3. Situational
COT138
COT.002.138
HEALTH-HOME-ENTITY-NAME
Health Home Entity Name
Conditional
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(50)
105
877
926
1. Value must not contain a pipe or asterisk symbols
2. Value must 50 characters or less
3. Conditional
COT140
COT.002.140
THIRD-PARTY-COINSURANCE-AMOUNT-PAID
Third Party Coinsurance Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
106
927
939
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. Situational
COT141
COT.002.141
THIRD-PARTY-COINSURANCE-DATE-PAID
Third Party Coinsurance Date Paid
Conditional
The date the third party paid the coinsurance amount
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
107
940
947
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Coinsurance Amount
3. Conditional
COT142
COT.002.142
THIRD-PARTY-COPAYMENT-AMOUNT-PAID
Third Party Copayment Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards copayment.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
108
948
960
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. Situational
COT143
COT.002.143
THIRD-PARTY-COPAYMENT-DATE-PAID
Third Party Copayment Date Paid
Situational
The date the third party paid the copayment amount.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
9(8)
109
961
968
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Copayment Amount
3. Situational
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
COT147
COT.002.147
MEDICARE-BENEFICIARY-IDENTIFIER
Medicare Beneficiary Identifier
Conditional
The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(12)
111
979
990
1. Conditional
2. Value must be an 11-character string
3. Character 1 must be numeric values 1 thru 9
4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
6. Character 4 must be numeric values 0 thru 9
7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
9. Character 7 must be numeric values 0 thru 9
10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
12. Character 10 must be numeric values 0 thru 9
13. Character 11 must be numeric values 0 thru 9
14. Value must not contain a pipe or asterisk symbols
COT226
COT.002.226
PROV-LOCATION-ID
Provider Location ID
Mandatory
A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(5)
112
991
995
1. Value must be 5 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
COT230
COT.002.230
TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
Total 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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
113
996
1008
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
COT231
COT.002.231
TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
Total 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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
114
1009
1021
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
COT232
COT.002.232
TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
Total 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 minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
115
1022
1034
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
COT233
COT.002.233
COMBINED-BENE-COST-SHARING-PAID-AMOUNT
Combined Beneficiary 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.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
116
1035
1047
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
COT235
COT.002.235
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
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
117
1048
1060
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

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
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
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
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
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
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)
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

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

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

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

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
COT247
COT.002.247
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
COT00002
CLAIM-HEADER-RECORD-OT
X(2)
129
1389
1390
1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code List (VVL)
3. Mandatory
COT248
COT.002.248
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
COT00002
CLAIM-HEADER-RECORD-OT
X(50)
130
1391
1440
1. Value must not be more than 50 characters long
2. Conditional
3. Value must be provided when corresponding Provider Claim Form Code is "Other"
COT249
COT.002.249
TOT-GME-AMOUNT-PAID
Total GME Amount Paid
Conditional
The amount included in the Total Medicaid Amount (COT.002.050) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
131
1441
1453
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. 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
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
COT252
COT.002.252
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
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
134
1494
1506
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

COT253
COT.002.253
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
COT00002
CLAIM-HEADER-RECORD-OT
S9(11)V99
135
1507
1519
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

COT152
COT.002.152
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
COT00002
CLAIM-HEADER-RECORD-OT
X(500)
136
1520
2019
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
COT154
COT.003.154
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
COT00003
CLAIM-LINE-RECORD-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 "COT00003"
COT155
COT.003.155
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
COT00003
CLAIM-LINE-RECORD-OT
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 (COT.001.007)
COT156
COT.003.156
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
COT00003
CLAIM-LINE-RECORD-OT
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
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

COT158
COT.003.158
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(50)
5
42
91
1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
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
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
COT161
COT.003.161
LINE-NUM-ADJ
Adjustment Line Number
Conditional
A unique number to identify the transaction line number that identifies the line number on the adjustment claim.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(3)
8
145
147
1. Value must be 3 characters or less
2. If associated Line Adjustment Indicator value equals "0", then value must not be populated
3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided
4. Conditional
5. When populated, value must be one or greater
COT162
COT.003.162
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
COT00003
CLAIM-LINE-RECORD-OT
X(1)
9
148
148
1. Value must be 1 character
2. Value must be in Line Adjustment Indicator List (VVL)
3. Value must be in [0,1,4]
4. Conditional
5. If associated Line Adjustment Number is populated, then value must be populated
COT163
COT.003.163
LINE-ADJUSTMENT-REASON-CODE
Line Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a service line was paid differently than it was billed.
LINE-ADJUSTMENT-REASON-CODE
COT00003
CLAIM-LINE-RECORD-OT
X(3)
10
149
151
1. Value must be 3 characters or less
2. Value must be in Line Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
COT164
COT.003.164
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(12)
11
152
163
1. Value must be 12 characters or less
2. Mandatory
COT165
COT.003.165
CLAIM-LINE-STATUS
Claim Line Status
Conditional
The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim.
CLAIM-STATUS
COT00003
CLAIM-LINE-RECORD-OT
X(3)
12
164
166
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2"
COT166
COT.003.166
BEGINNING-DATE-OF-SERVICE
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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(8)
13
167
174
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be less than or equal to associated Ending Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
7. Mandatory
COT167
COT.003.167
ENDING-DATE-OF-SERVICE
Ending Date of Service
Mandatory
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving 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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(8)
14
175
182
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be less than or equal to associated End of Time Period value
3. Value must be greater than or equal to associated Beginning Date of Service value
4. Value must be less than or equal to associated Adjudication Date value
5. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
6. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value
7. Mandatory
COT168
COT.003.168
REVENUE-CODE
Revenue Code
Conditional
A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims.
REVENUE-CODE
COT00003
CLAIM-LINE-RECORD-OT
X(4)
15
183
186
1. Value must be 4 characters or less
2. Value must be in Revenue Code List (VVL)
3. A Revenue Code value requires an associated Revenue Charge
4. 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

