Type of Service Reference

Definitions of Type of Service (TOS)

The following definitions are adaptations of those given in the Code of Federal Regulations. These definitions, although abbreviated, are intended to facilitate the classification of medical care and services for reporting purposes. They do not modify any requirements of the Act or supersede in any way the definitions included in the Code of Federal Regulations (CFR).

Effective FY 1999, services provided under Family Planning, EPSDT, Rural Health Clinics, FQHC’s, and Home-and-Community-Based Waiver programs will be coded according to the types of services listed below. Specific programs with which these services are associated will be identified using the program type coding as defined in Attachment 5.

1. Unduplicated Total.--Report the unduplicated total of recipients by maintenance assistance status (MAS) and by basis of eligibility (BOE). A recipient receiving more than one type of service is reported only once in the unduplicated total.

Facilities

2. Inpatient Hospital Services (TOS Code=001) These are services that are:

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

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

Furnished in an institution that:

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

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

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

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

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

3. Mental Health Facility Services (See 42 CFR § 440.140 , 440.160 , and 435.1009).--An institution for mental health conditions is a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment or care of individuals with mental health conditions, including medical care, nursing care, and related services. Report totals for services defined under 3a and 3b.

3a. Inpatient Psychiatric Facility Services for Individuals Age 21 and Under (TOS Code=048). These are services that:

3b. Other Mental Health Facility Services (Individuals Age 65 or Older) (TOS Code= 044 and 045) These are services provided under the direction of a physician for the care and treatment of recipients in an institution for mental health conditions that meets the requirements specified in 42 CFR § 440.140.

Nursing Facilities (NF) Services (TOS Code=009 and 047) These are services provided in an institution (or a distinct part of an institution) which:

Is primarily engaged in providing to residents:

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

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

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

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

- Requirements relating to provision of services;

- Requirements relating to residents’ rights; and

- Requirements relating to administration and other matters.

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

5. ICF Services for the Intellectually Disabled (TOS Code=046) (See 42 CFR § 440.150).--These are services provided in an institution for individuals with intellectual disabilities persons or persons with related conditions if the:

Services

6. Physicians' Services (TOS Code=012).--Whether furnished in a physician's office, a recipient's home, a hospital, a NF, or elsewhere, these are services provided:

7. Outpatient Hospital Services (TOS Codes=002) These are preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are furnished:

8. Prescribed Drugs (TOS Code=033) These are simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance that are:

9. Dental Services (TOS Code=029) These are diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist in the practice of his or her profession, including treatment of:

- The teeth and associated structures of the oral cavity; and

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

A dentist is an individual licensed to practice dentistry or dental surgery. Dental services include dental screening and dental clinic services.

NOTE: Include services related to providing and fitting dentures as dental services. Dentures mean artificial structures made by, or under the direction of, a dentist to replace a full or partial set of teeth.

Dental services do not include services provided as part of inpatient hospital, outpatient hospital, non-dental clinic, or laboratory services and billed by the hospital, non‑dental clinic, or laboratory or services which meet the requirements of 42 CFR 440.50(b) (i.e., are provided by a dentist but may be provided by either a dentist or physician under State law).

Other Services

10. Other Licensed Practitioners' Services (TOS Code=015) These are medical or remedial care or services, other than physician services or services of a dentist, provided by licensed practitioners within the scope of practice as defined under State law. The category “Other Licensed Practitioners' Services” is different than the “Other Care” category. Examples of other practitioners (if covered under State law) are:
- Chiropractors;
- Podiatrists;
- Psychologists; and
- Optometrists.

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

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

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

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

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

11. Clinic Services (TOS Code=028) Clinic services include preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that are provided:

- To outpatients;

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

- Except in the case of nurse-midwife services (see 42 CFR 440.165), are furnished by, or under, the direction of a physician.

