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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

Data Elements

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DE Number System DE Number Data Element Definition Valid Values File Segment Number File Segment Name
CIP001 CIP.001.001 RECORD-ID 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.). CIP001 Values CIP00001 FILE-HEADER-RECORD-IP
CIP002 CIP.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. CIP002 Values CIP00001 FILE-HEADER-RECORD-IP
CIP003 CIP.001.003 SUBMISSION-TRANSACTION-TYPE 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. CIP003 Values CIP00001 FILE-HEADER-RECORD-IP
CIP004 CIP.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. CIP004 Values CIP00001 FILE-HEADER-RECORD-IP
CIP005 CIP.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A CIP00001 FILE-HEADER-RECORD-IP
CIP006 CIP.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A CIP00001 FILE-HEADER-RECORD-IP
CIP007 CIP.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CIP007 Values CIP00001 FILE-HEADER-RECORD-IP
CIP008 CIP.001.008 DATE-FILE-CREATED The date on which the file was created. N/A CIP00001 FILE-HEADER-RECORD-IP
CIP009 CIP.001.009 START-OF-TIME-PERIOD This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. N/A CIP00001 FILE-HEADER-RECORD-IP
CIP010 CIP.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A CIP00001 FILE-HEADER-RECORD-IP
CIP011 CIP.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. CIP011 Values CIP00001 FILE-HEADER-RECORD-IP
CIP012 CIP.001.012 SSN-INDICATOR 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. CIP012 Values CIP00001 FILE-HEADER-RECORD-IP
CIP013 CIP.001.013 TOT-REC-CNT A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. N/A CIP00001 FILE-HEADER-RECORD-IP
CIP275 CIP.001.275 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A CIP00001 FILE-HEADER-RECORD-IP
CIP014 CIP.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CIP00001 FILE-HEADER-RECORD-IP
CIP016 CIP.002.016 RECORD-ID 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.). CIP016 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP017 CIP.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CIP017 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP018 CIP.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP019 CIP.002.019 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP020 CIP.002.020 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP021 CIP.002.021 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP022 CIP.002.022 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP023 CIP.002.023 CROSSOVER-INDICATOR An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. CIP023 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP024 CIP.002.024 TYPE-OF-HOSPITAL This code denotes the type of hospital on the claim (servicing facility). CIP024 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP025 CIP.002.025 1115A-DEMONSTRATION-IND 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. CIP025 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP026 CIP.002.026 ADJUSTMENT-IND Indicates the type of adjustment record. CIP026 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP027 CIP.002.027 ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a claim was paid differently than it was billed. CIP027 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP028 CIP.002.028 ADMISSION-TYPE The basic types of admission for Inpatient hospital stays and a code indicating the priority of this admission. CIP028 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP029 CIP.002.029 DRG-DESCRIPTION Description of the associated state-specific DRG code. If using standard MS-DRG classification system, leave blank. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP068 CIP.002.068 DIAGNOSIS-RELATED-GROUP A code representing the Diagnosis Related Group (DRG) that is applicable for the inpatient services being rendered. This field is required on FFS claims and encounters records in which diagnosis related groups are used to determine paid amounts. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP069 CIP.002.069 DIAGNOSIS-RELATED-GROUP-IND An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values.Values are generated by combining two types of information: Position 1-2, State/Group generating DRG: If state specific system, fill with two digit US postal code representation for state. If CMS Grouper, fill with 'HG'. If any other system, fill with 'XX'. Position 3-4, fill with the number that represents the DRG version used (01-98). For example, 'HG15' would represent CMS Grouper version 15. If version is unknown, fill with '99'. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP070 CIP.002.070 PROCEDURE-CODE-1 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. CIP070 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP072 CIP.002.072 PROCEDURE-CODE-FLAG-1 A flag that identifies the coding system used for an associated procedure code. CIP072 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP073 CIP.002.073 PROCEDURE-CODE-DATE-1 The date upon which a reported medical procedure was performed. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP074 CIP.002.074 PROCEDURE-CODE-2 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. CIP074 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP076 CIP.002.076 PROCEDURE-CODE-FLAG-2 A flag that identifies the coding system used for an associated procedure code. CIP076 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP077 CIP.002.077 PROCEDURE-CODE-DATE-2 The date upon which a reported medical procedure was performed. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP078 CIP.002.078 PROCEDURE-CODE-3 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. CIP078 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP080 CIP.002.080 PROCEDURE-CODE-FLAG-3 A flag that identifies the coding system used for an associated procedure code. CIP080 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP081 CIP.002.081 PROCEDURE-CODE-DATE-3 The date upon which a reported medical procedure was performed. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP082 CIP.002.082 PROCEDURE-CODE-4 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. CIP082 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP084 CIP.002.084 PROCEDURE-CODE-FLAG-4 A flag that identifies the coding system used for an associated procedure code. CIP084 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP085 CIP.002.085 PROCEDURE-CODE-DATE-4 The date upon which a reported medical procedure was performed. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP086 CIP.002.086 PROCEDURE-CODE-5 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. CIP086 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP088 CIP.002.088 PROCEDURE-CODE-FLAG-5 A flag that identifies the coding system used for an associated procedure code. CIP088 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP089 CIP.002.089 PROCEDURE-CODE-DATE-5 The date upon which a reported medical procedure was performed. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP090 CIP.002.090 PROCEDURE-CODE-6 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. CIP090 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP092 CIP.002.092 PROCEDURE-CODE-FLAG-6 A flag that identifies the coding system used for an associated procedure code. CIP092 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP093 CIP.002.093 PROCEDURE-CODE-DATE-6 The date upon which a reported medical procedure was performed. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP094 CIP.002.094 ADMISSION-DATE The date on which the recipient was admitted to a hospital. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP095 CIP.002.095 ADMISSION-HOUR The hour of admission to a hospital. CIP095 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP096 CIP.002.096 DISCHARGE-DATE The date on which the recipient was discharged from a hospital. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP097 CIP.002.097 DISCHARGE-HOUR The hour of discharge from a hospital. CIP097 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP098 CIP.002.098 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP099 CIP.002.099 MEDICAID-PAID-DATE The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP100 CIP.002.100 TYPE-OF-CLAIM A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C'or an S-CHIP sub-capitated encounter record. CIP100 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP101 CIP.002.101 TYPE-OF-BILL 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.) CIP101 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP102 CIP.002.102 CLAIM-STATUS 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. CIP102 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP103 CIP.002.103 CLAIM-STATUS-CATEGORY 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. CIP103 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP104 CIP.002.104 SOURCE-LOCATION The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. CIP104 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP105 CIP.002.105 CHECK-NUM The check or electronic funds transfer number. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP106 CIP.002.106 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP108 CIP.002.108 CLAIM-PYMT-REM-CODE-1 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). CIP108 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP109 CIP.002.109 CLAIM-PYMT-REM-CODE-2 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). CIP109 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP110 CIP.002.110 CLAIM-PYMT-REM-CODE-3 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). CIP110 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP111 CIP.002.111 CLAIM-PYMT-REM-CODE-4 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). CIP111 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP112 CIP.002.112 TOT-BILLED-AMT The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP113 CIP.002.113 TOT-ALLOWED-AMT The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP114 CIP.002.114 TOT-MEDICAID-PAID-AMT The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP116 CIP.002.116 TOT-MEDICARE-DEDUCTIBLE-AMT 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-HEADER-RECORD-IP
CIP117 CIP.002.117 TOT-MEDICARE-COINS-AMT 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-HEADER-RECORD-IP
CIP118 CIP.002.118 TOT-TPL-AMT 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-HEADER-RECORD-IP