COT170
COT.003.170
PROCEDURE-CODE-DATE
Procedure Code Date
Conditional
The date upon which a reported medical procedure was performed.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(8)
17
195
202
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated Discharge Date value
3. Value must be provided with an associated Procedure Code value
4. Value must be on or after associated Beginning Date of Service value
5. Value must be on or before associated Eligible Date of Death value
6. Value must be not be populated when associated Procedure Code is not populated
7. Conditional
COT171
COT.003.171
PROCEDURE-CODE-FLAG
Procedure Code Flag
Conditional
A flag that identifies the coding system used for an associated procedure code.
PROCEDURE-CODE-FLAG
COT00003
CLAIM-LINE-RECORD-OT
X(2)
18
203
204
1. Value must be 2 characters
2. Value must be in Procedure Code Flag List (VVL)
3. When populated, there must be a corresponding Procedure Code
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
COT174
COT.003.174
BILLED-AMT
Billed Amount
Conditional
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.

COT175
COT.003.175
ALLOWED-AMT
Allowed Amount
Conditional
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.

COT176
COT.003.176
BENEFICIARY-COPAYMENT-PAID-AMOUNT
Beneficiary Copayment Paid Amount
Conditional
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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
S9(11)V99
22
233
245
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
COT177
COT.003.177
TPL-AMT
TPL Amount
Conditional
Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party.
N/A
COT00003
CLAIM-LINE-RECORD-OT
S9(11)V99
23
246
258
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.

COT187
COT.003.187
HCBS-SERVICE-CODE
HCBS Service Code
Conditional
A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services).
HCBS-SERVICE-CODE
COT00003
CLAIM-LINE-RECORD-OT
X(1)
30
323
323
1. Value must be 1 character
2. Value must be in HCBS Service Code List (VVL)
3. If value is in [1-7], then HCBS Taxonomy must be populated
4. Conditional
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.

COT193
COT.003.193
SERVICING-PROV-SPECIALTY
Servicing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
COT00003
CLAIM-LINE-RECORD-OT
X(2)
36
383
384
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional

COT194
COT.003.194
OTHER-TPL-COLLECTION
Other TPL Collection
Mandatory
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.
OTHER-TPL-COLLECTION
COT00003
CLAIM-LINE-RECORD-OT
X(3)
37
385
387
1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory
COT195
COT.003.195
TOOTH-DESIGNATION-SYSTEM
Tooth Designation System
Conditional
A code to identify the tooth numbering system being used.
TOOTH-DESIGNATION-SYSTEM
COT00003
CLAIM-LINE-RECORD-OT
X(2)
38
388
389
1. Value must be 2 characters
2. Value must be in Tooth Designation System List (VVL)
3. Value must not contain a pipe symbol
4. Conditional
COT196
COT.003.196
TOOTH-NUM
Tooth Number
Conditional
The tooth number serviced based on the tooth numbering system identified in the TOOTH-DESIGNATION-SYSTEM field.
TOOTH-NUM
COT00003
CLAIM-LINE-RECORD-OT
X(2)
39
390
391
1. Value must be 2 characters or less
2. Value must be in Tooth Number List (VVL)
3. If Tooth Designation System (COT.003.195) is "JP" value must be found in [1..32][51-82][A..T]or [AS..KS]
4. If Tooth Designation System (COT.003.195) is "JO" value must have 1 digit before and after the decimal (N.N)
5. If Tooth Designation System (COT.003.195) is "JO" value must be a first digit of 1-4 and the decimal must be between 1-8
6. Conditional
7. When value is in [A-T], the difference between Ending Date of Service (COT.002.034) and Date of Birth (COT.002.108) is less than 15 years
COT197
COT.003.197
TOOTH-QUAD-CODE
Tooth Quad Code
Conditional
The area of the oral cavity is designated by a two-digit code.
TOOTH-QUAD-CODE
COT00003
CLAIM-LINE-RECORD-OT
X(2)
40
392
393
1. Value must be 2 characters
2. Value must be in Tooth Quad Code List (VVL)
3. Conditional
4. When populated, associated type of service value must be in [013,029,035]
COT198
COT.003.198
TOOTH-SURFACE-CODE
Tooth Surface Code
Conditional
A code to identify the tooth's surface on which the service was performed.
TOOTH-SURFACE-CODE
COT00003
CLAIM-LINE-RECORD-OT
X(1)
41
394
394
1. Value must be 1 character
2. Value must be in Tooth Surface Code List (VVL)
3. Conditional
4. When populated, associated type of service value must be in [013,029,035]
COT199
COT.003.199
ORIGINATION-ADDR-LN1
Origination Address Line 1
Conditional
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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(60)
42
395
454
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. Conditional
COT200
COT.003.200
ORIGINATION-ADDR-LN2
Origination Address Line 2
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, this is only required if state has captured this information, otherwise it is conditional.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(60)
43
455
514
1. Value must be 60 characters or less
2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)
3. There must be an Address Line 1 in order to have an Address Line 2
4. Value must not contain a pipe or asterisk symbols
5. Conditional
COT201
COT.003.201
ORIGINATION-CITY
Origination City
Conditional
The name of the origination city from 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. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(28)
44
515
542
1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
COT202
COT.003.202
ORIGINATION-STATE
Origination State
Conditional
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.
STATE
COT00003
CLAIM-LINE-RECORD-OT
X(2)
45
543
544
1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. 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
COT204
COT.003.204
DESTINATION-ADDR-LN1
Destination Address Line 1
Conditional
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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(60)
47
554
613
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. Conditional
COT205
COT.003.205
DESTINATION-ADDR-LN2
Destination Address Line 2
Conditional
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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(60)
48
614
673
1. Value must be 60 characters or less
2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)
3. There must be an Address Line 1 in order to have an Address Line 2
4. Value must not contain a pipe or asterisk symbols
5. Conditional
COT206
COT.003.206
DESTINATION-CITY
Destination City
Conditional
The name of the destination city to 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. For transportation claims only. Required if state has captured this information, otherwise it is conditional.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(28)
49
674
701
1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
COT207
COT.003.207
DESTINATION-STATE
Destination State
Conditional
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. For transportation claims only. Required if state has captured this information, otherwise it is conditional.
STATE
COT00003
CLAIM-LINE-RECORD-OT
X(2)
50
702
703
1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. 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
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
COT213
COT.003.213
OTHER-INSURANCE-AMT
Other Insurance Amount
Conditional
The amount paid by insurance other than Medicare or Medicaid on this claim.
N/A
COT00003
CLAIM-LINE-RECORD-OT
S9(11)V99
53
715
727
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