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

12. Laboratory and X-Ray Services (TOS Code=005, 006, 007, and 008) These are professional or technical laboratory and radiological services that are:

13. Sterilizations (TOS Code=084) These are medical procedures, treatment or operations for the purpose of rendering an individual permanently incapable of reproducing.

14. Home Health Services (TOS Code=016, 017, 018, 019, 020 and 021) These are services provided at the patient's place of residence, in compliance with a physician's written plan of care that is reviewed every 62 days. The following items and services are mandatory.

15. Personal Support Services.--Report total unduplicated recipients and payments for services defined in 15a through 15i.

15a. Personal Care Services (TOS Code=051).--These are services furnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or institution for mental health conditions that are:

15b. Targeted Case Management Services (TOS Code=053) These are services that are furnished to individuals eligible under the plan to gain access to needed medical, social, educational, and other services. The agency may make available case management services to:

15c. Rehabilitative Services (TOS Code=043)--These include any medical or remedial services recommended by a physician or other licensed practitioner of the healing arts within the scope of his/her practice under State law for maximum reduction of physical or mental health condition and restoration of a recipient to his/her best possible functional level.

15d. Physical Therapy, Occupational Therapy, and Services For Individuals with Speech, Hearing, and Language Disorders (TOS Codes=030, 031, and 032). These are services prescribed by a physician or other licensed practitioner within the scope of his or her practice under State law and provided to a recipient by, or under the direction of, a qualified physical therapist, occupational therapist, speech pathologist, or audiologist. It includes any necessary supplies and equipment.

15e. Hospice Services (TOS Code=087) whether received in a hospice facility or elsewhere, these are services that are:

15f. Nurse Midwife (TOS Code=025).--These are services that are concerned with management and the care of mothers and newborns throughout the maternity cycle and are furnished within the scope of practice authorized by State law or regulation.

15g. Nurse Practitioner (TOS Code=026). These are services furnished by a registered professional nurse who meets State’s advanced educational and clinical practice requirements, if any, beyond the 2 to 4 years of basic nursing education required of all registered nurses.

15h. Private Duty Nursing (TOS Code=022). When covered in the State plan, these are services of registered nurses or licensed practical nurses provided under direction of a physician to recipients in their own homes, hospitals or nursing facilities (as specified by the State).

15i. Religious Non-Medical Health Care Institutions (TOS Code=058). These are non-medical health care services equivalent to a hospital or extended care level of care provided in facilities that meet the requirements of Section 1861(ss)(1) of the Act.

Other Care

16. Other Care--Report total unduplicated recipients and payments for services in sections 16a, 16b, and 16c. Such services do not meet the definition of, and are not classified under, any of the previously described categories.

16a. Transportation (TOS Code=056)--Report totals for services provided under this title to include transportation and other related travel services determined necessary by you to secure medical examinations and treatment for a recipient.

NOTE: Transportation, as defined above, is furnished only by a provider to whom a direct vendor payment can appropriately be made. If other arrangements are made to assure transportation under 42 CFR 431.53, FFP is available as an administrative cost.

16b. Other Pregnancy-related Procedures (TOS Code=086). In accordance with the terms of the DHHS Appropriations Bill and 42 CFR 441, Subpart E, FFP is available for other pregnancy-related procedures:

16c. Other Services (TOS Code= 035, 036, 037, 062, 063, 064, 065, 066, 067, 068, 069, 073, 074, 075, 076, 077, 078, 079, 080, 081, 082, 083).--These services do not meet the definitions of any of the previously described service categories. They may include, but are not limited to:

Prosthetic devices, which are replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of practice as defined by State law to:

17. Capitated Care -- This includes enrollees and capitated payments for the plan types defined in 17a and b below. Report unduplicated enrolled eligible and payments for 17a and b.

