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T-MSIS Data Dictionary - V4.1.1

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File Title	T-MSIS Data Dictionary - V4.1.1
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Centers for Medicaid and CHIP Services (CMCS)

T-MSIS Data Dictionary - v4.1.1
Last Updated: 2026-05-29

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 Medicai d and CHIP Scoreboard. Section 4735 of the Balanced
Budget Act of 1997 included a statutory requirement for states to submit claim s data, enrollee encounter data, and supporting information. Section 6504 of the Affordable Care Act strengthened this provis ion by requiring states to include
data elements the Secretary determines necessary for program integrity, program oversight, and a dministration. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the exte nt 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 1 1.25 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 s uggestions 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.

Table of Contents
T-MSIS Data Dictionary – CIP File .................................................................................................................................................................................................................................................................................................................................... 3
T-MSIS Data Dictionary – CLT File ...................................................................................................................................................................................................................................................................................................................................72
T-MSIS Data Dictionary – COT File ................................................................................................................................................................................................................................................................................................................................ 142
T-MSIS Data Dictionary – CRX File ................................................................................................................................................................................................................................................................................................................................ 237
T-MSIS Data Dictionary – ELG File ................................................................................................................................................................................................................................................................................................................................. 297
T-MSIS Data Dictionary – MCR File ............................................................................................................................................................................................................................................................................................................................... 387
T-MSIS Data Dictionary – PRV File ................................................................................................................................................................................................................................................................................................................................ 418
T-MSIS Data Dictionary – TPL File ................................................................................................................................................................................................................................................................................................................................. 456
T-MSIS Data Dictionary – FTX File ................................................................................................................................................................................................................................................................................................................................. 482

T-MSIS Data Dictionary – CIP File
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-HEADERRECORD-IP

X(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

DATADICTIONARY
-VERSION

Data
Dictionar
y Version

Mandatory

A data element to capture the version of the TMSIS data dictionary that was used to build the
file.

DATADICTIONARYVERSION

CIP00001

FILE-HEADERRECORD-IP

X(10)

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

SUBMISSIO
NTRANSACTI
ON-TYPE

Submissi
on
Transacti
on 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.

SUBMISSIONTRANSACTIONTYPE

CIP00001

FILE-HEADERRECORD-IP

X(1)

1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory

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

CIP004

CIP.001.004

FILEENCODINGSPECIFICATI
ON

File
Encoding
Specifica
tion

Mandatory

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

FILE-ENCODINGSPECIFICATION

CIP00001

FILE-HEADERRECORD-IP

X(3)

1. Value must be 3 characters
2. Value must be in File Encoding Specification List
(VVL)
3. Mandatory

CIP005

CIP.001.005

DATAMAPPINGDOCUMENT
-VERSION

Mandatory

Identifies the version of the T-MSIS data
mapping document used to build a state
submission file.

N/A

CIP00001

FILE-HEADERRECORD-IP

X(9)

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

CIP006

CIP.001.006

FILE-NAME

Data
Mapping
Docume
nt
Version
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-HEADERRECORD-IP

X(8)

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

CIP007

CIP.001.007

SUBMITTIN
G-STATE

Submitti
ng 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-HEADERRECORD-IP

X(2)

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

CIP008

CIP.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the file was created.

N/A

CIP00001

FILE-HEADERRECORD-IP

9(8)

1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Value of the CC component must be "20"
3. Value must be less than current date
4. Value must be equal to or after the value of
associated End of Time Period
5. Mandatory

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

CIP009

CIP.001.009

START-OFTIMEPERIOD

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-HEADERRECORD-IP

9(8)

CIP010

CIP.001.010

END-OFTIMEPERIOD

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-HEADERRECORD-IP

9(8)

CIP011

CIP.001.011

FILESTATUSINDICATOR

File
Status
Indicator

Mandatory

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

FILE-STATUSINDICATOR

CIP00001

FILE-HEADERRECORD-IP

X(1)

CIP012

CIP.001.012

SSNINDICATOR

SSN
Indicator

Mandatory

SSN-INDICATOR

CIP00001

FILE-HEADERRECORD-IP

X(1)

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

CIP013

CIP.001.013

TOT-RECCNT

Total
Record
Count

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

N/A

CIP00001

FILE-HEADERRECORD-IP

9(11)

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

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"
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
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

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

CIP275

CIP.001.275

SEQUENCENUMBER

Sequenc
e
Number

Mandatory

N/A

CIP00001

FILE-HEADERRECORD-IP

X(4)

1. Value must be 4 characters or less
2. Value must between 1 and 9999
3. Value must be equal to the largest of any prior
values for the same 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

STATENOTATION

State
Notation

Situational

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).
A free text field for the submitting state to
enter whatever information it chooses.

N/A

CIP00001

FILE-HEADERRECORD-IP

X(500)

582

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

CIP016

CIP.002.016

RECORD-ID

Record
ID

Mandatory

RECORD-ID

CIP00002

CLAIM-HEADERRECORD-IP

X(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

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

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

CIP018

CIP.002.018

RECORDNUMBER

Record
Number

Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(11)

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

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

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-HEADERRECORD-IP

X(50)

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

CIP020

CIP.002.020

ICN-ADJ

Adjustm
ent 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-HEADERRECORD-IP

X(50)

121

CIP021

CIP.002.021

SUBMITTERID

Submitte
r ID

Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

122

133

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

CIP022

CIP.002.022

MSISIDENTIFICAT
ION-NUM

MSIS
Identifica
tion
Number

Mandatory

The Submitter Identification number is the
value that identifies the provider/trading
partner/clearing house organization to the
state's claim adjudication system.
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/tmsis-coding-blog/reporting-shared-msisidentification-numbers-eligibility/

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(20)

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)

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

CIP023

CIP.002.023

CROSSOVER
-INDICATOR

Crossove
r
Indicator

Mandatory

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

CROSSOVERINDICATOR

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

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-OFHOSPITAL

Type of
Hospital

Mandatory

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

TYPE-OFHOSPITAL

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

155

156

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

CIP025

CIP.002.025

1115ADEMONSTR
ATION-IND

1115A
Demonst
ration
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.

1115ADEMONSTRATIO
N-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

157

CIP026

CIP.002.026

ADJUSTMEN
T-IND

Adjustm
ent
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

158

CIP027

CIP.002.027

ADJUSTMEN
T-REASONCODE

Adjustm
ent
Reason
Code

Conditional

Claim adjustment reason codes communicate
why a claim was paid differently than it was
billed.

ADJUSTMENTREASON-CODE

CIP00002

CLAIM-HEADERRECORD-IP

X(3)

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

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

CIP028

CIP.002.028

ADMISSIONTYPE

Admissio
n Type

Mandatory

The basic types of admission for Inpatient
hospital stays and a code indicating the priority
of this admission.

ADMISSIONTYPE

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

162

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

CIP029

CIP.002.029

CIP00002

CLAIM-HEADERRECORD-IP

X(20)

163

182

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(4)

183

186

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

CIP069

CIP.002.069

DIAGNOSISRELATEDGROUP-IND

Diagnosis
Related
Group
Indicator

Conditional

Description of the associated state-specific DRG
code. If using standard MS-DRG classification
system, leave blank.
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.
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

CIP.002.068

DRG
Descripti
on
Diagnosis
Related
Group

Conditional

CIP068

DRGDESCRIPTIO
N
DIAGNOSISRELATEDGROUP

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(4)

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

Conditional

Coding Requirements

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

CIP070

CIP.002.070

PROCEDURE
-CODE-1

Procedur
e 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.

PROCEDURECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(8)

191

198

CIP072

CIP.002.072

PROCEDURE
-CODEFLAG-1

Procedur
e Code
Flag 1

Conditional

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

PROCEDURECODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

199

200

CIP073

CIP.002.073

PROCEDURE
-CODEDATE-1

Procedur
e Code
Date 1

Conditional

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

201

208

Coding Requirements

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 TMSIS 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
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)
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

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

Procedure Code is not populated
7. Conditional

CIP074

CIP.002.074

PROCEDURE
-CODE-2

Procedur
e 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.

PROCEDURECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(8)

209

216

CIP076

CIP.002.076

PROCEDURE
-CODEFLAG-2

Procedur
e Code
Flag 2

Conditional

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

PROCEDURECODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

217

218

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

CIP077

CIP.002.077

PROCEDURE
-CODEDATE-2

Procedur
e Code
Date 2

Conditional

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

219

226

CIP078

CIP.002.078

PROCEDURE
-CODE-3

Procedur
e 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.

PROCEDURECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(8)

227

234

CIP080

CIP.002.080

PROCEDURE
-CODEFLAG-3

Procedur
e Code
Flag 3

Conditional

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

PROCEDURECODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

235

236

Coding Requirements

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
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 TMSIS 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
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

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

CIP081

CIP.002.081

PROCEDURE
-CODEDATE-3

Procedur
e Code
Date 3

Conditional

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

237

244

CIP082

CIP.002.082

PROCEDURE
-CODE-4

Procedur
e 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.

PROCEDURECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(8)

245

252

CIP084

CIP.002.084

PROCEDURE
-CODEFLAG-4

Procedur
e Code
Flag 4

Conditional

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

PROCEDURECODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

253

254

Coding Requirements

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

CIP085

CIP.002.085

PROCEDURE
-CODEDATE-4

Procedur
e Code
Date 4

Conditional

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

255

262

CIP086

CIP.002.086

PROCEDURE
-CODE-5

Procedur
e 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.

PROCEDURECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(8)

263

270

CIP088

CIP.002.088

PROCEDURE
-CODEFLAG-5

Procedur
e Code
Flag 5

Conditional

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

PROCEDURECODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

271

272

Coding Requirements

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

CIP089

CIP.002.089

PROCEDURE
-CODEDATE-5

Procedur
e Code
Date 5

Conditional

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

273

280

CIP090

CIP.002.090

PROCEDURE
-CODE-6

Procedur
e 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.

PROCEDURECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(8)

281

288

CIP092

CIP.002.092

PROCEDURE
-CODEFLAG-6

Procedur
e Code
Flag 6

Conditional

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

PROCEDURECODE-FLAG

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

289

290

Coding Requirements

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

CIP093

CIP.002.093

PROCEDURE
-CODEDATE-6

Procedur
e Code
Date 6

Conditional

The date upon which a reported medical
procedure was performed.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

291

298

CIP094

CIP.002.094

ADMISSIONDATE

Admissio
n Date

Mandatory

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

299

306

CIP095

CIP.002.095

ADMISSIONHOUR

Admissio
n Hour

Conditional

The hour of admission to a hospital.

HOUR

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

307

308

Coding Requirements

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

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

CIP096

CIP.002.096

DISCHARGEDATE

Discharg
e Date

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

309

316

CIP097

CIP.002.097

DISCHARGEHOUR

Discharg
e Hour

Conditional

The hour of discharge from a hospital.

HOUR

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

317

318

CIP098

CIP.002.098

ADJUDICATI
ON-DATE

Adjudicat
ion 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-HEADERRECORD-IP

9(8)

319

326

CIP099

CIP.002.099

MEDICAIDPAID-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-HEADERRECORD-IP

9(8)

327

334

Coding Requirements

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
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
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
1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Must have an associated Total Medicaid Paid
Amount
3. Mandatory

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

CIP100

CIP.002.100

TYPE-OFCLAIM

Type of
Claim

Mandatory

TYPE-OF-CLAIM

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

335

1. Value must be 1 character
2. Value must be in Type of Claim List (VVL)
3. Mandatory

CIP101

CIP.002.101

TYPE-OFBILL

Type of
Bill

Mandatory

TYPE-OF-BILL

CIP00002

CLAIM-HEADERRECORD-IP

X(4)

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

CLAIMSTATUS

Claim
Status

Conditional

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

X(3)

340

342

CIP103

CIP.002.103

CLAIMSTATUSCATEGORY

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-STATUSCATEGORY

CIP00002

CLAIM-HEADERRECORD-IP

X(3)

343

345

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"
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

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

CIP104

CIP.002.104

SOURCELOCATION

Source
Location

Mandatory

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

SOURCELOCATION

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

346

347

1. Value must be 2 characters
2. Value must be in Source Location List (VVL)
3. Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(15)

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

363

370

1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Must have an associated Check Number
3. Conditional

For sub-capitated encounters from a subcapitated 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 subcapitated 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.

CIP105

CIP.002.105

CHECK-NUM

Check
Number

Conditional

CIP106

CIP.002.106

CHECK-EFFDATE

Check
Effective
Date

Conditional

For sub-capitated encounters from a subcapitated network provider, report a SOURCELOCATION = “23” to indicate that the subcapitated network provider provided the
service directly to the enrollee.
The check or electronic funds transfer number.

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

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

CIP108

CIP.002.108

CLAIMPYMT-REMCODE-1

Remittan
ce Advice
Remark
Code 1

Conditional

CLAIM-PYMTREM-CODE

CIP00002

CLAIM-HEADERRECORD-IP

X(5)

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

CLAIMPYMT-REMCODE-2

Remittan
ce 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).
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-PYMTREM-CODE

CIP00002

CLAIM-HEADERRECORD-IP

X(5)

376

380

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

CIP110

CIP.002.110

CLAIMPYMT-REMCODE-3

Remittan
ce Advice
Remark
Code 3

Conditional

CLAIM-PYMTREM-CODE

CIP00002

CLAIM-HEADERRECORD-IP

X(5)

381

385

CIP111

CIP.002.111

CLAIMPYMT-REMCODE-4

Remittan
ce Advice
Remark
Code 4

Conditional

CLAIM-PYMTREM-CODE

CIP00002

CLAIM-HEADERRECORD-IP

X(5)

386

390

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

CIP112

CIP.002.112

TOT-BILLEDAMT

Total
Billed
Amount

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

TOTALLOWEDAMT

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

404

416

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

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

417

429

Coding Requirements

that renders the service to the enrollee, report
a null value in this field.

CIP114

CIP.002.114

TOTMEDICAIDPAID-AMT

Total
Medicaid
Paid
Amount

Conditional

The total amount paid by Medicaid/CHIP or the
managed care plan on this claim or adjustment
at the claim header level, which is the sum of
the amounts paid by Medicaid or the managed
care plan at the detail level for the claim.
For sub-capitated encounters from a subcapitated entity that is not a sub-capitated
network provider, report the total amount that
the sub-capitated entity paid the provider for
the service. Report a null value in this field if the
provider is a sub-capitated network provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.

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

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

CIP116

CIP.002.116

TOTMEDICAREDEDUCTIBLE
-AMT

Total
Medicare
Deductib
le
Amount

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

430

442

CIP117

CIP.002.117

TOTMEDICARECOINS-AMT

Total
Medicare
Coinsura
nce
Amount

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

443

455

CIP118

CIP.002.118

TOT-TPLAMT

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

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

456

468

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"
(not a crossover claim), then value should not be
populated.
4. Conditional
5. If associated Medicare Combined Deductible
Indicator equals "1", then value must not be
populated
6. When populated, value must be less than or equal
to Total Billed Amount
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

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

CIP119

CIP.002.119

TOT-OTHERINSURANCEAMT

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

469

481

CIP121

CIP.002.121

OTHERINSURANCEIND

Total
Other
Insuranc
e
Amount
Other
Insuranc
e
Indicator

Conditional

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

OTHERINSURANCE-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

482

CIP122

CIP.002.122

OTHER-TPLCOLLECTION

Other
TPL
Collectio
n

Mandatory

OTHER-TPLCOLLECTION

CIP00002

CLAIM-HEADERRECORD-IP

X(3)

483

485

1. Value must be in Other TPL Collection List (VVL)
2. Value must be 3 characters
3. Mandatory

CIP125

CIP.002.125

FIXEDPAYMENTIND

Fixed
Payment
Indicator

Conditional

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.
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-PAYMENTIND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

486

1. Value must be 1 character
2. Value must be in Fixed Payment Indicator List (VVL)
3. Conditional

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

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

CIP126

CIP.002.126

FUNDINGCODE

Funding
Code

Conditional

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

FUNDING-CODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

487

488

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

CIP127

CIP.002.127

FUNDINGSOURCENONFEDERA
L-SHARE

Funding
Source
NonFederal
Share

Conditional

FUNDINGSOURCENONFEDERALSHARE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

489

490

CIP128

CIP.002.128

MEDICARECOMB-DEDIND

Medicare
Combine
d
Deductib
le
Indicator

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.
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.

MEDICARECOMB-DED-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

491

CIP129

CIP.002.129

PROGRAMTYPE

Program
Type

Mandatory

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

PROGRAM-TYPE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

492

493

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
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
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

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

CIP130

CIP.002.130

PLAN-IDNUMBER

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 allinclusive care for the elderly entity, or other
approved plans.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

494

505

Coding Requirements

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 (CIP.002.100) in [3,C,W] value
must have a managed care enrollment (ELG.014) for
the beneficiary where the Admission Date
(CIP.002.094) occurs between the managed care plan
enrollment eff/end dates (ELG.014.197/198)
7. When Type of Claim (CIP.002.100) in [3,C,W] value
must have a managed care main record (MCR.002) for
the plan where the Admission Date (CIP.002.094)
occurs between the managed care contract eff/end
dates (MCR.002.020/021)

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

CIP132

CIP.002.132

PAYMENTLEVEL-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 linelevel payment/allowed amounts (PAYMENTLEVEL-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.

PAYMENTLEVEL-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

506

Coding Requirements

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

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 (MEDICAIDPAID-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.

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

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.

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

CIP133

CIP.002.133

MEDICAREREIM-TYPE

Medicare
Reimburs
ement
Type

Conditional

A code to indicate the type of Medicare
reimbursement.