COT217
COT.003.217
NATIONAL-DRUG-CODE
National Drug Code
Conditional
A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(12)
54
728
739
1. Value must be 12 digits or less
2. Value must be a valid National Drug Code
3. 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
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
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
COT221
COT.003.221
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
COT00003
CLAIM-LINE-RECORD-OT
9(8)
58
746
753
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (COT.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
COT222
COT.003.222
SELF-DIRECTION-TYPE
Self Direction Type
Mandatory
A data element to identify how the beneficiary self-directed the service, i.e. hiring authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services), budget authority (The beneficiary has decision-making authority over how the Medicaid funds in a budget are spent), or both hiring and budget authority.
SELF-DIRECTION-TYPE
COT00003
CLAIM-LINE-RECORD-OT
X(3)
59
754
756
1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory
COT223
COT.003.223
PRE-AUTHORIZATION-NUM
Preauthorization Number
Conditional
A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number).
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(18)
60
757
774
1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
COT224
COT.003.224
NDC-UNIT-OF-MEASURE
NDC Unit of Measure
Conditional
A code to indicate the basis by which the quantity of the National Drug Code is expressed.
NDC-UNIT-OF-MEASURE
COT00003
CLAIM-LINE-RECORD-OT
X(2)
61
775
776
1. Value must be 2 characters
2. Value must be in NDC Unit of Measure List (VVL)
3. Conditional
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
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

COT254
COT.003.254
DIAGNOSIS-CODE-POINTER-1
Diagnosis Code Pointer 1
Mandatory
A pointer to the diagnosis code in the order of importance to this service.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(2)
64
796
797
1. Value must be numeric
2. Value must be 2 digits or less
3. Value must be between 1 and 12
4. Mandatory
COT287
COT.003.287
DIAGNOSIS-CODE-POINTER-2
Diagnosis Code Pointer 2
Conditional
A pointer to the diagnosis code in the order of importance to this service.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(2)
65
798
799
1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. Conditional
COT288
COT.003.288
DIAGNOSIS-CODE-POINTER-3
Diagnosis Code Pointer 3
Conditional
A pointer to the diagnosis code in the order of importance to this service.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(2)
66
800
801
1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. Conditional
COT289
COT.003.289
DIAGNOSIS-CODE-POINTER-4
Diagnosis Code Pointer 4
Conditional
A pointer to the diagnosis code in the order of importance to this service.
N/A
COT00003
CLAIM-LINE-RECORD-OT
9(2)
67
802
803
1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. Conditional
COT255
COT.003.255
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
COT00003
CLAIM-LINE-RECORD-OT
X(76)
68
804
879
1. Value must not be more than 76 characters long
2. Conditional
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
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-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3
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
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
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)
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

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

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

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

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
COT264
COT.003.264
PLACE-OF-SERVICE
Place of Service
Conditional
PLACE-OF-SERVICE is a pass-through data element meaning that the state should report the field in T-MSIS as reported by the provider on the claims form (i.e., 837P, CMS-1500, or 837D). If the claim is submitted on the 837p electronic claims form and the Facility Code Qualifier is reported with any value other than “B”, then the PLACE-OF-SERVICE value should be blank or space-filled. If the claim is submitted on the CMS 1450 (UB04) institutional claims form, the PLACE-OF-SERVICE field should be blank or space-filled. Otherwise, if the claim is submitted with the place of service populated with any value other than the valid values listed in T-MSIS Data Guide for PLACE-OF-SERVICE values, that value should still be reported in the PLACE-OF-SERVICE data element. If the claim is submitted by a provider with the place of service fields blank, then the PLACE-OF-SERVICE on the T-MSIS OT claims file should be blank or space-filled.
PLACE-OF-SERVICE
COT00003
CLAIM-LINE-RECORD-OT
X(2)
78
1105
1106
1. Value must not be more than 2 characters
2. Value must be in Place of Service Code List (VVL)
3. Conditional
4. if value is populated, then Revenue Code must be null
COT265
COT.003.265
GME-AMOUNT-PAID
GME Amount Paid
Conditional
The amount included in the Medicaid Amount (COT.003.178) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim.
N/A
COT00003
CLAIM-LINE-RECORD-OT
S9(11)V99
79
1107
1119
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. 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
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
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
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
COT270
COT.003.270
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.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(30)
84
1200
1229
1. Value must be 30 characters or less
2. 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
COT272
COT.003.272
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
COT00003
CLAIM-LINE-RECORD-OT
S9(11)V99
86
1240
1252
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

COT273
COT.003.273
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
COT00003
CLAIM-LINE-RECORD-OT
S9(11)V99
87
1253
1265
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

COT214
COT.003.214
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
COT00003
CLAIM-LINE-RECORD-OT
X(500)
88
1266
1765
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
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"
COT275
COT.004.275
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
COT00004
CLAIM-DX-OT
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 (COT.001.007)