17a. Health Maintenance Organization (HMO) and Health Insuring Organization (HIO) (TOS Code=119).--These include plans contracted to provide capitated comprehensive services. An HMO is a public or private organization that contracts on a prepaid capitated risk basis to provide a comprehensive set of services and is federally qualified or State-plan defined. An HIO is an entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

17b. Prepaid Health Plans (PHP) (TOS Code=122).--These include plans that are contracted to provide less than comprehensive services. Under a non-risk or risk arrangement, the State may contract with (but not limited to these entities) a physician, physician group, or clinic for a limited range of services under capitation. A PHP is an entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis or the entity provides comprehensive services on a non-risk basis.

NOTE: Include dental, mental health, and other plans covering limited services under PHP.

18. Primary Care Case Management (PCCM) (TOS Code=120)--The State contracts directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care physician a monthly case management fee. Report these recipients and associated PCCM fees in this section.

NOTE: Where the fee includes services beyond case management, report the enrollees and fees under prepaid health plans (17b).

19. COVID-19 Testing (See §1902(a)(10)(G) of the act). --This includes in vitro diagnostic products for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19, and any visit for COVID-19 testing-related services for which payment may be made under the State plan.

19a. COVID-19 Testing (TOS Code 136) should be reported for any COVID-19 diagnostic product that is administered during any portion of the emergency period, beginning March 18, 2020, to an uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testing-related services.

19b. COVID-19 Testing-Related Services (TOS Code 137) should be reported for any COVID-19 testing-related services provided to an uninsured individual who receives limited Medicaid coverage for COVID-19 testing and testing-related services for which payment may be made under the State plan.

20. Medication Assisted Treatment (MAT) services and drugs for evidenced-based treatment of Opioid Use Disorder (OUD) (TOS 145) (§1905(a)(29) of the Social Security Act) Effective October 1, 2020, state Medicaid programs are required to provide coverage of Medication Assisted Treatment (MAT) services and drugs under a new mandatory benefit. The SUPPORT Act of 2018 (P.L. 115-271) amended the Social Security Act (the Act) to add this new mandatory benefit. The purpose of the new mandatory MAT benefit found at section 1905(a)(29) of the Act is to increase access to evidenced-based treatment for Opioid Use Disorder (OUD) for all Medicaid beneficiaries and to allow patients to seek the best course of treatment and particular medications that may not have been previously covered. CMS interprets sections 1905(a)(29) and 1905(ee) of the Act to require that, as of October 1, 2020, states must include as part of the new MAT mandatory benefit all forms of drugs and biologicals that the Food and Drug Administration (FDA) has approved or licensed for MAT to treat OUD. More specifically, under the new mandatory MAT benefit, states are required to cover such FDA approved or licensed drugs and biologicals used for indications for MAT to treat OUD. States currently cover many of these MAT drugs and biologicals (for all medically-accepted indications) under the optional benefit for prescribed drugs described at section 1905(a)(12) of the Act

Program Type Reference

Definitions of Program Type Reference

The following definitions describe special Medicaid/CHIP programs that are coded independently of type of service for MSIS purposes. These programs tend to cover bands of services that cut across many types of service.

Program Type 1-3

Program Type 4-5

Program Type 7, 8 & 10

Program Type 11-13

Program Type 14

Program Type 15-16

Program Type 17

Eligibility Group Reference

MEDICAID MANDATORY COVERAGE

MEDICAID OPTIONS FOR COVERAGE

MEDICAID MEDICALLY NEEDY

CHIP COVERAGE

CHIP ADDITIONAL OPTIONS FOR COVERAGE

1115 EXPANSION ELIGIBILITY GROUPS

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

Submitting Adjustment Claims to T-MSIS

Brief Issue Description

There are two ways original claims, and their subsequent adjustments can be linked into a claim family - either through all adjustments linking back to the original claim or each subsequent adjustment linking back to the prior claim (i.e., “daisy chain”). Identifying the members of a claim family is necessary to evaluate the changes to a claim that occur throughout its life.