MEDICAREREIM-TYPE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

507

508

CIP134

CIP.002.134

NON-COVDAYS

NonCovered
Days

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(5)

509

513

CIP135

CIP.002.135

NON-COVCHARGES

NonCovered
Charges

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

514

526

CIP136

CIP.002.136

MEDICAIDCOVINPATIENTDAYS

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-HEADERRECORD-IP

S9(7)

527

533

Coding Requirements

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
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]

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

CIP137

CIP.002.137

CLAIM-LINECOUNT

Claim
Line
Count

Mandatory

The total number of lines on the claim.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(4)

534

537

CIP138

CIP.002.138

FORCEDCLAIM-IND

Forced
Claim
Indicator

Conditional

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

FORCED-CLAIMIND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

538

CIP139

CIP.002.139

HEALTHCAREACQUIREDCONDITIONIND

Healthca
re
Acquired
Conditio
n
Indicator

Conditional

HEALTH-CAREACQUIREDCONDITION-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

539

1. Value must be 1 character
2. Value must be in Healthcare Acquired Condition
Indicator List (VVL)
3. Conditional

CIP140

CIP.002.140

OCCURRENC
E-CODE-01

Occurren
ce Code
1

Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

540

541

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CIP141

CIP.002.141

OCCURRENC
E-CODE-02

Occurren
ce Code
2

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-Feefor-ServicePayment/HospitalAcqCond/index.html?redirect
=/hospitalacqcond/05_Coding.asp#TopOfPage
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.
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.

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

542

543

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

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 nonnumeric 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
1. Value must be 1 character
2. Value must be in Forced Claim Indicator List (VVL)
3. Conditional

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

CIP142

CIP.002.142

OCCURRENC
E-CODE-03

Occurren
ce Code
3

Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

544

545

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CIP143

CIP.002.143

OCCURRENC
E-CODE-04

Occurren
ce Code
4

Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

546

547

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CIP144

CIP.002.144

OCCURRENC
E-CODE-05

Occurren
ce Code
5

Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

548

549

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CIP145

CIP.002.145

OCCURRENC
E-CODE-06

Occurren
ce Code
6

Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

550

551

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CIP146

CIP.002.146

OCCURRENC
E-CODE-07

Occurren
ce Code
7

Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

552

553

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CIP147

CIP.002.147

OCCURRENC
E-CODE-08

Occurren
ce 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.
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.
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.
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.
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.
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

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

554

555

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

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

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

556

557

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

OCCURRENCECODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

558

559

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

560

567

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

568

575

can be used for either occurrences or
occurrence spans.

CIP148

CIP.002.148

OCCURRENC
E-CODE-09

Occurren
ce Code
9

Conditional

CIP149

CIP.002.149

OCCURRENC
E-CODE-10

Occurren
ce Code
10

Conditional

CIP150

CIP.002.150

OCCURRENC
E-CODE-EFFDATE-01

Occurren
ce Code
Effective
Date 1

Conditional

CIP151

CIP.002.151

OCCURRENC
E-CODE-EFFDATE-02

Occurren
ce Code
Effective
Date 2

Conditional

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

CIP152

CIP.002.152

OCCURRENC
E-CODE-EFFDATE-03

Occurren
ce Code
Effective
Date 3

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

576

583

CIP153

CIP.002.153

OCCURRENC
E-CODE-EFFDATE-04

Occurren
ce Code
Effective
Date 4

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

584

591

CIP154

CIP.002.154

OCCURRENC
E-CODE-EFFDATE-05

Occurren
ce Code
Effective
Date 5

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

592

599

CIP155

CIP.002.155

OCCURRENC
E-CODE-EFFDATE-06

Occurren
ce Code
Effective
Date 6

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

600

607

CIP156

CIP.002.156

OCCURRENC
E-CODE-EFFDATE-07

Occurren
ce Code
Effective
Date 7

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

608

615

Coding Requirements

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
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
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
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
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

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

CIP157

CIP.002.157

OCCURRENC
E-CODE-EFFDATE-08

Occurren
ce Code
Effective
Date 8

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

616

623

CIP158

CIP.002.158

OCCURRENC
E-CODE-EFFDATE-09

Occurren
ce Code
Effective
Date 9

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

624

631

CIP159

CIP.002.159

OCCURRENC
E-CODE-EFFDATE-10

Occurren
ce Code
Effective
Date 10

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

632

639

CIP160

CIP.002.160

OCCURRENC
E-CODEEND-DATE01

Occurren
ce 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-HEADERRECORD-IP

9(8)

640

647

CIP161

CIP.002.161

OCCURRENC
E-CODEEND-DATE02

Occurren
ce Code
End Date
2

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

648

655

Coding Requirements

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
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
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
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
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

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

CIP162

CIP.002.162

OCCURRENC
E-CODEEND-DATE03

Occurren
ce Code
End Date
3

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

656

663

CIP163

CIP.002.163

OCCURRENC
E-CODEEND-DATE04

Occurren
ce Code
End Date
4

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

664

671

CIP164

CIP.002.164

OCCURRENC
E-CODEEND-DATE05

Occurren
ce Code
End Date
5

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

672

679

CIP165

CIP.002.165

OCCURRENC
E-CODEEND-DATE06

Occurren
ce Code
End Date
6

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

100

680

687

CIP166

CIP.002.166

OCCURRENC
E-CODEEND-DATE07

Occurren
ce Code
End Date
7

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

101

688

695

CIP167

CIP.002.167

OCCURRENC
E-CODEEND-DATE08

Occurren
ce 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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

102

696

703

Coding Requirements

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
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
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
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
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
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

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

be equal to the value of the associated
Occurrence Code Effective Date.

Coding Requirements

Effective Date
4. Conditional

CIP168

CIP.002.168

OCCURRENC
E-CODEEND-DATE09

Occurren
ce Code
End Date
9

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

103

704

711

CIP169

CIP.002.169

OCCURRENC
E-CODEEND-DATE10

Occurren
ce Code
End Date
10

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

104

712

719

CIP170

CIP.002.170

BIRTHWEIGHTGRAMS

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-HEADERRECORD-IP

S9(6)V99
9

105

720

728

CIP171

CIP.002.171

PATIENTCONTROLNUM

Patient
Control
Number

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(20)

106

729

748

CIP172

CIP.002.172

ELIGIBLELAST-NAME

Eligible
Last
Name

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-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

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

CIP173

CIP.002.173

ELIGIBLEFIRST-NAME

Eligible
First
Name

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-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

ELIGIBLEMIDDLE-INIT

Eligible
Middle
Initial

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.)
Individual's middle initial; middle initial
component of full name (e.g. First Name,
Middle Initial, Last Name).

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

109

809

1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional

CIP175

CIP.002.175

DATE-OFBIRTH

Date of
Birth

Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

110

810

817

CIP176

CIP.002.176

HEALTHHOMEPROV-IND

Health
Home
Provider
Indicator

Conditional

HEALTH-HOMEPROV-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

111

818

1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Mandatory
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

WAIVERTYPE

Waiver
Type

Conditional

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

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

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-HEADERRECORD-IP

X(20)

113

821

840

CIP179

CIP.002.179

BILLINGPROV-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-HEADERRECORD-IP

X(30)

114

841

870

Coding Requirements

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
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)

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

CIP180

CIP.002.180

BILLINGPROV-NPINUM

Billing
Provider
NPI
Number

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(10)

115

871

880

CIP181

CIP.002.181

BILLINGPROVTAXONOMY

Billing
Provider
Taxonom
y

Conditional

The taxonomy code for the institution billing for
the beneficiary.

PROVTAXONOMY

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

116

881

892

CIP182

CIP.002.182

BILLINGPROV-TYPE

Billing
Provider
Type

Conditional

A code to describe the type of provider being
reported.

PROV-TYPE

CIP00002

CLAIM-HEADERRECORD-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

BILLINGPROVSPECIALTY

Billing
Provider
Specialty

Conditional

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

PROV-SPECIALTY

CIP00002

CLAIM-HEADERRECORD-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

ADMITTINGPROV-NPINUM

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-HEADERRECORD-IP

X(10)

119

897

906

CIP185

CIP.002.185

ADMITTINGPROV-NUM

Admittin
g
Provider
NPI
Number
Admittin
g
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-HEADERRECORD-IP

X(30)

120

907

936

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

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)
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional

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

CIP186

CIP.002.186

ADMITTINGPROVSPECIALTY

Admittin
g
Provider
Specialty

Conditional

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

PROV-SPECIALTY

CIP00002

CLAIM-HEADERRECORD-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

ADMITTINGPROVTAXONOMY

Conditional

Taxonomic classification (code) for a given
healthcare provider, as defined by the National
Uniform Claim Committee.

PROVTAXONOMY

CIP00002

CLAIM-HEADERRECORD-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

ADMITTINGPROV-TYPE

Admittin
g
Provider
Taxonom
y
Admittin
g
Provider
Type

Conditional

A code to describe the type of provider being
reported.

PROV-TYPE

CIP00002

CLAIM-HEADERRECORD-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

REFERRINGPROV-NUM

Referring
Provider
Number

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(30)

124

953

982

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

CIP190

CIP.002.190

REFERRINGPROV-NPINUM

Referring
Provider
NPI
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.
The National Provider ID (NPI) of the provider
who recommended the servicing provider to
the patient.

N/A

CIP00002

CLAIM-HEADERRECORD-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

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

CIP194

CIP.002.194

DRGOUTLIERAMT

DRG
Outlier
Amount

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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-RELWEIGHT

DRG
Relative
Weight

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(3)V99
999

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

MEDICAREHIC-NUM

Medicare
HIC
Number

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.
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.
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

N/A

CIP00002

CLAIM-HEADERRECORD-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

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

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/cmsdata/variables/medpar-drgoutlier-stay-code
This field specifies the number of days paid as
outliers under Prospective Payment System
(PPS) and the days over the threshold for the
DRG.

OUTLIER-CODE

CIP00002

CLAIM-HEADERRECORD-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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(5)

130

1028

1032

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-HEADERRECORD-IP

X(2)

131

1033

1034

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
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)

Railroad IDs) prefix and ID (not always SSN
based).

CIP197

CIP.002.197

OUTLIERCODE

Outlier
Code

Conditional

CIP198

CIP.002.198

OUTLIERDAYS

Outlier
Days

Conditional

CIP199

CIP.002.199

PATIENTSTATUS

Patient
Status

Mandatory

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

CIP202

CIP.002.202

REMITTANC
E-NUM

Remittan
ce
Number

Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-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

SPLITCLAIM-IND

Split
Claim
Indicator

Conditional

SPLIT-CLAIM-IND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

133

1065

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

CIP204

CIP.002.204

BORDERSTATE-IND

Border
State
Indicator

Conditional

BORDER-STATEIND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

134

1066

1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional

CIP206

CIP.002.206

Beneficia
ry
Coinsura
nce Paid
Amount

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

136

1080

1087

CIP.002.208

Beneficia
ry
Coinsura
nce Date
Paid
Total
Beneficia
ry
Copayme
nt Paid
Amount

Conditional

CIP208

TOTBENEFICIAR
YCOINSURAN
CE-PAIDAMOUNT
BENEFICIAR
YCOINSURAN
CE-DATEPAID
TOTBENEFICIAR
YCOPAYMEN
T-PAIDAMOUNT

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

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

137

1088

1100

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
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

Conditional

Coding Requirements

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

CIP209

CIP.002.209

The date the beneficiary paid the copayment
amount.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

138

1101

1108

CIP.002.210

Conditional

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

139

1109

1121

CIP.002.211

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

N/A

CIP211

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

140

1122

1129

CIP212

CIP.002.212

CLAIMDENIEDINDICATOR

Beneficia
ry
Copayme
nt Date
Paid
Total
Beneficia
ry
Deductib
le Paid
Amount
Beneficia
ry
Deductib
le Date
Paid
Claim
Denied
Indicator

Conditional

CIP210

BENEFICIAR
YCOPAYMEN
T-DATEPAID
TOTBENEFICIAR
YDEDUCTIBLE
-PAIDAMOUNT
BENEFICIAR
YDEDUCTIBLE
-DATE-PAID

Mandatory

An indicator to identify a claim that the state
refused pay in its entirety.

CLAIM-DENIEDINDICATOR

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

141

1130

CIP213

CIP.002.213

COPAYWAIVED-IND

Copayme
nt
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-WAIVEDIND

CIP00002

CLAIM-HEADERRECORD-IP

X(1)

142

1131

Conditional

Coding Requirements

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

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

CIP214

CIP.002.214

HEALTHHOMEENTITYNAME

Health
Home
Entity
Name

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

CIP.002.217

Conditional

The date the third party paid the coinsurance
amount

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

145

1195

1202

CIP218

CIP.002.218

Third
Party
Coinsura
nce
Amount
Paid
Third
Party
Coinsura
nce Date
Paid
Third
Party
Copayme
nt
Amount
Paid

Situational

CIP217

THIRDPARTYCOINSURAN
CEAMOUNTPAID
THIRDPARTYCOINSURAN
CE-DATEPAID
THIRDPARTYCOPAYMEN
T-AMOUNTPAID

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

Situational

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

146

1203

1215

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
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

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

CIP219

CIP.002.219

The date the third party paid the copayment
amount.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

147

1216

1223

CIP.002.220

Third
Party
Copayme
nt Date
Paid
Medicaid
Amount
Paid DSH

Situational

CIP220

THIRDPARTYCOPAYMEN
T-DATEPAID
MEDICAIDAMOUNTPAID-DSH

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

148

1224

1236

CIP221

CIP.002.221

HEALTHHOMEPROVIDERNPI

Health
Home
Provider
NPI
Number

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.
The National Provider ID (NPI) of the health
home provider.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(10)

149

1237

1246

Coding Requirements

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
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
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

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

CIP222

CIP.002.222

MEDICAREBENEFICIAR
YIDENTIFIER

Medicare
Beneficia
ry
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-HEADERRECORD-IP

X(12)

150

1247

1258

CIP223

CIP.002.223

OPERATINGPROVTAXONOMY

Conditional

Taxonomic classification (code) for a given
healthcare provider, as defined by the National
Uniform Claim Committee.

PROVTAXONOMY

CIP00002

CLAIM-HEADERRECORD-IP

X(12)

151

1259

1270

CIP228

CIP.002.228

MEDICAREPAID-AMT

Operatin
g
Provider
Taxonom
y
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-HEADERRECORD-IP

S9(11)V9
9

152

1271

1283

Coding Requirements

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
1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional

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

CIP289

CIP.002.289

PROVLOCATIONID

Provider
Location
ID

Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-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

BEGINNINGDATE-OFSERVICE

Beginnin
g Date of
Service

Mandatory

N/A

CIP00002

CLAIM-HEADERRECORD-IP

9(8)

154

1289

1296

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

CIP291

CIP.002.291

ENDINGDATE-OFSERVICE

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-HEADERRECORD-IP

9(8)

155

1297

1304

CIP292

CIP.002.292

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

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.
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.
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

CIP.002.293

Total
Beneficia
ry
Copayme
nt Liable
Amount
Total
Beneficia
ry
Coinsura
nce
Liable
Amount
Total
Beneficia
ry
Deductib
le Liable
Amount

Conditional

CIP293

TOTBENEFICIAR
YCOPAYMEN
T-LIABLEAMOUNT
TOTBENEFICIAR
YCOINSURAN
CE-LIABLEAMOUNT

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

TOTBENEFICIAR
YDEDUCTIBLE
-LIABLEAMOUNT

Conditional

Coding Requirements

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

CIP295

CIP.002.295

COMBINEDBENE-COSTSHARINGPAIDAMOUNT

Combine
d
Beneficia
ry Cost
Sharing
Paid
Amount

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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-RCPLIAB-AMT

LTC RCP
Liability
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.
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-HEADERRECORD-IP

S9(11)V9
9

160

1357

1369

CIP298

CIP.002.298

BILLINGPROVADDR-LN-1

Mandatory

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(60)

161

1370

1429

CIP299

CIP.002.299

BILLINGPROVADDR-LN-2

Billing
Provider
Address
Line 1
Billing
Provider
Address
Line 2

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

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(60)

162

1430

1489

CIP300

CIP.002.300

BILLINGPROV-CITY

Mandatory

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(28)

163

1490

1517

CIP301

CIP.002.301

BILLINGPROV-STATE

Billing
Provider
City
Billing
Provider
State
Code

Mandatory

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

STATE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

164

1518

1519

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
1. Value must not be more than 28 characters long
2. Mandatory
1. Value must not be more than 2 characters
2. Value must be in State Code List (VVL)
3. Mandatory

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

CIP302

CIP.002.302

BILLINGPROV-ZIPCODE

Billing
Provider
ZIP Code

Mandatory

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

ZIP-CODE

CIP00002

CLAIM-HEADERRECORD-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

SERVICEFACILITYLOCATIONORG-NPI

Service
Facility
Location
Organiza
tion NPI

Conditional

Service facility location organization NPI from
X12 837I loop 2310E.

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(10)

166

1529

1538

CIP304

CIP.002.304

SERVICEFACILITYLOCATIONADDR-LN-1

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(60)

167

1539

1598

CIP305

CIP.002.305

SERVICEFACILITYLOCATIONADDR-LN-2

Service
Facility
Location
Address
Line 1
Service
Facility
Location
Address
Line 2

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

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(60)

168

1599

1658

CIP306

CIP.002.306

SERVICEFACILITYLOCATIONCITY

Service
Facility
Location
City

Conditional

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

N/A

CIP00002

CLAIM-HEADERRECORD-IP

X(28)

169

1659

1686

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

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

CIP307

CIP.002.307

SERVICEFACILITYLOCATIONSTATE

Service
Facility
Location
State

Conditional

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

STATE

CIP00002

CLAIM-HEADERRECORD-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

SERVICEFACILITYLOCATIONZIP-CODE

Service
Facility
Location
ZIP Code

Conditional

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

ZIP-CODE

CIP00002

CLAIM-HEADERRECORD-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

PROVIDERCLAIMFORM-CODE

Mandatory

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

PROVIDERCLAIM-FORMCODE

CIP00002

CLAIM-HEADERRECORD-IP

X(2)

172

1698

1699

CIP310

CIP.002.310

PROVIDERCLAIMFORMOTHER-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-HEADERRECORD-IP

X(50)

173

1700

1749

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

Provider
Claim
Form
Code
Provider
Claim
Form
Other
Text
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-HEADERRECORD-IP

S9(11)V9
9

174

1750

1762

CIP338

CIP.002.338

TOT-SDPALLOWEDAMT

Total
State
Directed
Payment
Allowed
Amount

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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
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

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

CIP339

CIP.002.339

TOT-SDPPAID-AMT

Total
State
Directed
Payment
Paid
Amount

Conditional

N/A

CIP00002

CLAIM-HEADERRECORD-IP

S9(11)V9
9

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

STATENOTATION

State
Notation

Situational

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).
A free text field for the submitting state to
enter whatever information it chooses.