COT276
COT.004.276
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
COT00004
CLAIM-DX-OT
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
COT277
COT.004.277
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
COT00004
CLAIM-DX-OT
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
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
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)
COT280
COT.004.280
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
COT00004
CLAIM-DX-OT
9(8)
7
123
130
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (COT.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
COT281
COT.004.281
DIAGNOSIS-TYPE
Diagnosis Type
Mandatory
Indicates the context of the diagnosis code from the provider's claim (i.e., an 837I claim can have one principal diagnosis code, up to 12 external cause of injury diagnosis codes, and up to 24 other diagnosis codes; a UB-04 claim can have one principal diagnosis code, one admitting diagnosis code, and up to 17 other diagnosis codes; an 837P or CMS-1500 claim can have up to 12 diagnosis codes; an 837D or ADA claim can have up to 4 diagnosis codes). The type of diagnosis code (e.g., principal, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number.
DIAGNOSIS-TYPE
COT00004
CLAIM-DX-OT
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 [P,A,E,O]
4. 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
COT283
COT.004.283
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
COT00004
CLAIM-DX-OT
X(1)
10
134
134
1. Value must be 1 character
2. Value must be in Diagnosis Code Flag List (VVL)
3. Mandatory
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. Value must be a minimum of 3 characters
2. If associated Diagnosis Code Flag value equals "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)
3. If associated Diagnosis Code Flag value equals "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)
4. Value must not contain a decimal point
5. Mandatory
COT285
COT.004.285
STATE-NOTATION
State Notation
Situational
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. Situational

T-MSIS Data Dictionary – CRX File (No Changes Between Versions 4.0.0 and 4.1.0)

Data Element Number

System Data Element Number

Data Element

Data Element Name Text

Data Element Necessity

Definition

Valid Value List (VVL)

File Segment Number

File Segment Name

Size

Pipe Separated Value Segment Data Element Order
Fixed Length Field Start Position

Fixed Length Field Stop Position

Coding Requirements

CRX001
CRX.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
CRX00001
FILE-HEADER-RECORD-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 "CRX00001"
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
CRX003
CRX.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
CRX00001
FILE-HEADER-RECORD-RX
X(1)
3
19
19
1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory
CRX004
CRX.001.004
FILE-ENCODING-SPECIFICATION
File Encoding Specification
Mandatory
Denotes which supported file encoding standard was used to create the file.
FILE-ENCODING-SPECIFICATION
CRX00001
FILE-HEADER-RECORD-RX
X(3)
4
20
22
1. Value must be 3 characters
2. Value must be in File Encoding Specification List (VVL)
3. Mandatory
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
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
CRX007
CRX.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
CRX00001
FILE-HEADER-RECORD-RX
X(2)
7
40
41
1. Value must be 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

CRX008
CRX.001.008
DATE-FILE-CREATED
Date File Created
Mandatory
The date on which the file was created.
N/A
CRX00001
FILE-HEADER-RECORD-RX
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
CRX009
CRX.001.009
START-OF-TIME-PERIOD
Start of Time Period
Mandatory
This value must be the first day of the reporting month, regardless of the actual date span of the data in the file.
N/A
CRX00001
FILE-HEADER-RECORD-RX
9(8)
9
50
57
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be equal to or earlier than associated Date File Created
3. Value must be before associated End of Time Period
4. Mandatory
5. Value of the CC component must be "20"
CRX010
CRX.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
CRX00001
FILE-HEADER-RECORD-RX
9(8)
10
58
65
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be equal to or earlier than associated Date File Created
4. Value must be equal to or after associated Start of Time Period
5. Mandatory
CRX011
CRX.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
CRX00001
FILE-HEADER-RECORD-RX
X(1)
11
66
66
1. Value must be 1 character
2. For production files, value must be equal to "P"
3. Value must be in File Status Indicator List (VVL)
4. Mandatory
CRX012
CRX.001.012
SSN-INDICATOR
SSN Indicator
Mandatory
Indicates whether the state uses the eligible person's social security number instead of an MSIS Identification Number as the unique, unchanging eligible person identifier. A state's SSN/Non-SSN designation on the eligibility file should match on the claims and third party liability files.
SSN-INDICATOR
CRX00001
FILE-HEADER-RECORD-RX
X(1)
12
67
67
1. Value must be 1 character
2. Value must be in SSN Indicator List (VVL)
3. Mandatory
CRX013
CRX.001.013
TOT-REC-CNT
Total Record Count
Mandatory
A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission.
N/A
CRX00001
FILE-HEADER-RECORD-RX
9(11)
13
68
78
1. Value must be 11 digits or less
2. Value must be a positive integer
3. Value must be between 0:99999999999 (inclusive)
4. Value must equal the number of records included in the file submission except for the file header record.
5. Mandatory
CRX155
CRX.001.155
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
CRX00001
FILE-HEADER-RECORD-RX
X(4)
14
79
82
1. Value must be 4 characters or less
2. Value must between 1 and 9999
3. Value must be equal to the largest of any prior values for the same reporting period and file type, plus 1 (i.e. incremented by 1)
4. Value must not contain a pipe symbol
5. Mandatory
CRX014
CRX.001.014
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CRX00001
FILE-HEADER-RECORD-RX
X(500)
15
83
582
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
CRX016
CRX.002.016
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
CRX00002
CLAIM-HEADER-RECORD-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 "CRX00002"
CRX017
CRX.002.017
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
CRX00002
CLAIM-HEADER-RECORD-RX
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 (CRX.001.007)

CRX018
CRX.002.018
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
CRX00002
CLAIM-HEADER-RECORD-RX
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
CRX019
CRX.002.019
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CRX00002
CLAIM-HEADER-RECORD-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
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
CRX021
CRX.002.021
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(12)
6
122
133
1. Value must be 12 characters or less
2. Mandatory
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)
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
CRX024
CRX.002.024
1115A-DEMONSTRATION-IND
1115A Demonstration Indicator
Conditional
In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration.
1115A-DEMONSTRATION-IND
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
9
155
155
1. Value must be 1 character
2. Value must be in 1115A Demonstration Indicator List (VVL)
3. Conditional
4. 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
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"
CRX026
CRX.002.026
ADJUSTMENT-REASON-CODE
Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a claim was paid differently than it was billed.
ADJUSTMENT-REASON-CODE
CRX00002
CLAIM-HEADER-RECORD-RX
X(3)
11
157
159
1. Value must be 3 characters or less
2. Value must be in Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
CRX027
CRX.002.027
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
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
12
160
167
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CIP.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CRX028
CRX.002.028
MEDICAID-PAID-DATE
Medicaid Paid Date
Mandatory
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
13
168
175
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Total Medicaid Paid Amount
3. Mandatory