Background Discussion

Before delving into CMS' guidance on how to populate the ICN-ORIG and ICN-ADJ fields, some background discussion is needed on terminology and concepts.

What claim transactions should be submitted to T-MSIS?

Every "final” adjudicated version of the claim/encounter should be submitted to T-MSIS.

A "final” adjudicated version of the claim/encounter is a claim that has completed the adjudication process and the paid/denied process. The claim and each claim line will have one of the finalized claim status categories listed in Table 1, below. The actual disposition of the claim can be either "paid" or "denied".

Both original claims (or encounters) and adjusted claims (or encounters) can be a "final adjudicated version of the claim/encounter." Whenever a claim/encounter flows through the adjudication and payment processes (if applicable) and falls into one of the claim status categories in Table 1, the state should send the claim/encounter to T-MSIS.

If a claim flows through the adjudication and payment processes and falls into one of the finalized claim status categories multiple times within a single T-MSIS reporting period, CMS expects each of these final adjudicated versions of the claim/encounter to be submitted to T-MSIS, not just the one effective on the last day of the reporting period.

If the claim has not been through the final adjudication process or is "pending" (or in "suspense"), the claim should not be sent to T-MSIS until disposition has been settled to one of the finalized claim status categories. Table 2 provides examples and CMS' expectations.

What is a claim family?

A "claim family" (a.k.a. "adjustment set") is defined as a set of post-adjudication claim transactions in paid or denied status that relate to the same provider/enrollee/services/dates of service. This grouping of the original claim and all its subsequent adjustment and/or void claims shows the progression of changes that have occurred since it was first submitted.

Are there transactions impacting the cost of care that are not claims/encounters and therefore not subsect to the claims family algorithm?

In previous iterations of T-MSIS, the claim files were also used to capture expenditures that impacted the cost of care, but which were not technically claims or encounter records. These were referred to as “gross adjustments” and caused issues for states who were trying to build the T-MSIS Claim Files as well as problems for downstream users trying to interpret the T-MSIS data. These transactions have now been split out of the claims data files and put into their own file type. There are currently nine distinct types of financial transactions:

FTX002 – Individual Capitation PMPM,

FTX003 – Individual Health Insurance Premium Payment,

FTX004 – Group Insurance Premium Payment,

FTX005 – Cost Sharing Offset,

FTX006 – Value-Based Payment,

FTX007 – State-Directed Payment,

FTX008 – Cost Settlement Payment,

FTX009 - FQHC Wrap Payment and

FTX095 - Miscellaneous Payment.

As additional types of financial transactions are identified, new record layouts will be created and incorporated into the Financial Transaction File.

The concept of a “claim family” does not apply to financial transactions. Each of these transactions stands on its own and does not constitute a subsequent transaction that replaces the earlier transaction. In essence, a given series of financial transactions of the same type making payment to or recoupment from a given payee are additive. Each transaction remains active in the T-MSIS database. Whereas only the most recent member of a claim in a claim family is active. (The superseded members of the claim family are all inactive.)

For instance, a state pays a managed care entity a monthly capitation for 1,000 enrollees for the month of May, 2024. In June 2024, it is determined that 5 of the enrollees included in the May 2024 capitation were, in fact, not enrolled with the MCO. Rather than generating an adjustment transaction for the May 2024 capitation that reflects 995 enrollees, and which would need to be tied to the previous transaction through “claim family” logic, the June, 2024 capitation payment would be adjusted to reflect the recoupment of the capitation payment for the 5 enrollees paid erroneously to the MCO.

What alternatives are there for tying the members of a claim family together?

The Original ICN Approach

Under this approach, the state assigns an ICN to the initial final adjudicated version of the claim/encounter and records this identifier in the ICN-ORIG field. If adjustment claims subsequently are created, the ICN assigned to the initial final adjudicated version of the claim/encounter is carried forward on every subsequent adjustment claim. Table 3 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated when the original ICN approach is used.