N/A

CIP00002

CLAIM-HEADERRECORD-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

RECORD-ID

CIP00003

CLAIM-LINERECORD-IP

X(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

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

CIP00003

CLAIM-LINERECORD-IP

X(2)

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

CIP233

CIP.003.233

RECORDNUMBER

Record
Number

Mandatory

N/A

CIP00003

CLAIM-LINERECORD-IP

9(11)

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

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

CIP234

CIP.003.234

MSISIDENTIFICAT
ION-NUM

MSIS
Identifica
tion
Number

Mandatory

N/A

CIP00003

CLAIM-LINERECORD-IP

X(20)

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

CIP235

CIP.003.235

ICN-ORIG

Original
ICN

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/tmsis-coding-blog/reporting-shared-msisidentification-numbers-eligibility/
A unique number assigned by the state's
payment system that identifies an original or
adjustment claim.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(50)

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

CIP236

CIP.003.236

ICN-ADJ

Adjustm
ent 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-LINERECORD-IP

X(50)

141

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

CIP237

CIP.003.237

LINE-NUMORIG

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-LINERECORD-IP

X(3)

142

144

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

CIP238

CIP.003.238

LINE-NUMADJ

Adjustm
ent 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-LINERECORD-IP

X(3)

145

147

CIP239

CIP.003.239

LINEADJUSTMEN
T-IND

Line
Adjustm
ent
Indicator

Conditional

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

LINEADJUSTMENTIND

CIP00003

CLAIM-LINERECORD-IP

X(1)

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

LINEADJUSTMEN
T-REASONCODE

Line
Adjustm
ent
Reason
Code

Conditional

Claim adjustment reason codes communicate
why a service line was paid differently than it
was billed.

LINEADJUSTMENTREASON-CODE

CIP00003

CLAIM-LINERECORD-IP

X(3)

149

151

CIP241

CIP.003.241

SUBMITTERID

Submitte
r 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-LINERECORD-IP

X(12)

152

163

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

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

CIP242

CIP.003.242

CLAIM-LINESTATUS

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-LINERECORD-IP

X(3)

164

166

CIP243

CIP.003.243

BEGINNINGDATE-OFSERVICE

Beginnin
g 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-LINERECORD-IP

9(8)

167

174

CIP244

CIP.003.244

ENDINGDATE-OFSERVICE

Ending
Date of
Service

Mandatory

N/A

CIP00003

CLAIM-LINERECORD-IP

9(8)

175

182

Coding Requirements

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"
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
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

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

CIP245

CIP.003.245

REVENUECODE

Revenue
Code

Mandatory

REVENUE-CODE

CIP00003

CLAIM-LINERECORD-IP

X(4)

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

REVENUECENTERQUANTITYACTUAL

Revenue
Center
Quantity
Actual

Mandatory

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(6)V99
9

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

REVENUECENTERQUANTITYALLOWED

Revenue
Center
Quantity
Allowed

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.
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
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

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(6)V99
9

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

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

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

205

217

Coding Requirements

and CLAIMRX claims/encounters use the
Prescription Quantity Allowed field.

CIP251

CIP.003.251

REVENUECHARGE

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 subcapitated 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.

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

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

CIP252

CIP.003.252

ALLOWEDAMT

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 subcapitated 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.

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

218

230

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

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

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]

CIP254

CIP.003.254

MEDICAIDPAID-AMT

Medicaid
Paid
Amount

Conditional

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.
The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For subcapitated encounters from a sub-capitated
entity that is not a sub-capitated network
provider, report the amount that the subcapitated 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.

Coding Requirements

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider

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

that renders the service to the enrollee, report
a null value in this field.

CIP255

CIP.003.255

MEDICAIDFFSEQUIVALEN
T-AMT

Medicaid
FFS
Equivale
nt
Amount

Conditional

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

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

244

256

CIP256

CIP.003.256

BILLINGUNIT

Billing
Unit

Conditional

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

BILLING-UNIT

CIP00003

CLAIM-LINERECORD-IP

X(2)

257

258

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

CIP257

CIP.003.257

TYPE-OFSERVICE

Type of
Service

Mandatory

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

TYPE-OFSERVICE-IP

CIP00003

CLAIM-LINERECORD-IP

X(3)

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"

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

CIP260

CIP.003.260

SERVICINGPROV-NUM

Servicing
Provider
Number

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

X(30)

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

SERVICINGPROV-NPINUM

Servicing
Provider
NPI
Number

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

X(10)

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

SERVICINGPROV-TYPE

Servicing
Provider
Type

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.
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.
A code to describe the type of provider being
reported.

PROV-TYPE

CIP00003

CLAIM-LINERECORD-IP

X(2)

302

303

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

CIP264

CIP.003.264

SERVICINGPROVSPECIALTY

Servicing
Provider
Specialty

Conditional

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

PROV-SPECIALTY

CIP00003

CLAIM-LINERECORD-IP

X(2)

304

305

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

CIP265

CIP.003.265

OPERATINGPROV-NPINUM

Operatin
g
Provider
NPI
Number

Conditional

The National Provider ID (NPI) of the provider
who performed the surgical procedures on the
beneficiary.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(10)

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

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

CIP266

CIP.003.266

OTHER-TPLCOLLECTION

Other
TPL
Collectio
n

Mandatory

OTHER-TPLCOLLECTION

CIP00003

CLAIM-LINERECORD-IP

X(3)

316

318

1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory

CIP267

CIP.003.267

PROVFACILITYTYPE

Provider
Facility
Type

Mandatory

PROV-FACILITYTYPE

CIP00003

CLAIM-LINERECORD-IP

X(9)

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

CATEGORYFORFEDERALREIMBURSE
MENT

Category
for
Federal
Reimburs
ement

Conditional

CATEGORY-FORFEDERALREIMBURSEMEN
T

CIP00003

CLAIM-LINERECORD-IP

X(2)

328

329

CIP272

CIP.003.272

OTHERINSURANCEAMT

Other
Insuranc
e
Amount

Conditional

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

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

330

342

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
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

NDCQUANTITY

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-LINERECORD-IP

S9(9)V(9)

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

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

CIP284

CIP.003.284

NATIONALDRUG-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-LINERECORD-IP

X(12)

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-UNITOFMEASURE

NDC Unit
of
Measure

Conditional

A code to indicate the basis by which the
quantity of the National Drug Code is
expressed.

NDC-UNIT-OFMEASURE

CIP00003

CLAIM-LINERECORD-IP

X(2)

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

ADJUDICATI
ON-DATE

Adjudicat
ion Date

Mandatory

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

N/A

CIP00003

CLAIM-LINERECORD-IP

9(8)

375

382

CIP287

CIP.003.287

SELFDIRECTIONTYPE

Self
Direction
Type

Mandatory

This data element is not applicable to this file
type.

SELF-DIRECTIONTYPE

CIP00003

CLAIM-LINERECORD-IP

X(3)

383

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
(CRX.001.010)
3. Mandatory
4. Value should be on or after associated Admission
Date value
1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory

CIP288

CIP.003.288

PREAUTHORIZA
TION-NUM

Preautho
rization
Number

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

X(18)

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

IHSSERVICE-IND

IHS
Service
Indicator

Mandatory

IHS-SERVICE-IND

CIP00003

CLAIM-LINERECORD-IP

X(1)

404

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

CIP314

CIP.003.314

UNIQUEDEVICEIDENTIFIER

Unique
Device
Identifier

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).
To indicate Services received by Medicaideligible 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.
An unique identifier assigned to every medical
device that meets the requirements of 21 CFR
801 and 830.

N/A

CIP00003

CLAIM-LINERECORD-IP

X(76)

405

480

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

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

CIP340

CIP.003.340

MBESCBESFORMGROUP

MBESCB
ES Form
Group

Conditional

MBESCBESFORM-GROUP

CIP00003

CLAIM-LINERECORD-IP

X(1)

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

MBESCBESFORM

MBESCB
ES Form

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 CMS64.21 form is for Title XXI-funded Medicaidexpansion CHIP (M-CHIP), and the CMS-21 Base
form is for Title XXI-funded separate CHIP (SCHIP)).
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.

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

CIP00003

CLAIM-LINERECORD-IP

X(50)

482

531

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

CIP315

CIP.003.315

MBESCBESCATEGORYOF-SERVICE

MBESCB
ES
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,
64.10BASEFORM,
64.9P-FORM,
64.9A-FORM,
64.9BASE-FORM,
64.21UP-FORM

CIP00003

CLAIM-LINERECORD-IP

X(5)

532

536

1. Value must be 5 characters or less
2. When MBESCBES Form equals "21.P", value must be
in 21.P Form List (VVL)
3. When MBESCBES Form equals "21BASE", value must
be in 21BASE Form List (VVL)
4. When MBESCBES Form equals "64.21U", value must
be in 64.21U Form List (VVL)
5. When MBESCBES Form equals "64.10BASE", value
must be in 64.10BASE Form List (VVL)
6. When MBESCBES Form equals "64.9P", value must
be in 64.9P Form List (VVL)
7. When MBESCBES Form equals "64.9A", value must
be in 64.9A Form List (VVL)
8. When MBESCBES Form equals "64.9BASE", value
must be in 64.9BASE Form List (VVL)
9. When MBESCBES Form equals "64.21UP", value
must be in 64.21UP Form List (VVL)
10. 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

GMEAMOUNTPAID

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-LINERECORD-IP

S9(11)V9
9

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

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

CIP318

CIP.003.318

REFERRINGPROV-NUM

Referring
Provider
Number

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

X(30)

550

579

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

CIP319

CIP.003.319

REFERRINGPROV-NPINUM

Referring
Provider
NPI
Number

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

X(10)

580

589

CIP336

CIP.003.336

SDPALLOWEDAMT

State
Directed
Payment
Allowed
Amount

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

590

602

CIP337

CIP.003.337

SDP-PAIDAMT

State
Directed
Payment
Paid
Amount

Conditional

N/A

CIP00003

CLAIM-LINERECORD-IP

S9(11)V9
9

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

STATENOTATION

State
Notation

Situational

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).
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).
A free text field for the submitting state to
enter whatever information it chooses.

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
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

N/A

CIP00003

CLAIM-LINERECORD-IP

X(500)

616

1115

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

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

CIP322

CIP.004.322

RECORD-ID

Record
ID

Mandatory

RECORD-ID

CIP00004

CLAIM-DX-IP

X(8)

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

CIP323

CIP.004.323

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

CIP00004

CLAIM-DX-IP

X(2)

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

CIP324

CIP.004.324

RECORDNUMBER

Record
Number

Mandatory

N/A

CIP00004

CLAIM-DX-IP

9(11)

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

CIP325

CIP.004.325

ICN-ORIG

Original
ICN

Mandatory

A 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.
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)

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

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

CIP326

CIP.004.326

ICN-ADJ

Adjustm
ent 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)

121

CIP327

CIP.004.327

ADJUSTMEN
T-IND

Adjustm
ent
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

CIP00004

CLAIM-DX-IP

X(1)

122

CIP328

CIP.004.328

ADJUDICATI
ON-DATE

Adjudicat
ion Date

Mandatory

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

N/A

CIP00004

CLAIM-DX-IP

9(8)

123

130

1. 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)
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

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

CIP329

CIP.004.329

DIAGNOSISTYPE

Diagnosis
Type

Mandatory

DIAGNOSIS-TYPE

CIP00004

CLAIM-DX-IP

X(1)

131

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

CIP330

CIP.004.330

DIAGNOSISSEQUENCENUMBER

Diagnosis
Sequenc
e
Number

Mandatory

N/A

CIP00004

CLAIM-DX-IP

9(2)

132

133

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

CIP331

CIP.004.331

DIAGNOSISCODE-FLAG

Diagnosis
Code
Flag

Mandatory

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

DIAGNOSISCODE-FLAG

CIP00004

CLAIM-DX-IP

X(1)

134

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

CIP332

CIP.004.332

DIAGNOSISCODE

Diagnosis
Code

Mandatory

DIAGNOSISCODE

CIP00004

CLAIM-DX-IP

X(7)

135

141

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

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

CIP333

CIP.004.333

DIAGNOSISPOA-FLAG

Diagnosis
POA Flag

Conditional

DIAGNOSIS-POAFLAG

CIP00004

CLAIM-DX-IP

X(1)

142

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

CIP334

CIP.004.334

STATENOTATION

State
Notation

Situational

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.
A free text field for the submitting state to
enter whatever information it chooses.

N/A

CIP00004

CLAIM-DX-IP

X(500)

143

642

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

T-MSIS Data Dictionary – CLT File
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

RECORD-ID

CLT00001

FILE-HEADERRECORD-LT

X(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

DATADICTIONARY
-VERSION

Data
Dictionar
y Version

Mandatory

A data element to capture the version of the TMSIS data dictionary that was used to build the
file.

DATADICTIONARYVERSION

CLT00001

FILE-HEADERRECORD-LT

X(10)

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

SUBMISSIO
NTRANSACTIO
N-TYPE

Submissi
on
Transacti
on 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.

SUBMISSIONTRANSACTIONTYPE

CLT00001

FILE-HEADERRECORD-LT

X(1)

1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory

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

CLT004

CLT.001.004

FILEENCODINGSPECIFICATI
ON

File
Encoding
Specifica
tion

Mandatory

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

FILE-ENCODINGSPECIFICATION

CLT00001

FILE-HEADERRECORD-LT

X(3)

1. Value must be 3 characters
2. Value must be in File Encoding Specification List
(VVL)
3. Mandatory

CLT005

CLT.001.005

DATAMAPPINGDOCUMENTVERSION

Mandatory

Identifies the version of the T-MSIS data
mapping document used to build a state
submission file.

N/A

CLT00001

FILE-HEADERRECORD-LT

X(9)

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

CLT006

CLT.001.006

FILE-NAME

Data
Mapping
Docume
nt
Version
File
Name

Mandatory

N/A

CLT00001

FILE-HEADERRECORD-LT

X(8)

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

CLT007

CLT.001.007

SUBMITTIN
G-STATE

Submitti
ng 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-HEADERRECORD-LT

X(2)

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

CLT008

CLT.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the file was created.

N/A

CLT00001

FILE-HEADERRECORD-LT

9(8)

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

CLT009

CLT.001.009

START-OFTIMEPERIOD

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-HEADERRECORD-LT

9(8)

CLT010

CLT.001.010

END-OFTIMEPERIOD

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-HEADERRECORD-LT

9(8)

CLT011

CLT.001.011

FILE-STATUSINDICATOR

File
Status
Indicator

Mandatory

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

FILE-STATUSINDICATOR

CLT00001

FILE-HEADERRECORD-LT

X(1)

CLT012

CLT.001.012

SSNINDICATOR

SSN
Indicator

Mandatory

SSN-INDICATOR

CLT00001

FILE-HEADERRECORD-LT

X(1)

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

CLT013

CLT.001.013

TOT-RECCNT

Total
Record
Count

Mandatory

N/A

CLT00001

FILE-HEADERRECORD-LT

9(11)

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

CLT227

CLT.001.227

SEQUENCENUMBER

Sequenc
e
Number

Mandatory

N/A

CLT00001

FILE-HEADERRECORD-LT

X(4)

CLT014

CLT.001.014

STATENOTATION

State
Notation

Situational

N/A

CLT00001

FILE-HEADERRECORD-LT

X(500)

582

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

CLT016

CLT.002.016

RECORD-ID

Record
ID

Mandatory

RECORD-ID

CLT00002

CLAIM-HEADERRECORD-LT

X(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

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

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

CLT018

CLT.002.018

RECORDNUMBER

Record
Number

Mandatory

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(11)

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

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

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-HEADERRECORD-LT

X(50)

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

Adjustm
ent 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-HEADERRECORD-LT

X(50)

121

CLT021

CLT.002.021

SUBMITTERID

Submitte
r ID

Mandatory

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

122

133

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

CLT022

CLT.002.022

MSISIDENTIFICAT
ION-NUM

MSIS
Identifica
tion
Number

Mandatory

The Submitter Identification number is the value
that identifies the provider/trading
partner/clearing house organization to the
state's claim adjudication system.
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/tmsis-coding-blog/reporting-shared-msisidentification-numbers-eligibility/

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(20)

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

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

CLT023

CLT.002.023

CROSSOVERINDICATOR

Crossove
r
Indicator

Mandatory

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

CROSSOVERINDICATOR

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

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

1115ADEMONSTR
ATION-IND

1115A
Demonst
ration
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.

1115ADEMONSTRATIO
N-IND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

155

CLT025

CLT.002.025

ADJUSTMEN
T-IND

Adjustm
ent
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

156

CLT026

CLT.002.026

ADJUSTMEN
T-REASONCODE

Adjustm
ent
Reason
Code

Conditional

Claim adjustment reason codes communicate
why a claim was paid differently than it was
billed.

ADJUSTMENTREASON-CODE

CLT00002

CLAIM-HEADERRECORD-LT

X(3)

157

159

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
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)
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

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

CLT044

CLT.002.044

ADMISSIONDATE

Admissio
n Date

Mandatory

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

160

167

CLT045

CLT.002.045

ADMISSIONHOUR

Admissio
n Hour

Conditional

The time of admission to a psychiatric or longterm care facility.