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

CRX030
CRX.002.030
CLAIM-STATUS
Claim Status
Conditional
The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim.
CLAIM-STATUS
CRX00002
CLAIM-HEADER-RECORD-RX
X(3)
15
177
179
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [542,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2"
CRX031
CRX.002.031
CLAIM-STATUS-CATEGORY
Claim Status Category
Mandatory
The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status.
CLAIM-STATUS-CATEGORY
CRX00002
CLAIM-HEADER-RECORD-RX
X(3)
16
180
182
1. Value must be 3 characters or less
2. Value must be in Claim Status Category List (VVL)
3. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"
4. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"
5. Mandatory
CRX032
CRX.002.032
SOURCE-LOCATION
Source Location
Mandatory
The field denotes the claims payment system from which the claim was extracted.

CRX033
CRX.002.033
CHECK-NUM
Check Number
Conditional
The check or electronic funds transfer number.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(15)
18
185
199
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
CRX034
CRX.002.034
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
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
19
200
207
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Must have an associated Check Number
3. Conditional
CRX035
CRX.002.035
CLAIM-PYMT-REM-CODE-1
Remittance Advice Remark Code 1
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CRX00002
CLAIM-HEADER-RECORD-RX
X(5)
20
208
212
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
CRX036
CRX.002.036
CLAIM-PYMT-REM-CODE-2
Remittance Advice Remark Code 2
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CRX00002
CLAIM-HEADER-RECORD-RX
X(5)
21
213
217
1. Value must be 5 characters or less
2. Value must be in Claim Payment Remittance Code List (VVL)
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 1 (CRX.002.035) is not populated
CRX037
CRX.002.037
CLAIM-PYMT-REM-CODE-3
Remittance Advice Remark Code 3
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CRX00002
CLAIM-HEADER-RECORD-RX
X(5)
22
218
222
1. Value must be in Claim Payment Remittance Code List (VVL)
2. Value must be 5 characters or less
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 2 (CRX.002.036) is not populated
CRX038
CRX.002.038
CLAIM-PYMT-REM-CODE-4
Remittance Advice Remark Code 4
Conditional
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA).
CLAIM-PYMT-REM-CODE
CRX00002
CLAIM-HEADER-RECORD-RX
X(5)
23
223
227
1. Value must be in Claim Payment Remittance Code List (VVL)
2. Value must be 5 characters or less
3. Conditional
4. When more than one occurrence of Claim Payment Remark Code 1 through Claim Payment Remark Code 4 is populated on a claim, all values must be unique
5. Value must not be populated when Remittance Advice Remark Code 3 (CIP.002.110) is not populated
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
CRX040
CRX.002.040
TOT-ALLOWED-AMT
Total Allowed Amount
Conditional
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.

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.

CRX045
CRX.002.045
TOT-TPL-AMT
Total TPL Amount
Conditional
Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
29
293
305
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)
4. Conditional
CRX047
CRX.002.047
TOT-OTHER-INSURANCE-AMT
Total Other Insurance Amount
Conditional
The amount paid by insurance other than Medicare or Medicaid on this claim.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
30
306
318
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

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

CRX049
CRX.002.049
OTHER-TPL-COLLECTION
Other TPL Collection
Mandatory
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.
OTHER-TPL-COLLECTION
CRX00002
CLAIM-HEADER-RECORD-RX
X(3)
32
320
322
1. Value must be in Other TPL Collection List (VVL)
2. Value must be 3 characters
3. Mandatory
CRX052
CRX.002.052
FIXED-PAYMENT-IND
Fixed Payment Indicator
Conditional
This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review.
FIXED-PAYMENT-IND
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
33
323
323
1. Value must be 1 character
2. Value must be in Fixed Payment Indicator List (VVL)
3. 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 not in [3,C,W], then value must be populated
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

CRX055
CRX.002.055
PROGRAM-TYPE
Program Type
Mandatory
A code to indicate special Medicaid program under which the service was provided.
PROGRAM-TYPE
CRX00002
CLAIM-HEADER-RECORD-RX
X(2)
36
328
329
1. Value must be 2 characters
2. Value must be in Program Type List (VVL)
3. Mandatory
4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period
5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period
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 (CRX.002.029) 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 (CRX.002.029) 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)

CRX058
CRX.002.058
PAYMENT-LEVEL-IND
Payment Level Indicator
Mandatory
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.

CRX062
CRX.002.062
PATIENT-CONTROL-NUM
Patient Control Number
Conditional
A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(20)
42
350
369
1. Value must be 20 characters or less
2. Value must not contain a pipe or asterisk symbol
3. Conditional
CRX063
CRX.002.063
ELIGIBLE-LAST-NAME
Eligible Last Name
Conditional
The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(30)
43
370
399
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CRX064
CRX.002.064
ELIGIBLE-FIRST-NAME
Eligible First Name
Conditional
The first name of the individual to whom the services were provided.(The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.)
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(30)
44
400
429
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CRX065
CRX.002.065
ELIGIBLE-MIDDLE-INIT
Eligible Middle Initial
Conditional
Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name).
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
45
430
430
1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CRX066
CRX.002.066
DATE-OF-BIRTH
Date of Birth
Mandatory
An individual's date of birth.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
46
431
438
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Mandatory
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
CRX068
CRX.002.068
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 claim is submitted.
WAIVER-TYPE
CRX00002
CLAIM-HEADER-RECORD-RX
X(2)
48
440
441
1. Value must be 2 characters
2. Value must be in Waiver Type List (VVL)
3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)
4. Value must have a corresponding value in Waiver ID (CRX.002.069)
5. Conditional
6. Value must be in [06,07,08,09,10,11,12,13,14,15,16,17,18,19,20,33] when associated Program Type equals "07"
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
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)
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)
CRX072
CRX.002.072
BILLING-PROV-TAXONOMY
Billing Provider Taxonomy
Conditional
The taxonomy code for the provider billing for the service.
PROV-TAXONOMY
CRX00002
CLAIM-HEADER-RECORD-RX
X(12)
52
502
513
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional

CRX073
CRX.002.073
BILLING-PROV-SPECIALTY
Billing Provider Specialty
Conditional
This code describes the area of specialty for the provider being reported.
PROV-SPECIALTY
CRX00002
CLAIM-HEADER-RECORD-RX
X(2)
53
514
515
1. Value must be 2 characters
2. Value must be in Provider Specialty List (VVL)
3. Conditional

CRX074
CRX.002.074
PRESCRIBING-PROV-NUM
Prescribing Provider Number
Mandatory
A unique identification number assigned by the state to the provider who prescribed the drug, device, or supply. This must be the individual's ID number, not a group identification number. If the prescribing physician provider ID is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the state file, then the State should use the DEA ID for this data element
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(30)
54
516
545
1. Value must be 30 characters or less
2. 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)
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
CRX081
CRX.002.081
REMITTANCE-NUM
Remittance Number
Mandatory
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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(30)
57
568
597
1. Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory

CRX082
CRX.002.082
BORDER-STATE-IND
Border State Indicator
Conditional
A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)
BORDER-STATE-IND
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
58
598
598
1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional

CRX084
CRX.002.084
DATE-PRESCRIBED
Date Prescribed
Mandatory
The date the drug, device, or supply was prescribed by the physician or other practitioner. This should not be confused with the Prescription Fill Date, which represents the date the prescription was actually filled by the provider.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
59
599
606
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)
3. Value must be on or before associated Prescription Fill Date (CRX.002.085)
4. Value must be on or before associated Adjudication Date (CRX.002.027)
5. Value must be on or before associated eligible party's Date of Death (ELG.002.025)
6. Mandatory
7. Value should be on or before End of Time Period (CRX.001.010)
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. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value must be on or before associated End of Time Period (CRX.001.010)
3. Value must be on or after associated Start of Time Period (CRX.001.009)
4. Value must be on or after associated Date Prescribed (CRX.002.084)
5. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)
6. Value must be on or before associated eligible party's Date of Death (ELG.002.025)
7. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal "1"
8. Mandatory
CRX086
CRX.002.086
COMPOUND-DRUG-IND
Compound Drug Indicator
Conditional
Indicator to specify if the drug is compound or not.
COMPOUND-DRUG-IND
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
61
615
615
1. Value must be 1 character
2. Value must be in Compound Drug Indicator List (VVL)
3. Conditional
CRX087
CRX.002.087
TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
Total Beneficiary Coinsurance Paid Amount
Conditional
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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
62
616
628
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
CRX088
CRX.002.088
BENEFICIARY-COINSURANCE-DATE-PAID
Beneficiary Coinsurance Date Paid
Conditional
The date the beneficiary paid the coinsurance amount.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
63
629
636
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Coinsurance Amount
3. Conditional
CRX089
CRX.002.089
TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
Total Beneficiary Copayment Paid Amount
Conditional
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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
64
637
649
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
CRX090
CRX.002.090
BENEFICIARY-COPAYMENT-DATE-PAID
Beneficiary Copayment Date Paid
Conditional
The date the beneficiary paid the copayment amount.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
65
650
657
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Copayment Amount
3. Conditional
CRX092
CRX.002.092
TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
Total Beneficiary Deductible Paid Amount
Conditional
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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
66
658
670
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
CRX093
CRX.002.093
BENEFICIARY-DEDUCTIBLE-DATE-PAID
Beneficiary Deductible Date Paid
Conditional
The date the beneficiary paid the deductible amount.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
67
671
678
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Beneficiary Deductible Amount
3. Conditional
CRX094
CRX.002.094
CLAIM-DENIED-INDICATOR
Claim Denied Indicator
Mandatory
An indicator to identify a claim that the state refused pay in its entirety.
CLAIM-DENIED-INDICATOR
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
68
679
679
1. Value must be 1 character
2. Value must be in Claim Denied Indicator List (VVL)
3. If value equals "0", then Claim Status Category must equal "F2"
4. Mandatory