The Daisy-Chain ICN Approach

Under this approach, the state records the ICN of the previous final adjudicated version of the claim/encounter in the ICN-ORIG field of the adjustment claim record. If additional adjustment claims are subsequently created, the ICN-ORIG on the new adjustment claim only points back one generation. Table 4 illustrates how the ICN-ORIG and ICN-ADJ values on the members of a claim family are populated when the daisy-chain ICN approach is used.

How are ICN-ORIG and ICN-ADJ fields impacted when voids are submitted?

The primary purpose of void transactions (ADJUSTMENT-IND = 1) is to nullify a claim/encounter from T-MSIS when the state does not wish to replace it with an adjusted claim/encounter record. These records must have the same claim key data element values as the claim/encounter being voided. Dollar and quantity fields should be set to zero. There can be instances where a state populates these fields with a negative value or the original transaction amount. The ADJUDICATION-DATE on these records should be set to the date that the state voided the claim.

Refer to T-MSIS Coding Blog entry "Populating T-MSIS Claims File Data Elements on Void/Reversal/Cancel Records" for additional detailed information.

Table 5 illustrates an example of how the dollar and quantity fields on the members of a claim family are populated when the state wishes to void a claim.

If a state uses a process to record adjustments whereby, they void the previous version of the claim and then follow-up with the creation of a new original transaction, and the state can identify that the void and the new original claim are from the same adjudication set, the state should link them together into one claims family using the ICN-ORIG. CMS recognizes that some states may not be able to link a resubmitted claim after a void to the original claim. Table 6 illustrates how CMS is expecting the states to populate the ICN-ORIG/ICN-ADJ fields when the state processes a void/new original when adjusting claims.

How Adjustment Records will be Applied by CMS

There is an inherent limitation in the way that CMS can interpret what to do with two claim transactions having the same ICN-ORIG and ADJUDICATION-DATE when both transactions are received in a single submission file. The processing rules that T-MSIS will follow are outlined below. It is up to each state to ensure that claim transactions are processed in the appropriate sequence. If the rules below do not result in the sequence of transactions that the state desires, it is up to the state to submit transactions in separate files so that the desired sequence is attained.

Rules for inserting claim transactions into the T-MSIS database

The following five data elements identify a particular claim transaction (i.e., this is the claim key):

1) submitting_state

2) icn_orig

3) icn_adj

4) adjudication_date

5) adjustment_ind

In the “daisy-chain” claims family algorithm, T-MSIS uses the explicit ordering of the chain to set the sequence number for each claim in a family.

In the "original ICN" claims family algorithm, T-MSIS uses the claim with a null ICN-ADJ value as the root claim for the family. For subsequent claims, T-MSIS sorts by the following fields, in order:

1) ADJUDICATION-DATE

2) MEDICAID-PAID-DATE

3) CHECK-EFF-DATE

Within the T-MSIS system, claim family IDs are composed of the hash of the ANSI submitting state id, file type, reporting period, sequence number, and byte offset of the claim in the family from the earliest (by date received) file and with the lowest byte offset within that file. Inactive versions of claims in the claims family (that is inactive records with the same record key as any of the active claims that compose the claims family) are included in the set of claims considered for generation of the claims family id. This ensures that even if the claim that is used to generate a claims family's ID is subsequently updated, the claims family's ID will remain stable.

If two claim transactions have the same key, the active instance is determined by evaluating these data elements:

1) claim_header_reporting_period

2) claim_header_byte_offset

3) submitting_state

4) tms_run_id

Ties based on the above fields are broken by sorting on (a) reporting period of the file containing the claim, (b) sequence number of the file, and (c) byte offset of the claim within the file.

CMS Guidance

The state can use either the original ICN approach or the daisy-chain ICN approach to populate the ICN-ORIG field on each member of the claims family.

T-MSIS will group claim transactions into claim families as part of the ETL process.