HOUR

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

168

169

CLT046

CLT.002.046

DISCHARGEDATE

Discharg
e Date

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

170

177

CLT047

CLT.002.047

DISCHARGEHOUR

Discharg
e Hour

Conditional

The time of discharge from a psychiatric or longterm care facility.

HOUR

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

178

179

Coding Requirements

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

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

CLT048

CLT.002.048

BEGINNINGDATE-OFSERVICE

Beginnin
g 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-HEADERRECORD-LT

9(8)

180

187

CLT049

CLT.002.049

ENDINGDATE-OFSERVICE

Ending
Date of
Service

Mandatory

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

188

195

Coding Requirements

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
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

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

CLT050

CLT.002.050

ADJUDICATI
ON-DATE

Adjudicat
ion 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-HEADERRECORD-LT

9(8)

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

MEDICAIDPAID-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-HEADERRECORD-LT

9(8)

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-OFCLAIM

Type of
Claim

Mandatory

TYPE-OF-CLAIM

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

212

1. Value must be 1 character
2. Value must be in Type of Claim List (VVL)
3. Mandatory

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

CLT053

CLT.002.053

TYPE-OFBILL

Type of
Bill

Mandatory

TYPE-OF-BILL

CLT00002

CLAIM-HEADERRECORD-LT

X(4)

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

CLAIMSTATUS

Claim
Status

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.)
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-HEADERRECORD-LT

X(3)

217

219

CLT055

CLT.002.055

CLAIMSTATUSCATEGORY

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-STATUSCATEGORY

CLT00002

CLAIM-HEADERRECORD-LT

X(3)

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

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

CLT056

CLT.002.056

SOURCELOCATION

Source
Location

Mandatory

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

SOURCELOCATION

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

223

224

1. Value must be 2 characters
2. Value must be in Source Location List (VVL)
3. Mandatory

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(15)

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

For sub-capitated encounters from a subcapitated 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 subcapitated network provider that were submitted
to sub-capitated entity, report a SOURCELOCATION = '23' to indicate that the subcapitated network provider provided the service
directly to the enrollee.

CLT057

CLT.002.057

CHECK-NUM

Check
Number

Conditional

For sub-capitated encounters from a subcapitated network provider, report a SOURCELOCATION = “23” to indicate that the subcapitated network provider provided the service
directly to the enrollee.
The check or electronic funds transfer number.

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

CLT058

CLT.002.058

CHECK-EFFDATE

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-HEADERRECORD-LT

9(8)

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

CLAIMPYMT-REMCODE-1

Remittan
ce Advice
Remark
Code 1

Conditional

CLAIM-PYMTREM-CODE

CLT00002

CLAIM-HEADERRECORD-LT

X(5)

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

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

CLT060

CLT.002.060

CLAIMPYMT-REMCODE-2

Remittan
ce Advice
Remark
Code 2

Conditional

CLAIM-PYMTREM-CODE

CLT00002

CLAIM-HEADERRECORD-LT

X(5)

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

CLAIMPYMT-REMCODE-3

Remittan
ce Advice
Remark
Code 3

Conditional

CLAIM-PYMTREM-CODE

CLT00002

CLAIM-HEADERRECORD-LT

X(5)

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

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

CLT062

CLT.002.062

CLAIMPYMT-REMCODE-4

Remittan
ce Advice
Remark
Code 4

Conditional

CLAIM-PYMTREM-CODE

CLT00002

CLAIM-HEADERRECORD-LT

X(5)

263

267

CLT063

CLT.002.063

TOT-BILLEDAMT

Total
Billed
Amount

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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).

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

CLT064

CLT.002.064

TOTALLOWEDAMT

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 subcapitated 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.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

281

293

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

294

306

CLT065

CLT.002.065

TOTMEDICAIDPAID-AMT

Total
Medicaid
Paid
Amount

Conditional

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.
The total amount paid by Medicaid/CHIP or the
managed care plan on this claim or adjustment
at the claim header level, which is the sum of
the amounts paid by Medicaid or the managed
care plan at the detail level for the claim.
For sub-capitated encounters from a subcapitated entity that is not a sub-capitated
network provider, report the total amount that
the sub-capitated entity paid the provider for
the service. Report a null value in this field if the
provider is a sub-capitated network provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated

Coding Requirements

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

network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.

Coding Requirements

8. Value must not be greater than Total Allowed
Amount (CLT.002.064)

CLT067

CLT.002.067

TOTMEDICAREDEDUCTIBLE
-AMT

Total
Medicare
Deductib
le
Amount

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

307

319

CLT068

CLT.002.068

TOTMEDICARECOINS-AMT

Total
Medicare
Coinsura
nce
Amount

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

320

332

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"
(not a crossover claim), then value should not be
populated
4. (Medicare Enrolled) if associated Dual Eligible Code
(ELG.005.085) value is in [01,02,03,04,05,06,08,09,10],
then value is mandatory and must be provided
5. Conditional
6. When populated, value must be less than or equal
to Total Billed Amount
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"
(not a crossover claim), then value should not be
populated.
4. Conditional
5. If associated Medicare Combined Deductible
Indicator equals "1", then value must not be populated
6. When populated, value must be less than or equal
to Total Billed Amount

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

CLT069

CLT.002.069

TOT-TPLAMT

Total TPL
Amount

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

333

345

CLT070

CLT.002.070

TOT-OTHERINSURANCEAMT

Total
Other
Insuranc
e
Amount

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

346

358

CLT071

CLT.002.071

OTHERINSURANCEIND

Other
Insuranc
e
Indicator

Conditional

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

OTHERINSURANCE-IND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

359

1. Value must be 1 character
2. Value must be in Other Insurance Indicator List (VVL)
3. Conditional

CLT072

CLT.002.072

OTHER-TPLCOLLECTION

Other
TPL
Collectio
n

Mandatory

OTHER-TPLCOLLECTION

CLT00002

CLAIM-HEADERRECORD-LT

X(3)

360

362

1. Value must be in Other TPL Collection List (VVL)
2. Value must be 3 characters
3. Mandatory

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
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

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

CLT075

CLT.002.075

FIXEDPAYMENTIND

Fixed
Payment
Indicator

Conditional

FIXED-PAYMENTIND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

363

1. Value must be 1 character
2. Value must be in Fixed Payment Indicator List (VVL)
3. Conditional

CLT076

CLT.002.076

FUNDINGCODE

Funding
Code

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

FUNDING-CODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

364

365

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

CLT077

CLT.002.077

FUNDINGSOURCENONFEDERA
L-SHARE

Funding
Source
NonFederal
Share

Conditional

FUNDINGSOURCENONFEDERALSHARE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

366

367

CLT078

CLT.002.078

MEDICARECOMB-DEDIND

Medicare
Combine
d
Deductib
le
Indicator

Conditional

MEDICARECOMB-DED-IND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

368

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

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

CLT079

CLT.002.079

PROGRAMTYPE

Program
Type

Mandatory

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

PROGRAM-TYPE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

369

370

CLT080

CLT.002.080

PLAN-IDNUMBER

Plan ID
Number

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

371

382

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
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 not be populated when Type of Claim
is not in [3,C,W]
7. When Type of Claim in [3,C,W] value must have a
managed care enrollment (ELG.014) for the beneficiary
where the Beginning DOS (CLT.002.048) occurs
between the managed care plan enrollment eff/end
dates (ELG.014.197/198)
8. When Type of Claim in [3,C,W] value must have a
managed care main record (MCR.002) for the plan
where the Beginning DOS (CLT.002.048) occurs
between the managed care contract eff/end dates
(MCR.002.020/021)

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

CLT082

CLT.002.082

PAYMENTLEVEL-IND

Payment
Level
Indicator

Mandatory

PAYMENT-LEVELIND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

383

Coding Requirements

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

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 (MEDICAIDPAID-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.

Data
Element
Number

System
Data
Element
Number

Data
Element

Data
Element
Name
Text

Data
Element
Necessity

CLT083

CLT.002.083

MEDICAREREIM-TYPE

Medicare
Reimburs
ement
Type

Conditional

CLT084

CLT.002.084

NON-COVDAYS

NonCovered
Days

Conditional

Definition

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.

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

MEDICAREREIM-TYPE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

384

385

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(5)

386

390

Coding Requirements

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

CLT085

CLT.002.085

NON-COVCHARGES

NonCovered
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-HEADERRECORD-LT

S9(11)V9
9

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

MEDICAIDCOVINPATIENTDAYS

Medicaid
Covered
Inpatient
Days

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(5)

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

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

CLT087

CLT.002.087

CLAIM-LINECOUNT

Claim
Line
Count

Mandatory

The total number of lines on the claim.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(4)

409

412

CLT090

CLT.002.090

FORCEDCLAIM-IND

Forced
Claim
Indicator

Conditional

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

FORCED-CLAIMIND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

413

1. Value must be 1 character
2. Value must be in Forced Claim Indicator List (VVL)
3. Conditional

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

CLT091

CLT.002.091

HEALTHCAREACQUIREDCONDITIONIND

Healthca
re
Acquired
Conditio
n
Indicator

Conditional

HEALTH-CAREACQUIREDCONDITION-IND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

414

1. Value must be 1 character
2. Value must be in Healthcare Acquired Condition
Indicator List (VVL)
3. Conditional

CLT092

CLT.002.092

OCCURRENC
E-CODE-01

Occurren
ce Code
1

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

415

416

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

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

CLT093

CLT.002.093

OCCURRENC
E-CODE-02

Occurren
ce Code
2

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

417

418

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT094

CLT.002.094

OCCURRENC
E-CODE-03

Occurren
ce Code
3

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

419

420

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT095

CLT.002.095

OCCURRENC
E-CODE-04

Occurren
ce Code
4

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

421

422

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

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

CLT096

CLT.002.096

OCCURRENC
E-CODE-05

Occurren
ce Code
5

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

423

424

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT097

CLT.002.097

OCCURRENC
E-CODE-06

Occurren
ce Code
6

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

425

426

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT098

CLT.002.098

OCCURRENC
E-CODE-07

Occurren
ce Code
7

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

427

428

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT099

CLT.002.099

OCCURRENC
E-CODE-08

Occurren
ce Code
8

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

429

430

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

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

CLT100

CLT.002.100

OCCURRENC
E-CODE-09

Occurren
ce Code
9

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

431

432

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT101

CLT.002.101

OCCURRENC
E-CODE-10

Occurren
ce Code
10

Conditional

OCCURRENCECODE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

433

434

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

CLT102

CLT.002.102

OCCURRENC
E-CODE-EFFDATE-01

Occurren
ce Code
Effective
Date 1

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

435

442

CLT103

CLT.002.103

OCCURRENC
E-CODE-EFFDATE-02

Occurren
ce Code
Effective
Date 2

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

443

450

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

CLT104

CLT.002.104

OCCURRENC
E-CODE-EFFDATE-03

Occurren
ce Code
Effective
Date 3

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

451

458

Coding Requirements

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

CLT105

CLT.002.105

OCCURRENC
E-CODE-EFFDATE-04

Occurren
ce Code
Effective
Date 4

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

459

466

Coding Requirements

100

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

CLT106

CLT.002.106

OCCURRENC
E-CODE-EFFDATE-05

Occurren
ce Code
Effective
Date 5

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

467

474

CLT107

CLT.002.107

OCCURRENC
E-CODE-EFFDATE-06

Occurren
ce Code
Effective
Date 6

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

475

482

CLT108

CLT.002.108

OCCURRENC
E-CODE-EFFDATE-07

Occurren
ce Code
Effective
Date 7

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

483

490

CLT109

CLT.002.109

OCCURRENC
E-CODE-EFFDATE-08

Occurren
ce Code
Effective
Date 8

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

491

498

Coding Requirements

101

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

CLT110

CLT.002.110

OCCURRENC
E-CODE-EFFDATE-09

Occurren
ce Code
Effective
Date 9

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

499

506

CLT111

CLT.002.111

OCCURRENC
E-CODE-EFFDATE-10

Occurren
ce Code
Effective
Date 10

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

507

514

CLT112

CLT.002.112

OCCURRENC
E-CODEEND-DATE01

Occurren
ce Code
End Date
1

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

515

522

CLT113

CLT.002.113

OCCURRENC
E-CODEEND-DATE02

Occurren
ce Code
End Date
2

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

523

530

CLT114

CLT.002.114

OCCURRENC
E-CODEEND-DATE03

Occurren
ce Code
End Date
3

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

531

538

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
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
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
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

102

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

CLT115

CLT.002.115

OCCURRENC
E-CODEEND-DATE04

Occurren
ce Code
End Date
4

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

539

546

CLT116

CLT.002.116

OCCURRENC
E-CODEEND-DATE05

Occurren
ce Code
End Date
5

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

547

554

CLT117

CLT.002.117

OCCURRENC
E-CODEEND-DATE06

Occurren
ce Code
End Date
6

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

555

562

CLT118

CLT.002.118

OCCURRENC
E-CODEEND-DATE07

Occurren
ce Code
End Date
7

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

563

570

CLT119

CLT.002.119

OCCURRENC
E-CODEEND-DATE08

Occurren
ce Code
End Date
8

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

571

578

CLT120

CLT.002.120

OCCURRENC
E-CODEEND-DATE09

Occurren
ce 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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

579

586

Coding Requirements

103

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

be equal to the value of the associated
Occurrence Code Effective Date.

Coding Requirements

Effective Date
4. Conditional

CLT121

CLT.002.121

OCCURRENC
E-CODEEND-DATE10

Occurren
ce Code
End Date
10

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

587

594

CLT122

CLT.002.122

PATIENTCONTROLNUM

Patient
Control
Number

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(20)

595

614

CLT123

CLT.002.123

ELIGIBLELAST-NAME

Eligible
Last
Name

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(30)

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

ELIGIBLEFIRST-NAME

Eligible
First
Name

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
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.)
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-HEADERRECORD-LT

X(30)

645

674

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

104

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

CLT125

CLT.002.125

ELIGIBLEMIDDLE-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-HEADERRECORD-LT

X(1)

675

1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional

CLT126

CLT.002.126

DATE-OFBIRTH

Date of
Birth

Mandatory

An individual's date of birth.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

676

683

1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Mandatory

CLT127

CLT.002.127

HEALTHHOMEPROV-IND

Health
Home
Provider
Indicator

Conditional

HEALTH-HOMEPROV-IND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

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

WAIVERTYPE

Waiver
Type

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.
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-HEADERRECORD-LT

X(2)

685

686

105

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

CLT129

CLT.002.129

WAIVER-ID

Waiver
ID

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(20)

687

706

CLT130

CLT.002.130

BILLINGPROV-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-HEADERRECORD-LT

X(30)

707

736

CLT131

CLT.002.131

BILLINGPROV-NPINUM

Billing
Provider
NPI
Number

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(10)

737

746

Coding Requirements

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 [0220,32,33]
6. Conditional
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)
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

106

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

Code (PRV.002.028) must equal "01"
6. NPPES Entity Type Code associated with this NPI
must equal "2" (Organization)

CLT132

CLT.002.132

BILLINGPROVTAXONOMY

Billing
Provider
Taxonom
y

Conditional

The taxonomy code for the institution billing for
the beneficiary.

PROVTAXONOMY

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

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

BILLINGPROV-TYPE

Billing
Provider
Type

Conditional

A code to describe the type of provider being
reported.

PROV-TYPE

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

759

760

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

CLT134

CLT.002.134

BILLINGPROVSPECIALTY

Billing
Provider
Specialty

Conditional

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

PROV-SPECIALTY

CLT00002

CLAIM-HEADERRECORD-LT

X(2)

761

762

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

CLT135

CLT.002.135

REFERRINGPROV-NUM

Referring
Provider
Number

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(30)

763

792

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

107

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

CLT136

CLT.002.136

REFERRINGPROV-NPINUM

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-HEADERRECORD-LT

X(10)

793

802

CLT140

CLT.002.140

MEDICAREHIC-NUM

Medicare
HIC
Number

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

803

814

CLT141

CLT.002.141

PATIENTSTATUS

Patient
Status

Mandatory

PATIENT-STATUS

CLT00002

CLAIM-HEADERRECORD-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

REMITTANC
E-NUM

Remittan
ce
Number

Mandatory

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).
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
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-HEADERRECORD-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

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
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

108

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

CLT145

CLT.002.145

LTC-RCPLIAB-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-HEADERRECORD-LT

S9(11)V9
9

102

847

859

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-HEADERRECORD-LT

S9(5)

103

860

864

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-HEADERRECORD-LT

S9(5)

104

865

869

CLT149

CLT.002.149

NURSINGFACILITYDAYS

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-HEADERRECORD-LT

S9(5)

105

870

874

Coding Requirements

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
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
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]
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

109

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

"003" (Nursing Facility) for the same month as the
beginning and ending date of service
CLT150

CLT.002.150

SPLITCLAIM-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-HEADERRECORD-LT

X(1)

106

875

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

CLT151

CLT.002.151

BORDERSTATE-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-STATEIND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

107

876

1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional

CLT153

CLT.002.153

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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

CLT.002.154

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

109

890

897

CLT155

CLT.002.155

Total
Beneficia
ry
Coinsura
nce Paid
Amount
Beneficia
ry
Coinsura
nce Date
Paid
Total
Beneficia
ry
Copayme
nt Paid
Amount

Conditional

CLT154

TOTBENEFICIAR
YCOINSURAN
CE-PAIDAMOUNT
BENEFICIAR
YCOINSURAN
CE-DATEPAID
TOTBENEFICIAR
YCOPAYMENT
-PAIDAMOUNT

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

110

898

910

Conditional

110

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

CLT156

CLT.002.156

BENEFICIAR
YCOPAYMENT
-DATE-PAID

Beneficia
ry
Copayme
nt Date
Paid

Conditional

The date the beneficiary paid the copayment
amount.