CRX095
CRX.002.095
COPAY-WAIVED-IND
Copayment Waived Indicator
Situational
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.
COPAY-WAIVED-IND
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
69
680
680
1. Value must be 1 character
2. Value must be in Copay Waived Indicator List (VVL)
3. Situational
CRX096
CRX.002.096
HEALTH-HOME-ENTITY-NAME
Health Home Entity Name
Conditional
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(50)
70
681
730
1. Value must not contain a pipe or asterisk symbols
2. Value must 50 characters or less
3. Conditional
CRX098
CRX.002.098
THIRD-PARTY-COINSURANCE-AMOUNT-PAID
Third Party Coinsurance Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
71
731
743
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. Situational
CRX099
CRX.002.099
THIRD-PARTY-COINSURANCE-DATE-PAID
Third Party Coinsurance Date Paid
Conditional
The date the third party paid the coinsurance amount
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
72
744
751
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Coinsurance Amount
3. Conditional
CRX100
CRX.002.100
THIRD-PARTY-COPAYMENT-AMOUNT-PAID
Third Party Copayment Amount Paid
Situational
The amount of money paid by a third party on behalf of the beneficiary towards copayment.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
73
752
764
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. Situational
CRX101
CRX.002.101
THIRD-PARTY-COPAYMENT-DATE-PAID
Third Party Copayment Date Paid
Situational
The date the third party paid the copayment amount.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
9(8)
74
765
772
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. When populated, value must have an associated Third Party Copayment Amount
3. Situational
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)
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
CRX105
CRX.002.105
MEDICARE-BENEFICIARY-IDENTIFIER
Medicare Beneficiary Identifier
Conditional
The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(12)
77
793
804
1. Conditional
2. Value must be an 11-character string
3. Character 1 must be numeric values 1 thru 9
4. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
6. Character 4 must be numeric values 0 thru 9
7. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)
9. Character 7 must be numeric values 0 thru 9
10. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)
12. Character 10 must be numeric values 0 thru 9
13. Character 11 must be numeric values 0 thru 9
14. Value must not contain a pipe or asterisk symbols
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) equals "1"
4. Mandatory
CRX160
CRX.002.160
MEDICARE-COMB-DED-IND
Medicare Combined Deductible Indicator
Conditional
Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated.
MEDICARE-COMB-DED-IND
CRX00002
CLAIM-HEADER-RECORD-RX
X(1)
79
835
835
1. Value must be 1 character
2. Value must be in Medicare Combined Deductible Indicator List (VVL)
3. If value equals "1", then Total Medicare Coinsurance amount must not be populated
4. If value equals "0", then Crossover Indicator must equals "0"
5. If value equals "1", then Crossover Indicator must equals "1"
6. Conditional
CRX161
CRX.002.161
PROV-LOCATION-ID
Provider Location ID
Mandatory
A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(5)
80
836
840
1. Value must be 5 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
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
CRX163
CRX.002.163
TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
Total 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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
82
842
854
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CRX164
CRX.002.164
TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
Total 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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
83
855
867
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CRX165
CRX.002.165
TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
Total 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 minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
84
868
880
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
CRX166
CRX.002.166
COMBINED-BENE-COST-SHARING-PAID-AMOUNT
Combined Beneficiary 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.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
S9(11)V99
85
881
893
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional
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

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
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 must be provided when corresponding Provider Claim Form Code is "Other"
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-RX
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
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-RX
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

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-RX
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

CRX106
CRX.002.106
STATE-NOTATION
State Notation
Situational
A free text field for the submitting state to enter whatever information it chooses.
N/A
CRX00002
CLAIM-HEADER-RECORD-RX
X(500)
92
998
1497
1. Value must be 500 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Situational
CRX108
CRX.003.108
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
CRX00003
CLAIM-LINE-RECORD-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 "CRX00003"
CRX109
CRX.003.109
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
CRX00003
CLAIM-LINE-RECORD-RX
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 (CRX.001.007)

CRX110
CRX.003.110
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
CRX00003
CLAIM-LINE-RECORD-RX
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
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

CRX112
CRX.003.112
ICN-ORIG
Original ICN
Mandatory
A unique number assigned by the state's payment system that identifies an original or adjustment claim.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
X(50)
5
42
91
1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Mandatory
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
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
CRX115
CRX.003.115
LINE-NUM-ADJ
Adjustment Line Number
Conditional
A unique number to identify the transaction line number that identifies the line number on the adjustment claim.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
X(3)
8
145
147
1. Value must be 3 characters or less
2. If associated Line Adjustment Indicator value equals "0", then value must not be populated
3. If associated Line Adjustment Indicator value equals "1", then value is mandatory and must be provided
4. Conditional
5. When populated, value must be one or greater
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 1 character
2. Value must be in Line Adjustment Indicator List (VVL)
3. Value must be in [0,1,4]
4. Conditional
5. If associated Line Adjustment Number is populated, then value must be populated
CRX117
CRX.003.117
LINE-ADJUSTMENT-REASON-CODE
Line Adjustment Reason Code
Conditional
Claim adjustment reason codes communicate why a service line was paid differently than it was billed.
LINE-ADJUSTMENT-REASON-CODE
CRX00003
CLAIM-LINE-RECORD-RX
X(3)
10
149
151
1. Value must be 3 characters or less
2. Value must be in Line Adjustment Reason Code List (VVL)
3. Conditional
4. Value must be populated when the total paid amount is different from the total billed amount
CRX118
CRX.003.118
SUBMITTER-ID
Submitter ID
Mandatory
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
X(12)
11
152
163
1. Value must be 12 characters or less
2. Mandatory
CRX119
CRX.003.119
CLAIM-LINE-STATUS
Claim Line Status
Conditional
The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim.
CLAIM-STATUS
CRX00003
CLAIM-LINE-RECORD-RX
X(3)
12
164
166
1. Value must be 3 characters or less
2. Value must be in Claim Status List (VVL)
3. Conditional
4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be"F2"
CRX120
CRX.003.120
NATIONAL-DRUG-CODE
National Drug Code
Mandatory
A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
X(12)
13
167
178
1. Value must be 12 digits or less
2. Value must be a valid National Drug Code
3. Mandatory
4. Value must have an associated Metric Decimal Quantity (CRX.003.144)
5. Value must have an associated Unit of Measure (CRX.003.133)
CRX121
CRX.003.121
BILLED-AMT
Billed Amount
Conditional
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.

CRX122
CRX.003.122
ALLOWED-AMT
Allowed Amount
Conditional
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.

CRX123
CRX.003.123
BENEFICIARY-COPAYMENT-PAID-AMOUNT
Beneficiary Copayment Paid Amount
Conditional
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.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(5)V99
16
205
211
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

CRX124
CRX.003.124
TPL-AMT
Third Party Liability Amount
Conditional
Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
17
212
224
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. 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.

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
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)
CRX135
CRX.003.135
HCBS-SERVICE-CODE
HCBS Service Code
Conditional
A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services).
HCBS-SERVICE-CODE
CRX00003
CLAIM-LINE-RECORD-RX
X(1)
27
331
331
1. Value must be 1 character
2. Value must be in HCBS Service Code List (VVL)
3. If value is in [1-7], then HCBS Taxonomy must be populated
4. Conditional
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.