N/A

CLT00002

CLAIM-HEADERRECORD-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

TOTBENEFICIAR
YDEDUCTIBLE
-PAIDAMOUNT

Total
Beneficia
ry
Deductib
le Paid
Amount

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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

BENEFICIAR
YDEDUCTIBLE
-DATE-PAID

Beneficia
ry
Deductib
le Date
Paid

Conditional

The date the beneficiary paid the deductible
amount.

N/A

CLT00002

CLAIM-HEADERRECORD-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

111

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

CLT159

CLT.002.159

CLAIMDENIEDINDICATOR

Claim
Denied
Indicator

Mandatory

An indicator to identify a claim that the state
refused pay in its entirety.

CLAIM-DENIEDINDICATOR

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

114

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

COPAYWAIVED-IND

Copayme
nt
Waived
Indicator

Situational

COPAY-WAIVEDIND

CLT00002

CLAIM-HEADERRECORD-LT

X(1)

115

941

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

CLT161

CLT.002.161

HEALTHHOMEENTITYNAME

Health
Home
Entity
Name

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-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

112

Data
Element
Number

System
Data
Element
Number

Data
Element

CLT163

CLT.002.163

THIRDPARTYCOINSURAN
CEAMOUNTPAID
THIRDPARTYCOINSURAN
CE-DATEPAID
THIRDPARTYCOPAYMENT
-AMOUNTPAID

CLT164

CLT.002.164

CLT165

CLT.002.165

CLT166

CLT.002.166

THIRDPARTYCOPAYMENT
-DATE-PAID

CLT167

CLT.002.167

HEALTHHOMEPROVIDERNPI

Data
Element
Name
Text

Third
Party
Coinsura
nce
Amount
Paid
Third
Party
Coinsura
nce Date
Paid
Third
Party
Copayme
nt
Amount
Paid
Third
Party
Copayme
nt Date
Paid
Health
Home
Provider
NPI
Number

Data
Element
Necessity

Situational

Definition

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

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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
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
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

Conditional

The date the third party paid the coinsurance
amount

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

118

1005

1012

Situational

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

119

1013

1025

Situational

The date the third party paid the copayment
amount.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

9(8)

120

1026

1033

Conditional

The National Provider ID (NPI) of the health
home provider.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

121

1034

1045

Coding Requirements

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
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

113

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

CLT168

CLT.002.168

MEDICAREBENEFICIAR
Y-IDENTIFIER

Medicare
Beneficia
ry
Identifier

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(12)

122

1046

1057

CLT174

CLT.002.174

ADMITTINGPROV-NPINUM

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-HEADERRECORD-LT

X(10)

123

1058

1067

CLT175

CLT.002.175

ADMITTINGPROV-NUM

Admittin
g
Provider
NPI
Number
Admittin
g
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-HEADERRECORD-LT

X(30)

124

1068

1097

Coding Requirements

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

114

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

CLT176

CLT.002.176

ADMITTINGPROVSPECIALTY

Admittin
g
Provider
Specialty

Conditional

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

PROV-SPECIALTY

CLT00002

CLAIM-HEADERRECORD-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

ADMITTINGPROVTAXONOMY

Admittin
g
Provider
Taxonom
y

Conditional

Taxonomic classification (code) for a given
healthcare provider, as defined by the National
Uniform Claim Committee.

PROVTAXONOMY

CLT00002

CLAIM-HEADERRECORD-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

ADMITTINGPROV-TYPE

Admittin
g
Provider
Type

Conditional

A code to describe the type of provider being
reported.

PROV-TYPE

CLT00002

CLAIM-HEADERRECORD-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

MEDICAREPAID-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-HEADERRECORD-LT

S9(11)V9
9

128

1114

1126

115

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

CLT237

CLT.002.237

PROVLOCATIONID

Provider
Location
ID

Mandatory

N/A

CLT00002

CLAIM-HEADERRECORD-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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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

CLT.002.240

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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

Total
Beneficia
ry
Copayme
nt Liable
Amount
Total
Beneficia
ry
Coinsura
nce
Liable
Amount
Total
Beneficia
ry
Deductib
le Liable
Amount

Conditional

CLT240

TOTBENEFICIAR
YCOPAYMENT
-LIABLEAMOUNT
TOTBENEFICIAR
YCOINSURAN
CE-LIABLEAMOUNT

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.
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.
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.
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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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

TOTBENEFICIAR
YDEDUCTIBLE
-LIABLEAMOUNT

Conditional

Coding Requirements

116

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

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

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

N/A

CLT00002

CLAIM-HEADERRECORD-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

subtract out any payments for the given claim
that went toward the deductible.

CLT242

CLT.002.242

COMBINEDBENE-COSTSHARINGPAIDAMOUNT

Combine
d
Beneficia
ry Cost
Sharing
Paid
Amount

Conditional

CLT244

CLT.002.244

BILLINGPROV-ADDRLN-1

Billing
Provider
Address
Line 1

Mandatory

CLT245

CLT.002.245

BILLINGPROV-ADDRLN-2

Billing
Provider
Address
Line 2

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(60)

135

1244

1303

CLT246

CLT.002.246

BILLINGPROV-CITY

Billing
Provider
City

Mandatory

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(28)

136

1304

1331

117

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

CLT247

CLT.002.247

BILLINGPROV-STATE

Billing
Provider
State
Code

Mandatory

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

STATE

CLT00002

CLAIM-HEADERRECORD-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

BILLINGPROV-ZIPCODE

Billing
Provider
ZIP Code

Mandatory

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

ZIP-CODE

CLT00002

CLAIM-HEADERRECORD-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

SERVICEFACILITYLOCATIONORG-NPI

Service
Facility
Location
Organizat
ion NPI

Conditional

Service facility location organization NPI from
X12 837I loop 2310E.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(10)

139

1343

1352

CLT250

CLT.002.250

SERVICEFACILITYLOCATIONADDR-LN-1

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(60)

140

1353

1412

CLT251

CLT.002.251

SERVICEFACILITYLOCATIONADDR-LN-2

Service
Facility
Location
Address
Line 1
Service
Facility
Location
Address
Line 2

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

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(60)

141

1413

1472

118

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

CLT252

CLT.002.252

SERVICEFACILITYLOCATIONCITY

Service
Facility
Location
City

Conditional

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

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(28)

142

1473

1500

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

CLT253

CLT.002.253

SERVICEFACILITYLOCATIONSTATE

Service
Facility
Location
State

Conditional

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

STATE

CLT00002

CLAIM-HEADERRECORD-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

SERVICEFACILITYLOCATIONZIP-CODE

Service
Facility
Location
ZIP Code

Conditional

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

ZIP-CODE

CLT00002

CLAIM-HEADERRECORD-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

PROVIDERCLAIMFORM-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".

PROVIDERCLAIM-FORMCODE

CLT00002

CLAIM-HEADERRECORD-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

PROVIDERCLAIMFORMOTHER-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-HEADERRECORD-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"

119

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

CLT257

CLT.002.257

TOT-GMEAMOUNTPAID

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-HEADERRECORD-LT

S9(11)V9
9

147

1564

1576

CLT258

CLT.002.258

TOT-SDPALLOWEDAMT

Total
State
Directed
Payment
Allowed
Amount

Conditional

N/A

CLT00002

CLAIM-HEADERRECORD-LT

S9(11)V9
9

148

1577

1589

CLT259

CLT.002.259

TOT-SDPPAID-AMT

Total
State
Directed
Payment
Paid
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).
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-HEADERRECORD-LT

S9(11)V9
9

149

1590

1602

Coding Requirements

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

120

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

CLT173

CLT.002.173

STATENOTATION

State
Notation

Situational

A free text field for the submitting state to enter
whatever information it chooses.

N/A

CLT00002

CLAIM-HEADERRECORD-LT

X(500)

150

1603

2102

CLT184

CLT.003.184

RECORD-ID

Record
ID

Mandatory

RECORD-ID

CLT00003

CLAIM-LINERECORD-LT

X(8)

Coding Requirements

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

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "CLT00003"

121

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

CLT185

CLT.003.185

SUBMITTIN
G-STATE

Submitti
ng 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-LINERECORD-LT

X(2)

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

CLT186

CLT.003.186

RECORDNUMBER

Record
Number

Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

9(11)

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

122

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

CLT187

CLT.003.187

MSISIDENTIFICAT
ION-NUM

MSIS
Identifica
tion
Number

Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

X(20)

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

CLT188

CLT.003.188

ICN-ORIG

Original
ICN

Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

X(50)

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

123

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

CLT189

CLT.003.189

ICN-ADJ

Adjustm
ent 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-LINERECORD-LT

X(50)

141

CLT190

CLT.003.190

LINE-NUMORIG

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-LINERECORD-LT

X(3)

142

144

CLT191

CLT.003.191

LINE-NUMADJ

Adjustm
ent 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-LINERECORD-LT

X(3)

145

147

CLT192

CLT.003.192

LINEADJUSTMEN
T-IND

Line
Adjustm
ent
Indicator

Conditional

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

LINEADJUSTMENTIND

CLT00003

CLAIM-LINERECORD-LT

X(1)

148

CLT193

CLT.003.193

LINEADJUSTMEN
T-REASONCODE

Line
Adjustm
ent
Reason
Code

Conditional

Claim adjustment reason codes communicate
why a service line was paid differently than it
was billed.

LINEADJUSTMENTREASON-CODE

CLT00003

CLAIM-LINERECORD-LT

X(3)

149

151

Coding Requirements

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
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
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
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
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

124

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

CLT194

CLT.003.194

SUBMITTERID

Submitte
r ID

Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

X(12)

152

163

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

CLT195

CLT.003.195

CLAIM-LINESTATUS

Claim
Line
Status

Conditional

The Submitter Identification number is the value
that identifies the provider/trading
partner/clearing house organization to the
state's claim adjudication system.
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-LINERECORD-LT

X(3)

164

166

CLT196

CLT.003.196

BEGINNINGDATE-OFSERVICE

Beginnin
g 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-LINERECORD-LT

9(8)

167

174

CLT197

CLT.003.197

ENDINGDATE-OFSERVICE

Ending
Date of
Service

Mandatory

N/A

CLT00003

CLAIM-LINERECORD-LT

9(8)

175

182

125

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

6. Value must be equal to or greater than associated
Date of Birth (ELG.002.024) value
7. Mandatory
CLT198

CLT.003.198

REVENUECODE

Revenue
Code

Mandatory

CLT202

CLT.003.202

REVENUECENTERQUANTITYACTUAL

Revenue
Center
Quantity
Actual

Mandatory

CLT203

CLT.003.203

REVENUECENTERQUANTITYALLOWED

Revenue
Center
Quantity
Allowed

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 TMSIS 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.
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
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

REVENUE-CODE

CLT00003

CLAIM-LINERECORD-LT

X(4)

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

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(6)V99
9

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

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(6)V99
9

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

126

Data
Element
Number

CLT204

System
Data
Element
Number

CLT.003.204

Data
Element

REVENUECHARGE

Data
Element
Name
Text

Revenue
Charge

Data
Element
Necessity

Conditional

Definition

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.
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.

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

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

205

217

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

218

230

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

For sub-capitated encounters from a subcapitated 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.

CLT205

CLT.003.205

ALLOWEDAMT

Allowed
Amount

Conditional

Coding Requirements

127

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

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

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

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

244

256

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

257

269

organization. For sub-capitated encounters from
a sub-capitated entity that is not a subcapitated 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.

CLT206

CLT.003.206

TPL-AMT

TPL
Amount

Conditional

CLT207

CLT.003.207

OTHERINSURANCEAMT

Other
Insuranc
e
Amount

Conditional

CLT208

CLT.003.208

MEDICAIDPAID-AMT

Medicaid
Paid
Amount

Conditional

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.
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.
The amount paid by insurance other than
Medicare or Medicaid on this claim.

The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For subcapitated encounters from a sub-capitated
entity that is not a sub-capitated network
provider, report the amount that the subcapitated 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.

128

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

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

270

282

Coding Requirements

CLT209

CLT.003.209

MEDICAIDFFSEQUIVALENT
-AMT

Medicaid
FFS
Equivale
nt
Amount

Conditional

CLT210

CLT.003.210

BILLINGUNIT

Billing
Unit

Conditional

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

BILLING-UNIT

CLT00003

CLAIM-LINERECORD-LT

X(2)

283

284

CLT211

CLT.003.211

TYPE-OFSERVICE

Type of
Service

Mandatory

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

TYPE-OFSERVICE-LT

CLT00003

CLAIM-LINERECORD-LT

X(3)

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

SERVICINGPROV-NUM

Servicing
Provider
Number

Conditional

N/A

CLT00003

CLAIM-LINERECORD-LT

X(30)

288

317

129

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

CLT213

CLT.003.213

SERVICINGPROV-NPINUM

Servicing
Provider
NPI
Number

Conditional

N/A

CLT00003

CLAIM-LINERECORD-LT

X(10)

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

SERVICINGPROV-TYPE

Servicing
Provider
Type

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.
A code to describe the type of provider being
reported.

PROV-TYPE

CLT00003

CLAIM-LINERECORD-LT

X(2)

328

329

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

CLT216

CLT.003.216

SERVICINGPROVSPECIALTY

Servicing
Provider
Specialty

Conditional

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

PROV-SPECIALTY

CLT00003

CLAIM-LINERECORD-LT

X(2)

330

331

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

CLT217

CLT.003.217

OTHER-TPLCOLLECTION

Other
TPL
Collectio
n

Mandatory

OTHER-TPLCOLLECTION

CLT00003

CLAIM-LINERECORD-LT

X(3)

332

334

1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory

130

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

CLT219

CLT.003.219

CATEGORYFORFEDERALREIMBURSE
MENT

Category
for
Federal
Reimburs
ement

Conditional

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

CATEGORY-FORFEDERALREIMBURSEMEN
T

CLT00003

CLAIM-LINERECORD-LT

X(2)

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

PROVFACILITYTYPE

Provider
Facility
Type

Mandatory

PROV-FACILITYTYPE

CLT00003

CLAIM-LINERECORD-LT

X(9)

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

NATIONALDRUG-CODE

National
Drug
Code

Conditional

The type of facility in which services on the
claim were rendered. The Provider Facility Type
code set is based on corresponding groups of
HIPAA provider taxonomy codes.
A code following the National Drug Code format
indicating the drug, device, or medical supply
covered by this claim.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(12)

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-UNITOFMEASURE

NDC Unit
of
Measure

Conditional

A code to indicate the basis by which the
quantity of the National Drug Code is expressed.

NDC-UNIT-OFMEASURE

CLT00003

CLAIM-LINERECORD-LT

X(2)

358

359

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

131

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

CLT230

CLT.003.230

NDCQUANTITY

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-LINERECORD-LT

S9(9)V(9)

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

ADJUDICATI
ON-DATE

Adjudicat
ion Date

Mandatory

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

N/A

CLT00003

CLAIM-LINERECORD-LT

9(8)

378

385

CLT234

CLT.003.234

SELFDIRECTIONTYPE

Self
Direction
Type

Mandatory

This data element is not applicable to this file
type.

SELF-DIRECTIONTYPE

CLT00003

CLAIM-LINERECORD-LT

X(3)

386

388

1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory

CLT235

CLT.003.235

PREAUTHORIZA
TION-NUM

Preautho
rization
Number

Conditional

N/A

CLT00003

CLAIM-LINERECORD-LT

X(18)

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

IHSSERVICE-IND

IHS
Service
Indicator

Mandatory

IHS-SERVICE-IND

CLT00003

CLAIM-LINERECORD-LT

X(1)

407

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

132

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

CLT260

CLT.003.260

UNIQUEDEVICEIDENTIFIER

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-LINERECORD-LT

X(76)

408

483

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

CLT282

CLT.003.282

MBESCBESFORMGROUP

MBESCB
ES Form
Group

Conditional

MBESCBESFORM-GROUP

CLT00003

CLAIM-LINERECORD-LT

X(1)

484

133

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

CLT262

CLT.003.262

MBESCBESFORM

MBESCB
ES 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.

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

CLT00003

CLAIM-LINERECORD-LT

X(50)

485

534

CLT261

CLT.003.261

MBESCBESCATEGORYOF-SERVICE

MBESCB
ES
Category
of
Service

Conditional

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

CLT00003

CLAIM-LINERECORD-LT

X(5)

535

539

Coding Requirements

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
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

134

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

CLT263

CLT.003.263

GMEAMOUNTPAID

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-LINERECORD-LT

S9(11)V9
9

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

REFERRINGPROV-NUM

Referring
Provider
Number

Conditional

N/A

CLT00003

CLAIM-LINERECORD-LT

X(30)

553

582

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

135

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

CLT265

CLT.003.265

REFERRINGPROV-NPINUM

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-LINERECORD-LT

X(10)

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

SDPALLOWEDAMT

State
Directed
Payment
Allowed
Amount

Conditional

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

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

136

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

CLT267

CLT.003.267

SDP-PAIDAMT

State
Directed
Payment
Paid
Amount

Conditional

N/A

CLT00003

CLAIM-LINERECORD-LT

S9(11)V9
9

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

STATENOTATION

State
Notation

Situational

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).
A free text field for the submitting state to enter
whatever information it chooses.

N/A

CLT00003

CLAIM-LINERECORD-LT

X(500)

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

RECORD-ID

CLT00004

CLAIM-DX-LT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "CLT00004"

CLT269

CLT.004.269

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

CLT00004

CLAIM-DX-LT

X(2)

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

137

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

CLT270

CLT.004.270

RECORDNUMBER

Record
Number

Mandatory

N/A

CLT00004

CLAIM-DX-LT

9(11)

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

CLT271

CLT.004.271

ICN-ORIG

Original
ICN

Mandatory

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

N/A

CLT00004

CLAIM-DX-LT

X(50)

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

CLT272

CLT.004.272

ICN-ADJ

Adjustm
ent 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)

121

CLT273

CLT.004.273

ADJUSTMEN
T-IND

Adjustm
ent
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

CLT00004

CLAIM-DX-LT

X(1)

122

138

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

CLT274

CLT.004.274

ADJUDICATI
ON-DATE

Adjudicat
ion Date

Mandatory

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

N/A

CLT00004

CLAIM-DX-LT

9(8)

123

130

CLT275

CLT.004.275

DIAGNOSISTYPE

Diagnosis
Type

Mandatory

DIAGNOSIS-TYPE

CLT00004

CLAIM-DX-LT

X(1)

131

CLT276

CLT.004.276

DIAGNOSISSEQUENCENUMBER

Diagnosis
Sequenc
e
Number

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.
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)

132

133

Coding Requirements

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
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

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

139

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

CLT277

CLT.004.277

DIAGNOSISCODE-FLAG

Diagnosis
Code
Flag

Mandatory

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

DIAGNOSISCODE-FLAG

CLT00004

CLAIM-DX-LT

X(1)

134

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

CLT278

CLT.004.278

DIAGNOSISCODE

Diagnosis
Code

Mandatory

DIAGNOSISCODE

CLT00004

CLAIM-DX-LT

X(7)

135

141

CLT279

CLT.004.279

DIAGNOSISPOA-FLAG

Diagnosis
POA Flag

Conditional

DIAGNOSIS-POAFLAG

CLT00004

CLAIM-DX-LT

X(1)

142

CLT280

CLT.004.280

STATENOTATION

State
Notation

Situational

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'.
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.
A free text field for the submitting state to enter
whatever information it chooses.

N/A

CLT00004

CLAIM-DX-LT

X(500)

143

642

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

140

141

T-MSIS Data Dictionary – COT File
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

RECORD-ID

COT00001

FILE-HEADERRECORD-OT

X(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

DATADICTIONAR
Y-VERSION

Data
Dictionar
y Version

Mandatory

A data element to capture the version of the TMSIS data dictionary that was used to build the
file.

DATADICTIONARYVERSION

COT00001

FILE-HEADERRECORD-OT

X(10)

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

142

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

COT003

COT.001.003

SUBMISSIO
NTRANSACTI
ON-TYPE

Submissi
on
Transacti
on 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.

SUBMISSIONTRANSACTIONTYPE

COT00001

FILE-HEADERRECORD-OT

X(1)

1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory

COT004

COT.001.004

File
Encoding
Specifica
tion

Mandatory

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

FILE-ENCODINGSPECIFICATION

COT00001

FILE-HEADERRECORD-OT

X(3)

1. Value must be 3 characters
2. Value must be in File Encoding Specification List
(VVL)
3. Mandatory

COT005

COT.001.005

FILEENCODING
SPECIFICAT
ION
DATAMAPPINGDOCUMEN
T-VERSION

Mandatory

Identifies the version of the T-MSIS data
mapping document used to build a state
submission file.

N/A

COT00001

FILE-HEADERRECORD-OT

X(9)

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

COT006

COT.001.006

FILE-NAME

Data
Mapping
Docume
nt
Version
File
Name

Mandatory

N/A

COT00001

FILE-HEADERRECORD-OT

X(8)

1. Value must equal "CLAIM-OT"
2. Mandatory

COT007

COT.001.007

SUBMITTIN
G-STATE

Submitti
ng 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-HEADERRECORD-OT

X(2)

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

143

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

COT008

COT.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the file was created.

N/A

COT00001

FILE-HEADERRECORD-OT

9(8)

COT009

COT.001.009

START-OFTIMEPERIOD

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-HEADERRECORD-OT

9(8)

COT010

COT.001.010

END-OFTIMEPERIOD

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-HEADERRECORD-OT

9(8)

COT011

COT.001.011

FILESTATUSINDICATOR

File
Status
Indicator

Mandatory

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

FILE-STATUSINDICATOR

COT00001

FILE-HEADERRECORD-OT

X(1)

COT012

COT.001.012

SSNINDICATOR

SSN
Indicator

Mandatory

SSN-INDICATOR

COT00001

FILE-HEADERRECORD-OT

X(1)

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

144

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

COT013

COT.001.013

TOT-RECCNT

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-HEADERRECORD-OT

9(11)

COT216

COT.001.216

SEQUENCENUMBER

Sequenc
e
Number

Mandatory

N/A

COT00001

FILE-HEADERRECORD-OT

X(4)

COT014

COT.001.014

STATENOTATION

State
Notation

Situational

N/A

COT00001

FILE-HEADERRECORD-OT

X(500)

582

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

COT016

COT.002.016

RECORD-ID

Record
ID

Mandatory

RECORD-ID

COT00002

CLAIM-HEADERRECORD-OT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "COT00002"

145

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

COT017

COT.002.017

SUBMITTIN
G-STATE

Submitti
ng 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-HEADERRECORD-OT

X(2)

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

COT018

COT.002.018

RECORDNUMBER

Record
Number

Mandatory

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(11)

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

COT019

COT.002.019

ICN-ORIG

Original
ICN

Mandatory

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(50)

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

COT020

COT.002.020

ICN-ADJ

Adjustm
ent 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-HEADERRECORD-OT

X(50)

121

COT021

COT.002.021

SUBMITTER
-ID

Submitte
r 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-HEADERRECORD-OT

X(12)

122

133

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

146

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

COT022

COT.002.022

MSISIDENTIFICA
TION-NUM

MSIS
Identifica
tion
Number

Mandatory

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(20)

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

CROSSOVE
RINDICATOR

Crossove
r
Indicator

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/tmsis-coding-blog/reporting-shared-msisidentification-numbers-eligibility/
An indicator specifying whether the claim is a
crossover claim where a portion is paid by
Medicare.

CROSSOVERINDICATOR

COT00002

CLAIM-HEADERRECORD-OT

X(1)

154

COT024

COT.002.024

1115ADEMONSTR
ATION-IND

1115A
Demonst
ration
Indicator

Conditional

1115ADEMONSTRATIO
N-IND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

155

147

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

COT025

COT.002.025

ADJUSTME
NT-IND

Adjustm
ent
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

156

COT026

COT.002.026

ADJUSTME
NTREASONCODE

Adjustm
ent
Reason
Code

Conditional

Claim adjustment reason codes communicate
why a claim was paid differently than it was
billed.

ADJUSTMENTREASON-CODE

COT00002

CLAIM-HEADERRECORD-OT

X(3)

157

159

COT033

COT.002.033

BEGINNING
-DATE-OFSERVICE

Beginnin
g 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-HEADERRECORD-OT

9(8)

160

167

148

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

COT034

COT.002.034

ENDINGDATE-OFSERVICE

Ending
Date of
Service

Mandatory

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

168

175

COT035

COT.002.035

ADJUDICAT
ION-DATE

Adjudicat
ion 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-HEADERRECORD-OT

9(8)

176

183

COT036

COT.002.036

MEDICAIDPAID-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-HEADERRECORD-OT

9(8)

184

191

Coding Requirements

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
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
1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Must have an associated Total Medicaid Paid
Amount
3. Mandatory

149

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

COT037

COT.002.037

TYPE-OFCLAIM

Type of
Claim

Mandatory

TYPE-OF-CLAIM

COT00002

CLAIM-HEADERRECORD-OT

X(1)

192

1. Value must be 1 character
2. Value must be in Type of Claim List (VVL)
3. Mandatory

COT038

COT.002.038

TYPE-OFBILL

Type of
Bill

Conditional

TYPE-OF-BILL

COT00002

CLAIM-HEADERRECORD-OT

X(4)

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

CLAIMSTATUS

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-HEADERRECORD-OT

X(3)

197

199

150

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

COT040

COT.002.040

CLAIMSTATUSCATEGORY

Claim
Status
Category

Mandatory

CLAIM-STATUSCATEGORY

COT00002

CLAIM-HEADERRECORD-OT

X(3)

200

202

COT041

COT.002.041

SOURCELOCATION

Source
Location

Mandatory

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

SOURCELOCATION

COT00002

CLAIM-HEADERRECORD-OT

X(2)

203

204

1. Value must be 2 characters
2. Value must be in Source Location List (VVL)
3. Mandatory

151

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

COT042

COT.002.042

CHECKNUM

Check
Number

Conditional

The check or electronic funds transfer number.

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(15)

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-EFFDATE

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-HEADERRECORD-OT

9(8)

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

CLAIMPYMTREMCODE-1

Remittan
ce Advice
Remark
Code 1

Conditional

CLAIM-PYMTREM-CODE

COT00002

CLAIM-HEADERRECORD-OT

X(5)

228

232

152

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

COT045

COT.002.045

CLAIMPYMTREMCODE-2

Remittan
ce Advice
Remark
Code 2

Conditional

CLAIM-PYMTREM-CODE

COT00002

CLAIM-HEADERRECORD-OT

X(5)

233

237

COT046

COT.002.046

CLAIMPYMTREMCODE-3

Remittan
ce Advice
Remark
Code 3

Conditional

CLAIM-PYMTREM-CODE

COT00002

CLAIM-HEADERRECORD-OT

X(5)

238

242

153

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

COT047

COT.002.047

CLAIMPYMTREMCODE-4

Remittan
ce Advice
Remark
Code 4

Conditional

CLAIM-PYMTREM-CODE

COT00002

CLAIM-HEADERRECORD-OT

X(5)

243

247

COT048

COT.002.048

TOTBILLEDAMT

Total
Billed
Amount

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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)

154

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

COT049

COT.002.049

TOTALLOWEDAMT

Total
Allowed
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

261

273

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

274

286

COT050

COT.002.050

TOTMEDICAIDPAID-AMT

Total
Medicaid
Paid
Amount

Conditional

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated
network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.
The total amount paid by Medicaid/CHIP or the
managed care plan on this claim or adjustment
at the claim header level, which is the sum of
the amounts paid by Medicaid or the managed
care plan at the detail level for the claim.
For sub-capitated encounters from a subcapitated entity that is not a sub-capitated
network provider, report the total amount that
the sub-capitated entity paid the provider for
the service. Report a null value in this field if the
provider is a sub-capitated network provider.
For sub-capitated encounters from a subcapitated network provider, if the sub-capitated

Coding Requirements

155

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

network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.

COT052

COT.002.052

TOTMEDICAREDEDUCTIBL
E-AMT

Total
Medicare
Deductib
le
Amount

Conditional

Coding Requirements

8. Value must not be greater than Total Allowed
Amount (COT.002.049)

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

287

299

156

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

COT053

COT.002.053

TOTMEDICARECOINSAMT

Total
Medicare
Coinsura
nce
Amount

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

300

312

COT054

COT.002.054

TOT-TPLAMT

Total TPL
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

313

325

COT056

COT.002.056

TOTOTHERINSURANC
E-AMT

Total
Other
Insuranc
e
Amount

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

157

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

COT057

COT.002.057

OTHERINSURANC
E-IND

Other
Insuranc
e
Indicator

Conditional

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

OTHERINSURANCE-IND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

339

1. Value must be 1 character
2. Value must be in Other Insurance Indicator List
(VVL)
3. Conditional

COT058

COT.002.058

OTHERTPLCOLLECTIO
N

Other
TPL
Collectio
n

Mandatory

OTHER-TPLCOLLECTION

COT00002

CLAIM-HEADERRECORD-OT

X(3)

340

342

1. Value must be in Other TPL Collection List (VVL)
2. Value must be 3 characters
3. Mandatory

COT061

COT.002.061

FIXEDPAYMENTIND

Fixed
Payment
Indicator

Conditional

FIXED-PAYMENTIND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

343

1. Value must be 1 character
2. Value must be in Fixed Payment Indicator List (VVL)
3. Conditional

158

Data
Element
Number

System
Data
Element
Number

Data
Element

Data
Element
Name
Text

Data
Element
Necessity

Definition

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

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

FUNDING-CODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

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

COT062

COT.002.062

FUNDINGCODE

Funding
Code

Conditional

COT063

COT.002.063

FUNDINGSOURCENONFEDER
AL-SHARE

Funding
Source
NonFederal
Share

Conditional

FUNDINGSOURCENONFEDERALSHARE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

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

MEDICARECOMBDED-IND

Medicare
Combine
d
Deductib
le
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.

MEDICARECOMB-DED-IND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

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"

159

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

5. If value equals "1", then Crossover Indicator must
equals "1"
6. Conditional

COT065

COT.002.065

PROGRAMTYPE

Program
Type

Mandatory

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

PROGRAM-TYPE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

349

350

COT066

COT.002.066

PLAN-IDNUMBER

Plan ID
Number

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(12)

351

362

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

1. Value must be 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
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)

160

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

COT068

COT.002.068

PAYMENTLEVEL-IND

Payment
Level
Indicator

Mandatory

PAYMENTLEVEL-IND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

363

Coding Requirements

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

161

Data
Element
Number

System
Data
Element
Number

Data
Element

Data
Element
Name
Text

Data
Element
Necessity

COT069

COT.002.069

MEDICAREREIM-TYPE

Medicare
Reimburs
ement
Type

Conditional

COT070

COT.002.070

CLAIMLINECOUNT

Claim
Line
Count

Mandatory

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

MEDICAREREIM-TYPE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

364

365

The total number of lines on the claim.

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(4)

366

369

Coding Requirements

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
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 nonnumeric 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

162

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

COT072

COT.002.072

FORCEDCLAIM-IND

Forced
Claim
Indicator

Conditional

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

FORCED-CLAIMIND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

370

1. Value must be 1 character
2. Value must be in Forced Claim Indicator List (VVL)
3. Conditional

COT073

COT.002.073

HEALTHCAREACQUIREDCONDITION
-IND

Healthca
re
Acquired
Conditio
n
Indicator

Conditional

HEALTH-CAREACQUIREDCONDITION-IND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

371

1. Value must be 1 character
2. Value must be in Healthcare Acquired Condition
Indicator List (VVL)
3. Conditional

COT074

COT.002.074

OCCURREN
CE-CODE01

Occurren
ce Code
1

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

372

373

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

163

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

COT075

COT.002.075

OCCURREN
CE-CODE02

Occurren
ce Code
2

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

374

375

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

COT076

COT.002.076

OCCURREN
CE-CODE03

Occurren
ce Code
3

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

376

377

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

164

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

COT077

COT.002.077

OCCURREN
CE-CODE04

Occurren
ce Code
4

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

378

379

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

COT078

COT.002.078

OCCURREN
CE-CODE05

Occurren
ce Code
5

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

380

381

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

165

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

COT079

COT.002.079

OCCURREN
CE-CODE06

Occurren
ce Code
6

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

382

383

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

COT080

COT.002.080

OCCURREN
CE-CODE07

Occurren
ce Code
7

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

384

385

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

166

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

COT081

COT.002.081

OCCURREN
CE-CODE08

Occurren
ce Code
8

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

386

387

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

COT082

COT.002.082

OCCURREN
CE-CODE09

Occurren
ce Code
9

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

388

389

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

167

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

COT083

COT.002.083

OCCURREN
CE-CODE10

Occurren
ce Code
10

Conditional

OCCURRENCECODE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

390

391

1. Value must be 2 characters
2. Value must be in Occurrence Code List (VVL)
3. Conditional

COT084

COT.002.084

OCCURREN
CE-CODEEFF-DATE01

Occurren
ce Code
Effective
Date 1

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

392

399

168

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

COT085

COT.002.085

OCCURREN
CE-CODEEFF-DATE02

Occurren
ce Code
Effective
Date 2

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

400

407

COT086

COT.002.086

OCCURREN
CE-CODEEFF-DATE03

Occurren
ce Code
Effective
Date 3

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

408

415

169

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

COT087

COT.002.087

OCCURREN
CE-CODEEFF-DATE04

Occurren
ce Code
Effective
Date 4

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

416

423

COT088

COT.002.088

OCCURREN
CE-CODEEFF-DATE05

Occurren
ce Code
Effective
Date 5

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

424

431

170

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

COT089

COT.002.089

OCCURREN
CE-CODEEFF-DATE06

Occurren
ce Code
Effective
Date 6

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

432

439

COT090

COT.002.090

OCCURREN
CE-CODEEFF-DATE07

Occurren
ce Code
Effective
Date 7

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

440

447

171

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

COT091

COT.002.091

OCCURREN
CE-CODEEFF-DATE08

Occurren
ce Code
Effective
Date 8

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

448

455

COT092

COT.002.092

OCCURREN
CE-CODEEFF-DATE09

Occurren
ce Code
Effective
Date 9

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

456

463

172

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

COT093

COT.002.093

OCCURREN
CE-CODEEFF-DATE10

Occurren
ce Code
Effective
Date 10

Conditional

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

464

471

COT094

COT.002.094

OCCURREN
CE-CODEEND-DATE01

Occurren
ce Code
End Date
1

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

173

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

COT095

COT.002.095

OCCURREN
CE-CODEEND-DATE02

Occurren
ce Code
End Date
2

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

OCCURREN
CE-CODEEND-DATE03

Occurren
ce Code
End Date
3

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

174

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

COT097

COT.002.097

OCCURREN
CE-CODEEND-DATE04

Occurren
ce Code
End Date
4

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

OCCURREN
CE-CODEEND-DATE05

Occurren
ce Code
End Date
5

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

175

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

COT099

COT.002.099

OCCURREN
CE-CODEEND-DATE06

Occurren
ce Code
End Date
6

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

OCCURREN
CE-CODEEND-DATE07

Occurren
ce Code
End Date
7

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

176

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

COT101

COT.002.101

OCCURREN
CE-CODEEND-DATE08

Occurren
ce Code
End Date
8

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

OCCURREN
CE-CODEEND-DATE09

Occurren
ce Code
End Date
9

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

177

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

COT103

COT.002.103

OCCURREN
CE-CODEEND-DATE10

Occurren
ce Code
End Date
10

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

PATIENTCONTROLNUM

Patient
Control
Number

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(20)

552

571

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

178

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

COT105

COT.002.105

ELIGIBLELASTNAME

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-HEADERRECORD-OT

X(30)

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

ELIGIBLEFIRSTNAME

Eligible
First
Name

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(30)

602

631

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

179

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

COT107

COT.002.107

ELIGIBLEMIDDLEINIT

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-HEADERRECORD-OT

X(1)

632

1. Value must be 1 character
2. Value must not contain a pipe or asterisk symbols
3. Conditional

COT108

COT.002.108

DATE-OFBIRTH

Date of
Birth

Mandatory

An individual's date of birth.