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
CRX137
CRX.003.137
OTHER-TPL-COLLECTION
Other TPL Collection
Mandatory
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary.
OTHER-TPL-COLLECTION
CRX00003
CLAIM-LINE-RECORD-RX
X(3)
29
337
339
1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory
CRX138
CRX.003.138
DAYS-SUPPLY
Days Supply
Mandatory
Number of days supply dispensed.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(5)
30
340
344
1. Value must be 5 digits or less
2. Mandatory
3. Value should be between -365 and 365
CRX139
CRX.003.139
NEW-REFILL-IND
New Refill Indicator
Mandatory
Indicator showing whether the prescription being filled was a new prescription or a refill. If it is a refill, the indicator will indicate the number of refills.
NEW-REFILL-IND
CRX00003
CLAIM-LINE-RECORD-RX
X(2)
31
345
346
1. Value must be 2 characters
2. Value must be in New Refill Indicator List (VVL)
3. Mandatory
CRX140
CRX.003.140
BRAND-GENERIC-IND
Brand Generic Indicator
Mandatory
Indicates whether the drug is a brand name, generic, single-source, or multi-source drug.
BRAND-GENERIC-IND
CRX00003
CLAIM-LINE-RECORD-RX
X(1)
32
347
347
1. Value must be 1 character
2. Value must be in Brand Generic Indicator List (VVL)
3. Mandatory
CRX141
CRX.003.141
DISPENSE-FEE-SUBMITTED
Dispense Fee Submitted
Mandatory
The charge to cover the cost of the professional dispensing fee for the prescription.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(6)V99
33
348
355
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 may include up to 6 digits to the left of the decimal point, and 2 digits to the right e.g. 123456.78
4. Mandatory
CRX142
CRX.003.142
PRESCRIPTION-NUM
Prescription Number
Mandatory
The unique identification number assigned by the pharmacy or supplier to the prescription.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
X(12)
34
356
367
1. Value must be 12 characters or less
2. Value must not contain a pipe or asterisk symbol
3. Mandatory
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
CRX144
CRX.003.144
DTL-METRIC-DEC-QTY
Metric Decimal Quantity
Conditional
Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter).
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(7)V999
36
374
383
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
CRX145
CRX.003.145
COMPOUND-DOSAGE-FORM
Compound Dosage Form
Conditional
The physical form of a dose of medication, such as a capsule or injection.
COMPOUND-DOSAGE-FORM
CRX00003
CLAIM-LINE-RECORD-RX
X(2)
37
384
385
1. Value must be 2 characters
2. Value must be in Compound Dosage Form List (VVL)
3. Conditional
CRX146
CRX.003.146
REBATE-ELIGIBLE-INDICATOR
Rebate Eligible Indicator
Conditional
An indicator to identify claim lines with an NDC that is eligible for the drug rebate program.
REBATE-ELIGIBLE-INDICATOR
CRX00003
CLAIM-LINE-RECORD-RX
X(1)
38
386
386
1. Value must be 1 character
2. Value must be in Rebate Eligible Indicator List (VVL)
3. Conditional
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
CRX152
CRX.003.152
OTHER-INSURANCE-AMT
Other Insurance Amount
Conditional
The amount paid by insurance other than Medicare or Medicaid on this claim.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
40
389
401
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

CRX157
CRX.003.157
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
CRX00003
CLAIM-LINE-RECORD-RX
9(8)
41
402
409
1. The date must be a valid calendar date in the form "CCYYMMDD"
2. Value should be on or before End of Time Period (CIP.001.010)
3. Mandatory
4. Value should be on or after associated Admission Date value
CRX158
CRX.003.158
SELF-DIRECTION-TYPE
Self Direction Type
Mandatory
This data element is not applicable to this file type.
SELF-DIRECTION-TYPE
CRX00003
CLAIM-LINE-RECORD-RX
X(3)
42
410
412
1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory
CRX159
CRX.003.159
PRE-AUTHORIZATION-NUM
Preauthorization Number
Conditional
A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number).
N/A
CRX00003
CLAIM-LINE-RECORD-RX
X(18)
43
413
430
1. Value must be 18 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional
CRX167
CRX.003.167
INGREDIENT-COST-SUBMITTED
Ingredient Cost Submitted
Conditional
The charge to cover the cost of ingredients for the prescription or drug.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
44
431
443
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

CRX168
CRX.003.168
INGREDIENT-COST-PAID-AMT
Ingredient Cost Paid Amount
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.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
45
444
456
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

CRX169
CRX.003.169
DISPENSE-FEE-PAID-AMT
Dispense Fee Paid Amount
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.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
46
457
469
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

CRX170
CRX.003.170
PROFESSIONAL-SERVICE-FEE-SUBMITTED
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).
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
47
470
482
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

CRX171
CRX.003.171
PROFESSIONAL-SERVICE-FEE-PAID-AMT
Professional Service Fee Paid Amount
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.
N/A
CRX00003
CLAIM-LINE-RECORD-RX
S9(11)V99
48
483
495
1. Value must be between -99999999999.99 and 99999999999.99
2. Value must be expressed as a number with 2-digit precision (e.g. 100.50)
3. Conditional

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

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
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
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-FORMGP-1, MBESCBES-FORMGP-2, MBESCBES-FORMGP-3
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
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
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 NCPDP transaction.
PROCEDURE-CODE
CRX00003
CLAIM-LINE-RECORD-RX
X(6)
54
629
634
1. Value must not be more than 6 characters
2. Value must be in Procedure Code List (VVL)
3. 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
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
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
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
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
CRX188
CRX.003.188
PROCEDURE-CODE-MOD-6
Procedure Code Modifier 6
Conditional
The sixth m