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

633

640

1. The date must be a valid calendar date in the form
"CCYYMMDD"
2. Mandatory

180

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

COT109

COT.002.109

HEALTHHOMEPROV-IND

Health
Home
Provider
Indicator

Conditional

HEALTH-HOMEPROV-IND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

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

WAIVERTYPE

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-HEADERRECORD-OT

X(2)

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"

181

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

COT111

COT.002.111

WAIVER-ID

Waiver
ID

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(20)

644

663

COT112

COT.002.112

BILLINGPROV-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-HEADERRECORD-OT

X(30)

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'.

182

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

COT113

COT.002.113

BILLINGPROV-NPINUM

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-HEADERRECORD-OT

X(10)

694

703

COT114

COT.002.114

BILLINGPROVTAXONOM
Y

Billing
Provider
Taxonom
y

Conditional

The taxonomy code for the provider billing for
the service.

PROVTAXONOMY

COT00002

CLAIM-HEADERRECORD-OT

X(12)

704

715

1. Value must be in Provider Taxonomy List (VVL)
2. Value must be 12 characters or less
3. Conditional

183

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

COT115

COT.002.115

BILLINGPROV-TYPE

Billing
Provider
Type

Conditional

A code to describe the type of provider being
reported.

PROV-TYPE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

716

717

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

COT116

COT.002.116

BILLINGPROVSPECIALTY

Billing
Provider
Specialty

Conditional

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

PROV-SPECIALTY

COT00002

CLAIM-HEADERRECORD-OT

X(2)

718

719

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

184

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

COT117

COT.002.117

REFERRING
-PROVNUM

Referring
Provider
Number

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(30)

720

749

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

COT118

COT.002.118

REFERRING
-PROV-NPINUM

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-HEADERRECORD-OT

X(10)

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

185

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

COT122

COT.002.122

MEDICAREHIC-NUM

Medicare
HIC
Number

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(12)

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-OFSERVICE

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-OFSERVICE

COT00002

CLAIM-HEADERRECORD-OT

X(2)

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

186

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

COT126

COT.002.126

REMITTAN
CE-NUM

Remittan
ce
Number

Mandatory

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(30)

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-HEADERRECORD-OT

S9(5)V99

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)

187

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

COT128

COT.002.128

BORDERSTATE-IND

Border
State
Indicator

Conditional

BORDER-STATEIND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

811

1. Value must be 1 character
2. Value must be in Border State Indicator List (VVL)
3. Conditional

COT130

COT.002.130

TOTBENEFICIA
RYCOINSURA
NCE-PAIDAMOUNT

Total
Beneficia
ry
Coinsura
nce Paid
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

188

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

COT131

COT.002.131

BENEFICIA
RYCOINSURA
NCE-DATEPAID

Beneficia
ry
Coinsura
nce Date
Paid

Conditional

The date the beneficiary paid the coinsurance
amount.

N/A

COT00002

CLAIM-HEADERRECORD-OT

9(8)

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

TOTBENEFICIA
RYCOPAYMEN
T-PAIDAMOUNT

Total
Beneficia
ry
Copayme
nt Paid
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

189

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

COT133

COT.002.133

BENEFICIA
RYCOPAYMEN
T-DATEPAID

Beneficia
ry
Copayme
nt Date
Paid

Conditional

The date the beneficiary paid the copayment
amount.

N/A

COT00002

CLAIM-HEADERRECORD-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

TOTBENEFICIA
RYDEDUCTIBL
E-PAIDAMOUNT

Total
Beneficia
ry
Deductib
le Paid
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

190

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

COT135

COT.002.135

BENEFICIA
RYDEDUCTIBL
E-DATEPAID

Beneficia
ry
Deductib
le Date
Paid

Conditional

The date the beneficiary paid the deductible
amount.

N/A

COT00002

CLAIM-HEADERRECORD-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

CLAIMDENIEDINDICATOR

Claim
Denied
Indicator

Mandatory

An indicator to identify a claim that the state
refused pay in its entirety.

CLAIM-DENIEDINDICATOR

COT00002

CLAIM-HEADERRECORD-OT

X(1)

103

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

191

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

COT137

COT.002.137

COPAYWAIVEDIND

Copayme
nt
Waived
Indicator

Situational

An indicator signifying that the copay was
waived by the provider

COPAY-WAIVEDIND

COT00002

CLAIM-HEADERRECORD-OT

X(1)

104

876

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

COT138

COT.002.138

HEALTHHOMEENTITYNAME

Health
Home
Entity
Name

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-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

192

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

COT140

COT.002.140

THIRDPARTYCOINSURA
NCEAMOUNTPAID

Third
Party
Coinsura
nce
Amount
Paid

Situational

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

THIRDPARTYCOINSURA
NCE-DATEPAID

Third
Party
Coinsura
nce Date
Paid

Conditional

The date the third party paid the coinsurance
amount

N/A

COT00002

CLAIM-HEADERRECORD-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

193

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

COT142

COT.002.142

THIRDPARTYCOPAYMEN
TAMOUNTPAID

Third
Party
Copayme
nt
Amount
Paid

Situational

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

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

THIRDPARTYCOPAYMEN
T-DATEPAID

Third
Party
Copayme
nt Date
Paid

Situational

The date the third party paid the copayment
amount.

N/A

COT00002

CLAIM-HEADERRECORD-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

194

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

COT146

COT.002.146

HEALTHHOMEPROVIDERNPI

Health
Home
Provider
NPI
Number

Conditional

The National Provider ID (NPI) of the health
home provider.

N/A

COT00002

CLAIM-HEADERRECORD-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

MEDICAREBENEFICIA
RYIDENTIFIER

Medicare
Beneficia
ry
Identifier

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(12)

111

979

990

195

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

14. Value must not contain a pipe or asterisk symbols

COT226

COT.002.226

PROVLOCATIONID

Provider
Location
ID

Mandatory

N/A

COT00002

CLAIM-HEADERRECORD-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

196

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

COT230

COT.002.230

TOTBENEFICIA
RYCOPAYMEN
T-LIABLEAMOUNT

Total
Beneficia
ry
Copayme
nt Liable
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

TOTBENEFICIA
RYCOINSURA
NCELIABLEAMOUNT

Total
Beneficia
ry
Coinsura
nce
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-HEADERRECORD-OT

S9(11)V9
9

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

197

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

COT232

COT.002.232

TOTBENEFICIA
RYDEDUCTIBL
E-LIABLEAMOUNT

Total
Beneficia
ry
Deductib
le 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-HEADERRECORD-OT

S9(11)V9
9

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
-BENECOSTSHARINGPAIDAMOUNT

Combine
d
Beneficia
ry Cost
Sharing
Paid
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

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

198

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

COT235

COT.002.235

LTC-RCPLIAB-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-HEADERRECORD-OT

S9(11)V9
9

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

BILLINGPROVADDR-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-HEADERRECORD-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

199

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

COT237

COT.002.237

BILLINGPROVADDR-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-HEADERRECORD-OT

X(60)

119

1121

1180

COT238

COT.002.238

BILLINGPROV-CITY

Billing
Provider
City

Mandatory

Billing provider address city name from X12
837I, 837P, and 837D loop 2010AA.

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(28)

120

1181

1208

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

200

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

COT239

COT.002.239

BILLINGPROVSTATE

Billing
Provider
State
Code

Mandatory

Billing provider address state code from X12
837I, 837P, and 837D loop 2010AA.

STATE

COT00002

CLAIM-HEADERRECORD-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

BILLINGPROV-ZIPCODE

Billing
Provider
ZIP Code

Mandatory

Billing provider address ZIP code from X12 837I,
837P, and 837D loop 2010AA.

ZIP-CODE

COT00002

CLAIM-HEADERRECORD-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

201

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

COT241

COT.002.241

SERVICEFACILITYLOCATIONORG-NPI

Service
Facility
Location
Organiza
tion NPI

Conditional

Service facility location organization NPI from
X12 837I loop 2310E or 837P and 837D loop
2310C.

N/A

COT00002

CLAIM-HEADERRECORD-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

SERVICEFACILITYLOCATIONADDR-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-HEADERRECORD-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

SERVICEFACILITYLOCATIONADDR-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-HEADERRECORD-OT

X(60)

125

1290

1349

202

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

COT244

COT.002.244

SERVICEFACILITYLOCATIONCITY

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-HEADERRECORD-OT

X(28)

126

1350

1377

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

COT245

COT.002.245

SERVICEFACILITYLOCATIONSTATE

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-HEADERRECORD-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

SERVICEFACILITYLOCATIONZIP-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-HEADERRECORD-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

PROVIDERCLAIMFORMCODE

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".

PROVIDERCLAIM-FORMCODE

COT00002

CLAIM-HEADERRECORD-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

PROVIDERCLAIMFORMOTHERTEXT

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-HEADERRECORD-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"

203

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

COT249

COT.002.249

TOT-GMEAMOUNTPAID

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-HEADERRECORD-OT

S9(11)V9
9

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
-PROVNUM-2

Referring
Provider
Number
2

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-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-NPINUM-2

Referring
Provider
NPI
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.
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-HEADERRECORD-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

204

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

COT252

COT.002.252

TOT-SDPALLOWEDAMT

Total
State
Directed
Payment
Allowed
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

134

1494

1506

Coding Requirements

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

205

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

COT253

COT.002.253

TOT-SDPPAID-AMT

Total
State
Directed
Payment
Paid
Amount

Conditional

N/A

COT00002

CLAIM-HEADERRECORD-OT

S9(11)V9
9

135

1507

1519

Coding Requirements

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

206

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

COT152

COT.002.152

STATENOTATION

State
Notation

Situational

A free text field for the submitting state to enter
whatever information it chooses.

N/A

COT00002

CLAIM-HEADERRECORD-OT

X(500)

136

1520

2019

COT154

COT.003.154

RECORD-ID

Record
ID

Mandatory

RECORD-ID

COT00003

CLAIM-LINERECORD-OT

X(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

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

COT00003

CLAIM-LINERECORD-OT

X(2)

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

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

207

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

COT156

COT.003.156

RECORDNUMBER

Record
Number

Mandatory

N/A

COT00003

CLAIM-LINERECORD-OT

9(11)

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

COT157

COT.003.157

MSISIDENTIFICA
TION-NUM

MSIS
Identifica
tion
Number

Mandatory

N/A

COT00003

CLAIM-LINERECORD-OT

X(20)

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

208

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

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-LINERECORD-OT

X(50)

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

Adjustm
ent 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-LINERECORD-OT

X(50)

141

COT160

COT.003.160

LINE-NUMORIG

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-LINERECORD-OT

X(3)

142

144

COT161

COT.003.161

LINE-NUMADJ

Adjustm
ent 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-LINERECORD-OT

X(3)

145

147

COT162

COT.003.162

LINEADJUSTME
NT-IND

Line
Adjustm
ent
Indicator

Conditional

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

LINEADJUSTMENTIND

COT00003

CLAIM-LINERECORD-OT

X(1)

148

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
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

209

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

COT163

COT.003.163

LINEADJUSTME
NTREASONCODE

Line
Adjustm
ent
Reason
Code

Conditional

Claim adjustment reason codes communicate
why a service line was paid differently than it
was billed.

LINEADJUSTMENTREASON-CODE

COT00003

CLAIM-LINERECORD-OT

X(3)

149

151

COT164

COT.003.164

SUBMITTER
-ID

Submitte
r 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-LINERECORD-OT

X(12)

152

163

COT165

COT.003.165

CLAIMLINESTATUS

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-LINERECORD-OT

X(3)

164

166

COT166

COT.003.166

BEGINNING
-DATE-OFSERVICE

Beginnin
g 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-LINERECORD-OT

9(8)

167

174

Coding Requirements

210

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

COT167

COT.003.167

ENDINGDATE-OFSERVICE

Ending
Date of
Service

Mandatory

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

175

182

COT168

COT.003.168

REVENUECODE

Revenue
Code

Conditional

REVENUE-CODE

COT00003

CLAIM-LINERECORD-OT

X(4)

183

186

COT169

COT.003.169

PROCEDUR
E-CODE

Procedur
e Code

Conditional

PROCEDURECODE

COT00003

CLAIM-LINERECORD-OT

X(8)

187

194

Coding Requirements

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
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

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 TMSIS system with State-specific procedure code list,

211

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

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

PROCEDUR
E-CODEDATE

Procedur
e Code
Date

Conditional

The date upon which a reported medical
procedure was performed.

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

195

202

COT171

COT.003.171

PROCEDUR
E-CODEFLAG

Procedur
e Code
Flag

Conditional

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

PROCEDURECODE-FLAG

COT00003

CLAIM-LINERECORD-OT

X(2)

203

204

COT172

COT.003.172

PROCEDUR
E-CODEMOD-1

Procedur
e 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.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

205

206

212

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

COT174

COT.003.174

BILLEDAMT

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 subcapitated 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.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

207

219

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

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

220

232

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

COT175

COT.003.175

ALLOWEDAMT

Allowed
Amount

Conditional

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

Coding Requirements

For sub-capitated encounters from a subcapitated network provider, if the sub-capitated

213

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

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

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

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

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

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

259

271

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

network provider directly employs the provider
that renders the service to the enrollee, report
a null value in this field.

COT176

COT.003.176

BENEFICIA
RYCOPAYMEN
T-PAIDAMOUNT

Beneficia
ry
Copayme
nt Paid
Amount

Conditional

COT177

COT.003.177

TPL-AMT

TPL
Amount

Conditional

COT178

COT.003.178

MEDICAIDPAID-AMT

Medicaid
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.
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.
The amount paid by Medicaid/CHIP agency or
the managed care plan on this claim or
adjustment at the claim detail level. For subcapitated encounters from a sub-capitated
entity that is not a sub-capitated network
provider, report the amount that the sub-

214

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

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.

COT179

COT.003.179

MEDICAIDFFSEQUIVALEN
T-AMT

Medicaid
FFS
Equivale
nt
Amount

Conditional

COT182

COT.003.182

MEDICAREPAID-AMT

Medicare
Paid
Amount

Conditional

COT183

COT.003.183

SERVICEQUANTITYACTUAL

Service
Quantity
Actual

Mandatory

Coding Requirements

4. Value should not be populated or should be equal
to zero, when associated Claim Line Status is in
[542,585,654]\

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

272

284

The amount paid by Medicare on this claim. For
claims where Medicare payment is only
available at the header level, report the entire
payment amount on the T-MSIS claim line with
the highest charge or the 1st non-denied line.
Zero fill Medicare Paid Amount on all other
claim lines.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

285

297

The quantity of a service or product that is
rendered for a specific date of service or billing
time span as reported by revenue code or
procedure code on the claim/encounter line.
For use with CLAIMOT claims. For CLAIMRX
claims/encounters, use the Prescription
Quantity Actual field. For CLAIMIP and CLAIMLT
claims/encounters, use the Revenue Center
Quantity Actual field.

N/A

COT00003

CLAIM-LINERECORD-OT

S9(8)V99
9

298

308

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
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"
1. Value may include up to 8 digits to the left of the
decimal point, and 3 digits to the right e.g.
12345678.999
2. Mandatory

215

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

COT184

COT.003.184

SERVICEQUANTITYALLOWED

Service
Quantity
Allowed

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

S9(8)V99
9

309

319

1. Value may include up to 8 digits to the left of the
decimal point, and 3 digits to the right e.g.
12345678.999
2. Conditional

COT186

COT.003.186

TYPE-OFSERVICE

Type of
Service

Mandatory

The maximum allowable quantity of a service
that may be rendered per date of service or per
month. For use with CLAIMOT
claims/encounters. For CLAIMIP and CLAIMLT
claims/encounters, use the Revenue Center
Quantity Allowed field. NOTE: One prescription
for 100 250 milligram tablets results in Service
Quantity Allowed = 100. This field is only
applicable when the service being billed can be
quantified in discrete units, e.g., a number of
visits or the number of units of a
prescription/refill that were filled. For
prescriptions/refills, use the Medicaid Drug
Rebate definition of a unit, which is the smallest
unit by which the drug is normally measured;
e.g. tablet, capsule, milliliter, etc. For drugs not
identifiable or dispensed by a normal unit, e.g.
powder filled vials, use 1 as the number of
units.
A code to categorize the services provided to a
Medicaid or CHIP enrollee.

TYPE-OFSERVICE-OT

COT00003

CLAIM-LINERECORD-OT

X(3)

320

322

1. Value must be 3 characters.
2. Mandatory
3. Value must be in Type of Service OT List (VVL)
4. When value is not in [025,085], Sex (ELG.002.023)
equals "M"

COT187

COT.003.187

HCBSSERVICECODE

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 longterm care provided in the home and community
setting (e.g. 1915(c), 1915(i), 1915(j), and
1915(k) services).

HCBS-SERVICECODE

COT00003

CLAIM-LINERECORD-OT

X(1)

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

216

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

COT188

COT.003.188

HCBSTAXONOM
Y

HCBS
Taxonom
y

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.

HCBSTAXONOMY

COT00003

CLAIM-LINERECORD-OT

X(5)

324

328

Coding Requirements

1. Value must be 5 characters or less
2. Value must be in HCBS Taxonomy Code List (VVL)
3. Conditional

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

217

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

N/A

COT00003

CLAIM-LINERECORD-OT

X(30)

329

358

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

359

368

1. Value must be 10 digits
2. Value must have an associated Provider Identifier
Type equal to "2"
3. Conditional
4. If Type of Claim (COT.002.037) not in [3,C,W], then
value must match Provider Identifier (PRV.005.081)
5. Value must exist in the NPPES NPI data file

PROVTAXONOMY

COT00003

CLAIM-LINERECORD-OT

X(12)

369

380

1. Value must be 12 characters or less
2. Value must be in Provider Taxonomy List (VVL)
3. Conditional

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.

COT189

COT.003.189

SERVICINGPROV-NUM

Servicing
Provider
Number

Conditional

COT190

COT.003.190

SERVICINGPROV-NPINUM

Servicing
Provider
NPI
Number

Conditional

COT191

COT.003.191

SERVICINGPROVTAXONOM
Y

Servicing
Provider
Taxonom
y

Conditional

Documentation of the HCBS Taxonomy from the
CMS Waiver Management System can be found
here: https://wmsmmdl.cms.gov/WMS/help/TaxonomyCategoryD
efinitions.pdf.
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.
The NPI of the health care professional who
delivers or completes a particular medical
service or non-surgical procedure. The
SERVICING-PROV-NPI-NUM is required when
rendering provider is different than the
attending provider and state or federal
regulatory requirements call for a "combined
claim" (i.e., a claim that includes both facility
and professional components). Examples are
Medicaid clinic bills or critical access hospital
claims.
The taxonomy code for the provider who
treated the recipient.

218

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

COT192

COT.003.192

SERVICINGPROV-TYPE

Servicing
Provider
Type

Conditional

A code to describe the type of provider being
reported.

PROV-TYPE

COT00003

CLAIM-LINERECORD-OT

X(2)

381

382

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

COT193

COT.003.193

SERVICINGPROVSPECIALTY

Servicing
Provider
Specialty

Conditional

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

PROV-SPECIALTY

COT00003

CLAIM-LINERECORD-OT

X(2)

383

384

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

COT194

COT.003.194

OTHERTPLCOLLECTIO
N

Other
TPL
Collectio
n

Mandatory

OTHER-TPLCOLLECTION

COT00003

CLAIM-LINERECORD-OT

X(3)

385

387

1. Value must be 3 characters
2. Value must be in Other TPL Collection List (VVL)
3. Mandatory

COT195

COT.003.195

TOOTHDESIGNATI
ONSYSTEM

Tooth
Designati
on
System

Conditional

TOOTHDESIGNATIONSYSTEM

COT00003

CLAIM-LINERECORD-OT

X(2)

388

389

COT196

COT.003.196

TOOTHNUM

Tooth
Number

Conditional

The tooth number serviced based on the tooth
numbering system identified in the TOOTHDESIGNATION-SYSTEM field.

TOOTH-NUM

COT00003

CLAIM-LINERECORD-OT

X(2)

390

391

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
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

219

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

COT197

COT.003.197

TOOTHQUADCODE

Tooth
Quad
Code

Conditional

The area of the oral cavity is designated by a
two-digit code.

TOOTH-QUADCODE

COT00003

CLAIM-LINERECORD-OT

X(2)

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

TOOTHSURFACECODE

Tooth
Surface
Code

Conditional

A code to identify the tooth's surface on which
the service was performed.

TOOTHSURFACE-CODE

COT00003

CLAIM-LINERECORD-OT

X(1)

394

COT199

COT.003.199

ORIGINATI
ON-ADDRLN1

Originati
on
Address
Line 1

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

395

454

COT200

COT.003.200

ORIGINATI
ON-ADDRLN2

Originati
on
Address
Line 2

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.
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.

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]
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

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

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

ORIGINATI
ON-CITY

Originati
on 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-LINERECORD-OT

X(28)

515

542

1. Value must be 28 characters or less
2. Value must not contain a pipe or asterisk symbols
3. Conditional

220

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

COT202

COT.003.202

ORIGINATI
ON-STATE

Originati
on 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-LINERECORD-OT

X(2)

543

544

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

COT203

COT.003.203

ORIGINATI
ON-ZIPCODE

Originati
on 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-LINERECORD-OT

X(9)

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

221

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

COT204

COT.003.204

DESTINATI
ON-ADDRLN1

Destinati
on
Address
Line 1

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

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

DESTINATI
ON-ADDRLN2

Destinati
on
Address
Line 2

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

614

673

COT206

COT.003.206

DESTINATI
ON-CITY

Destinati
on City

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

X(28)

674

701

COT207

COT.003.207

DESTINATI
ON-STATE

Destinati
on State

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.
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.
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-LINERECORD-OT

X(2)

702

703

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

222

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

COT208

COT.003.208

DESTINATI
ON-ZIPCODE

Destinati
on ZIP
Code

Conditional

ZIP-CODE

COT00003

CLAIM-LINERECORD-OT

X(9)

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

CATEGORYFORFEDERALREIMBURS
EMENT

Category
for
Federal
Reimburs
ement

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

CATEGORY-FORFEDERALREIMBURSEMEN
T

COT00003

CLAIM-LINERECORD-OT

X(2)

713

714

COT213

COT.003.213

OTHERINSURANC
E-AMT

Other
Insuranc
e
Amount

Conditional

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

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

715

727

COT217

COT.003.217

NATIONALDRUGCODE

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-LINERECORD-OT

X(12)

728

739

1. Value must be 12 digits or less
2. Value must be a valid National Drug Code
3. Conditional

223

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

COT227

COT.003.227

PROCEDUR
E-CODEMOD-2

Procedur
e 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.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

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

PROCEDUR
E-CODEMOD-3

Procedur
e 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.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

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

PROCEDUR
E-CODEMOD-4

Procedur
e 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.

PROCEDURECODE-MOD

COT00003

CLAIM-LINERECORD-OT

X(2)

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

ADJUDICAT
ION-DATE

Adjudicat
ion Date

Mandatory

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

N/A

COT00003

CLAIM-LINERECORD-OT

9(8)

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

224

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

COT222

COT.003.222

SELFDIRECTION
-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 decisionmaking authority over how the Medicaid funds
in a budget are spent), or both hiring and
budget authority.

SELF-DIRECTIONTYPE

COT00003

CLAIM-LINERECORD-OT

X(3)

754

756

1. Value must be 3 characters
2. Value must be in Self Direction Type List (VVL)
3. Mandatory

COT223

COT.003.223

PREAUTHORIZ
ATIONNUM

Preautho
rization
Number

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

X(18)

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-UNITOFMEASURE

NDC Unit
of
Measure

Conditional

A code to indicate the basis by which the
quantity of the National Drug Code is
expressed.

NDC-UNIT-OFMEASURE

COT00003

CLAIM-LINERECORD-OT

X(2)

775

776

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

225

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

COT225

COT.003.225

NDCQUANTITY

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-LINERECORD-OT

S9(9)V(9)

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

IHSSERVICEIND

IHS
Service
Indicator

Mandatory

To indicate Services received by Medicaideligible 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-LINERECORD-OT

X(1)

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
-CODEPOINTER-1

Diagnosis
Code
Pointer 1

Mandatory

A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

796

797

1. Value must be numeric
2. Value must be 2 digits or less
3. Value must be between 1 and 12
4. Mandatory

COT287

COT.003.287

DIAGNOSIS
-CODEPOINTER-2

Diagnosis
Code
Pointer 2

Conditional

A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

798

799

COT288

COT.003.288

DIAGNOSIS
-CODEPOINTER-3

Diagnosis
Code
Pointer 3

Conditional

A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

800

801

1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. Conditional
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
-CODEPOINTER-4

Diagnosis
Code
Pointer 4

Conditional

A pointer to the diagnosis code in the order of
importance to this service.

N/A

COT00003

CLAIM-LINERECORD-OT

9(2)

802

803

1. Value must be numeric
2. Value must not be more than 2 digits long
3. Value must be between 1 and 12
4. Conditional

COT255

COT.003.255

UNIQUEDEVICEIDENTIFIER

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-LINERECORD-OT

X(76)

804

879

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

226

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

COT290

COT.003.290

MBESCBESFORMGROUP

MBESCB
ES Form
Group

Conditional

MBESCBESFORM-GROUP

COT00003

CLAIM-LINERECORD-OT

X(1)

880

COT257

COT.003.257

MBESCBESFORM

MBESCB
ES Form

Conditional

MBESCBESFORMGP-1,
MBESCBESFORMGP-2,
MBESCBESFORMGP-3

COT00003

CLAIM-LINERECORD-OT

X(50)

881

930

COT256

COT.003.256

MBESCBESCATEGORYOF-SERVICE

MBESCB
ES
Category
of
Service

Conditional

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

COT00003

CLAIM-LINERECORD-OT

X(5)

931

935

227

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

COT258

COT.003.258

SERVICEFACILITYLOCATIONORG-NPI

Service
Facility
Location
Organiza
tion NPI

Conditional

Service facility location organization NPI from
X12 837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

936

945

COT259

COT.003.259

SERVICEFACILITYLOCATIONADDR-LN-1

Service
Facility
Location
Address
Line 1

Conditional

Service facility location address line 1 from X12
837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(60)

946

1005

COT260

COT.003.260

SERVICEFACILITYLOCATIONADDR-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-LINERECORD-OT

X(60)

1006

1065

Coding Requirements

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

228

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

COT261

COT.003.261

SERVICEFACILITYLOCATIONCITY

Service
Facility
Location
City

Conditional

Service facility location address city name from
X12 837P loop 2420C and 837D loop 2420D.

N/A

COT00003

CLAIM-LINERECORD-OT

X(28)

1066

1093

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

COT262

COT.003.262

SERVICEFACILITYLOCATIONSTATE

Service
Facility
Location
State

Conditional

Service facility location address state code from
X12 837P loop 2420C and 837D loop 2420D.

STATE

COT00003

CLAIM-LINERECORD-OT

X(2)

1094

1095

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

COT263

COT.003.263

SERVICEFACILITYLOCATIONZIP-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-LINERECORD-OT

X(9)

1096

1104

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

COT264

COT.003.264

PLACE-OFSERVICE

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

PLACE-OFSERVICE

COT00003

CLAIM-LINERECORD-OT

X(2)

1105

1106

1. Value must not be more than 2 characters
2. Value must be in Place of Service Code List (VVL)
3. Conditional
4. if value is populated, then Revenue Code must be
null

229

Data
Element
Number

System
Data
Element
Number

Data
Element

Data
Element
Name
Text

Data
Element
Necessity

COT265

COT.003.265

GMEAMOUNTPAID

GME
Amount
Paid

Conditional

COT266

COT.003.266

REFERRING
-PROVNUM

Referring
Provider
Number

Conditional

COT267

COT.003.267

REFERRING
-PROV-NPINUM

Referring
Provider
NPI
Number

Conditional

Definition

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.
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.
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.
The National Provider ID (NPI) of the provider
who recommended the servicing provider to
the patient.

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

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

1107

1119

N/A

COT00003

CLAIM-LINERECORD-OT

X(30)

1120

1149

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

1150

1159

Coding Requirements

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

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

230

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

COT268

COT.003.268

REFERRING
-PROVNUM-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-LINERECORD-OT

X(30)

1160

1189

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

COT269

COT.003.269

REFERRING
-PROV-NPINUM-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-LINERECORD-OT

X(10)

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

231

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

COT270

COT.003.270

ORDERINGPROV-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-LINERECORD-OT

X(30)

1200

1229

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

COT271

COT.003.271

ORDERINGPROV-NPINUM

order
Provider
NPI
Number

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

X(10)

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

232

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

COT272

COT.003.272

SDPALLOWEDAMT

State
Directed
Payment
Allowed
Amount

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

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-PAIDAMT

State
Directed
Payment
Paid
Amount

Conditional

N/A

COT00003

CLAIM-LINERECORD-OT

S9(11)V9
9

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

STATENOTATION

State
Notation

Situational

A free text field for the submitting state to enter
whatever information it chooses.

N/A

COT00003

CLAIM-LINERECORD-OT

X(500)

1266

1765

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

233

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

COT274

COT.004.274

RECORD-ID

Record
ID

Mandatory

RECORD-ID

COT00004

CLAIM-DX-OT

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "COT00004"

COT275

COT.004.275

SUBMITTIN
G-STATE

Submitti
ng State

Mandatory

STATE

COT00004

CLAIM-DX-OT

X(2)

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

COT276

COT.004.276

RECORDNUMBER

Record
Number

Mandatory

N/A

COT00004

CLAIM-DX-OT

9(11)

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

COT277

COT.004.277

ICN-ORIG

Original
ICN

Mandatory

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)

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

Adjustm
ent 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)

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

234

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

4. Conditional
5. If associated Adjustment Indicator value equals "4",
then value must be populated
COT279

COT.004.279

ADJUSTME
NT-IND

Adjustm
ent
Indicator

Mandatory

Indicates the type of adjustment record.

ADJUSTMENTIND

COT00004

CLAIM-DX-OT

X(1)

122

COT280

COT.004.280

ADJUDICAT
ION-DATE

Adjudicat
ion Date

Mandatory

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

N/A

COT00004

CLAIM-DX-OT

9(8)

123

130

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)

131

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)
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
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

235

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

COT282

COT.004.282

DIAGNOSIS
SEQUENCENUMBER

Diagnosis
Sequenc
e
Number

Mandatory

N/A

COT00004

CLAIM-DX-OT

9(2)

132

133

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

COT283

COT.004.283

DIAGNOSIS
-CODEFLAG

Diagnosis
Code
Flag

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

DIAGNOSISCODE-FLAG

COT00004

CLAIM-DX-OT

X(1)

134

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

COT284

COT.004.284

DIAGNOSIS
-CODE

Diagnosis
Code

Mandatory

DIAGNOSISCODE

COT00004

CLAIM-DX-OT

X(7)

135

141

COT285

COT.004.285

STATENOTATION

State
Notation

Situational

N/A

COT00004

CLAIM-DX-OT

X(500)

142

641

236

T-MSIS Data Dictionary – CRX File
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

RECORD-ID

CRX00001

FILE-HEADERRECORD-RX

X(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

DATADICTIONARY
-VERSION

Data
Dictionar
y Version

Mandatory

A data element to capture the version of the TMSIS data dictionary that was used to build the
file.

DATADICTIONARYVERSION

CRX00001

FILE-HEADERRECORD-RX

X(10)

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

237

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

CRX003

CRX.001.003

SUBMISSIO
NTRANSACTI
ON-TYPE

Submissi
on
Transacti
on 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.

SUBMISSIONTRANSACTIONTYPE

CRX00001

FILE-HEADERRECORD-RX

X(1)

1. Value must be 1 character
2. Value must be in Subcapitation Indicator List (VVL)
3. Mandatory

CRX004

CRX.001.004

FILEENCODINGSPECIFICATI
ON

File
Encoding
Specifica
tion

Mandatory

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

FILE-ENCODINGSPECIFICATION

CRX00001

FILE-HEADERRECORD-RX

X(3)

1. Value must be 3 characters
2. Value must be in File Encoding Specification List
(VVL)
3. Mandatory

CRX005

CRX.001.005

DATAMAPPINGDOCUMENT
-VERSION

Mandatory

Identifies the version of the T-MSIS data
mapping document used to build a state
submission file.

N/A

CRX00001

FILE-HEADERRECORD-RX

X(9)

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

CRX006

CRX.001.006

FILE-NAME

Data
Mapping
Docume
nt
Version
File
Name

Mandatory

N/A

CRX00001

FILE-HEADERRECORD-RX

X(8)

1. Value must equal "CLAIM-RX"
2. Mandatory

CRX007

CRX.001.007

SUBMITTIN
G-STATE

Submitti
ng 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-HEADERRECORD-RX

X(2)

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

238

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

CRX008

CRX.001.008

DATE-FILECREATED

Date File
Created

Mandatory

The date on which the file was created.

N/A

CRX00001

FILE-HEADERRECORD-RX

9(8)

CRX009

CRX.001.009

START-OFTIMEPERIOD

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-HEADERRECORD-RX

9(8)

CRX010

CRX.001.010

END-OFTIMEPERIOD

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-HEADERRECORD-RX

9(8)

CRX011

CRX.001.011

FILESTATUSINDICATOR

File
Status
Indicator

Mandatory

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

FILE-STATUSINDICATOR

CRX00001

FILE-HEADERRECORD-RX

X(1)

CRX012

CRX.001.012

SSNINDICATOR

SSN
Indicator

Mandatory

SSN-INDICATOR

CRX00001

FILE-HEADERRECORD-RX

X(1)

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

239

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

CRX013

CRX.001.013

TOT-RECCNT

Total
Record
Count

Mandatory

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

N/A

CRX00001

FILE-HEADERRECORD-RX

9(11)

CRX155

CRX.001.155

SEQUENCENUMBER

Sequenc
e
Number

Mandatory

N/A

CRX00001

FILE-HEADERRECORD-RX

X(4)

CRX014

CRX.001.014

STATENOTATION

State
Notation

Situational

N/A

CRX00001

FILE-HEADERRECORD-RX

X(500)

582

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

CRX016

CRX.002.016

RECORD-ID

Record
ID

Mandatory

RECORD-ID

CRX00002

CLAIM-HEADERRECORD-RX

X(8)

1. Value must be 8 characters
2. Mandatory
3. Value must be in Record ID List (VVL)
4. Value must equal "CRX00002"

240

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

CRX017

CRX.002.017

SUBMITTIN
G-STATE

Submitti
ng 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-HEADERRECORD-RX

X(2)

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

CRX018

CRX.002.018

RECORDNUMBER

Record
Number

Mandatory

N/A

CRX00002

CLAIM-HEADERRECORD-RX

9(11)

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

CRX019

CRX.002.019

ICN-ORIG

Original
ICN

Mandatory

N/A

CRX00002

CLAIM-HEADERRECORD-RX

X(50)

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

Adjustm
ent 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-HEADERRECORD-RX

X(50)

121

CRX021

CRX.002.021

SUBMITTERID

Submitte
r 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-HEADERRECORD-RX

X(12)

122

133

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

241

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

CRX022

CRX.002.022

MSISIDENTIFICAT
ION-NUM

MSIS
Identifica
tion
Number

Mandatory

N/A

CRX00002

CLAIM-HEADERRECORD-RX

X(20)

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

Crossove
r
Indicator

Mandatory