CIP119 CIP.002.119 TOT-OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP121 CIP.002.121 OTHER-INSURANCE-IND The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. CIP121 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP122 CIP.002.122 OTHER-TPL-COLLECTION 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. CIP122 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP125 CIP.002.125 FIXED-PAYMENT-IND 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. CIP125 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP126 CIP.002.126 FUNDING-CODE A code to indicate the source of non-federal share funds. CIP126 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP127 CIP.002.127 FUNDING-SOURCE-NONFEDERAL-SHARE 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. CIP127 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP128 CIP.002.128 MEDICARE-COMB-DED-IND 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. CIP128 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP129 CIP.002.129 PROGRAM-TYPE A code to indicate special Medicaid program under which the service was provided. CIP129 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP130 CIP.002.130 PLAN-ID-NUMBER A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP132 CIP.002.132 PAYMENT-LEVEL-IND The field denotes whether the payment amount was determined at the claim header or line/detail level. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines� associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. CIP132 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP133 CIP.002.133 MEDICARE-REIM-TYPE A code to indicate the type of Medicare reimbursement. CIP133 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP134 CIP.002.134 NON-COV-DAYS The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP135 CIP.002.135 NON-COV-CHARGES The charges for inpatient care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP136 CIP.002.136 MEDICAID-COV-INPATIENT-DAYS The number of days covered by Medicaid on this claim. For states that combine delivery/birth services on a single claim, include covered days for both the mother and the neonate in this field. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP137 CIP.002.137 CLAIM-LINE-COUNT The total number of lines on the claim. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP138 CIP.002.138 FORCED-CLAIM-IND Indicates if the claim was processed by forcing it through a manual override process. CIP138 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP139 CIP.002.139 HEALTH-CARE-ACQUIRED-CONDITION-IND This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage CIP139 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP140 CIP.002.140 OCCURRENCE-CODE-01 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP140 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP141 CIP.002.141 OCCURRENCE-CODE-02 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP141 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP142 CIP.002.142 OCCURRENCE-CODE-03 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP142 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP143 CIP.002.143 OCCURRENCE-CODE-04 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP143 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP144 CIP.002.144 OCCURRENCE-CODE-05 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP144 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP145 CIP.002.145 OCCURRENCE-CODE-06 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP145 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP146 CIP.002.146 OCCURRENCE-CODE-07 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP146 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP147 CIP.002.147 OCCURRENCE-CODE-08 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP147 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP148 CIP.002.148 OCCURRENCE-CODE-09 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP148 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP149 CIP.002.149 OCCURRENCE-CODE-10 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CIP149 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP150 CIP.002.150 OCCURRENCE-CODE-EFF-DATE-01 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP151 CIP.002.151 OCCURRENCE-CODE-EFF-DATE-02 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP152 CIP.002.152 OCCURRENCE-CODE-EFF-DATE-03 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP153 CIP.002.153 OCCURRENCE-CODE-EFF-DATE-04 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP154 CIP.002.154 OCCURRENCE-CODE-EFF-DATE-05 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP155 CIP.002.155 OCCURRENCE-CODE-EFF-DATE-06 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP156 CIP.002.156 OCCURRENCE-CODE-EFF-DATE-07 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP157 CIP.002.157 OCCURRENCE-CODE-EFF-DATE-08 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP158 CIP.002.158 OCCURRENCE-CODE-EFF-DATE-09 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP159 CIP.002.159 OCCURRENCE-CODE-EFF-DATE-10 The start date of the corresponding occurrence code or occurrence span codes. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP160 CIP.002.160 OCCURRENCE-CODE-END-DATE-01 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP161 CIP.002.161 OCCURRENCE-CODE-END-DATE-02 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP162 CIP.002.162 OCCURRENCE-CODE-END-DATE-03 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP163 CIP.002.163 OCCURRENCE-CODE-END-DATE-04 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP164 CIP.002.164 OCCURRENCE-CODE-END-DATE-05 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP165 CIP.002.165 OCCURRENCE-CODE-END-DATE-06 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP166 CIP.002.166 OCCURRENCE-CODE-END-DATE-07 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP167 CIP.002.167 OCCURRENCE-CODE-END-DATE-08 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP168 CIP.002.168 OCCURRENCE-CODE-END-DATE-09 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP169 CIP.002.169 OCCURRENCE-CODE-END-DATE-10 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP170 CIP.002.170 BIRTH-WEIGHT-GRAMS The weight of a newborn at time of birth in grams (applicable to newborns only). The field is required when a claim involves a child birth. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP171 CIP.002.171 PATIENT-CONTROL-NUM A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP172 CIP.002.172 ELIGIBLE-LAST-NAME The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP173 CIP.002.173 ELIGIBLE-FIRST-NAME The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP174 CIP.002.174 ELIGIBLE-MIDDLE-INIT Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP175 CIP.002.175 DATE-OF-BIRTH Date of birth of the individual to whom the services were provided. A patient's age should not be greater than 112 years. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP176 CIP.002.176 HEALTH-HOME-PROV-IND 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. CIP176 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP177 CIP.002.177 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. CIP177 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP178 CIP.002.178 WAIVER-ID Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP179 CIP.002.179 BILLING-PROV-NUM A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP180 CIP.002.180 BILLING-PROV-NPI-NUM The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP181 CIP.002.181 BILLING-PROV-TAXONOMY The taxonomy code for the institution billing for the beneficiary. CIP181 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP182 CIP.002.182 BILLING-PROV-TYPE A code to describe the type of provider being reported. CIP182 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP183 CIP.002.183 BILLING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CIP183 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP184 CIP.002.184 ADMITTING-PROV-NPI-NUM The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP185 CIP.002.185 ADMITTING-PROV-NUM The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP186 CIP.002.186 ADMITTING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CIP186 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP187 CIP.002.187 ADMITTING-PROV-TAXONOMY Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee. CIP187 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP188 CIP.002.188 ADMITTING-PROV-TYPE A code to describe the type of provider being reported. CIP188 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP189 CIP.002.189 REFERRING-PROV-NUM A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP190 CIP.002.190 REFERRING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP194 CIP.002.194 DRG-OUTLIER-AMT The additional payment on a claim that is associated with either a cost outlier or length of stay outlier. Outlier payments compensate hospitals paid on a fixed amount per Medicare 'diagnosis related group' discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP195 CIP.002.195 DRG-REL-WEIGHT The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average. This data element in T-MSIS is expected to capture the relative weight of the DRG in the state's system regardless of which DRG system the state uses. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP196 CIP.002.196 MEDICARE-HIC-NUM The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP197 CIP.002.197 OUTLIER-CODE This code indicates the Type of Outlier Code or DRG Source. The field identifies two mutually exclusive conditions. The first, for PPS providers (codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), denotes the source for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code CIP197 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP198 CIP.002.198 OUTLIER-DAYS This field specifies the number of days paid as outliers under Prospective Payment System (PPS) and the days over the threshold for the DRG. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP199 CIP.002.199 PATIENT-STATUS 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 CIP199 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP202 CIP.002.202 REMITTANCE-NUM The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP203 CIP.002.203 SPLIT-CLAIM-IND 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. CIP203 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP204 CIP.002.204 BORDER-STATE-IND 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.) CIP204 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP206 CIP.002.206 TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP207 CIP.002.207 BENEFICIARY-COINSURANCE-DATE-PAID The date the beneficiary paid the coinsurance amount. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP208 CIP.002.208 TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP209 CIP.002.209 BENEFICIARY-COPAYMENT-DATE-PAID The date the beneficiary paid the copayment amount. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP210 CIP.002.210 TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP211 CIP.002.211 BENEFICIARY-DEDUCTIBLE-DATE-PAID The date the beneficiary paid the deductible amount. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP212 CIP.002.212 CLAIM-DENIED-INDICATOR An indicator to identify a claim that the state refused pay in its entirety. CIP212 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP213 CIP.002.213 COPAY-WAIVED-IND An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. CIP213 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP214 CIP.002.214 HEALTH-HOME-ENTITY-NAME A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP216 CIP.002.216 THIRD-PARTY-COINSURANCE-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP217 CIP.002.217 THIRD-PARTY-COINSURANCE-DATE-PAID The date the third party paid the coinsurance amount N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP218 CIP.002.218 THIRD-PARTY-COPAYMENT-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards copayment. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP219 CIP.002.219 THIRD-PARTY-COPAYMENT-DATE-PAID The date the third party paid the copayment amount. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP220 CIP.002.220 MEDICAID-AMOUNT-PAID-DSH The amount included in the Total Medicaid Amount (CIP.002.114) that is attributable to a Disproportionate Share Hospital (DSH) payment, when the state makes DSH payments by claim. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP221 CIP.002.221 HEALTH-HOME-PROVIDER-NPI The National Provider ID (NPI) of the health home provider. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP222 CIP.002.222 MEDICARE-BENEFICIARY-IDENTIFIER 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 identity theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP223 CIP.002.223 OPERATING-PROV-TAXONOMY Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee. CIP223 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP228 CIP.002.228 MEDICARE-PAID-AMT The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP289 CIP.002.289 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP290 CIP.002.290 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP291 CIP.002.291 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP292 CIP.002.292 TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP293 CIP.002.293 TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP294 CIP.002.294 TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP295 CIP.002.295 COMBINED-BENE-COST-SHARING-PAID-AMOUNT The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP297 CIP.002.297 LTC-RCP-LIAB-AMT The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP298 CIP.002.298 BILLING-PROV-ADDR-LN-1 Billing provider address line 1 from X12 837I loop 2010AA. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP299 CIP.002.299 BILLING-PROV-ADDR-LN-2 Billing provider address line 2 from X12 837I loop 2010AA. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP300 CIP.002.300 BILLING-PROV-CITY Billing provider address city name from X12 837I loop 2010AA. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP301 CIP.002.301 BILLING-PROV-STATE Billing provider address state code from X12 837I loop 2010AA. CIP301 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP302 CIP.002.302 BILLING-PROV-ZIP-CODE Billing provider address ZIP code from X12 837I loop 2010AA. CIP302 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP303 CIP.002.303 SERVICE-FACILITY-LOCATION-ORG-NPI Service facility location organization NPI from X12 837I loop 2310E. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP304 CIP.002.304 SERVICE-FACILITY-LOCATION-ADDR-LN-1 Service facility location address line 1 from X12 837I loop 2310E. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP305 CIP.002.305 SERVICE-FACILITY-LOCATION-ADDR-LN-2 Service facility location address line 2 from X12 837I loop 2310E. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP306 CIP.002.306 SERVICE-FACILITY-LOCATION-CITY Service facility location address city name from X12 837I loop 2310E. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP307 CIP.002.307 SERVICE-FACILITY-LOCATION-STATE Service facility location address state code from X12 837I loop 2310E. CIP307 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP308 CIP.002.308 SERVICE-FACILITY-LOCATION-ZIP-CODE Service facility location address ZIP code from X12 837I loop 2310E. CIP308 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP309 CIP.002.309 PROVIDER-CLAIM-FORM-CODE A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". CIP309 Values CIP00002 CLAIM-HEADER-RECORD-IP
CIP310 CIP.002.310 PROVIDER-CLAIM-FORM-OTHER-TEXT A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP311 CIP.002.311 TOT-GME-AMOUNT-PAID The amount included in the Total Medicaid Amount (CIP.002.114) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP338 CIP.002.338 TOT-SDP-ALLOWED-AMT The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP339 CIP.002.339 TOT-SDP-PAID-AMT The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP229 CIP.002.229 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CIP00002 CLAIM-HEADER-RECORD-IP
CIP231 CIP.003.231 RECORD-ID 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.). CIP231 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP232 CIP.003.232 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CIP232 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP233 CIP.003.233 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP234 CIP.003.234 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP235 CIP.003.235 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP236 CIP.003.236 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP237 CIP.003.237 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP238 CIP.003.238 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP239 CIP.003.239 LINE-ADJUSTMENT-IND A code to indicate the type of adjustment record claim/encounter represents at claim detail level. CIP239 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP240 CIP.003.240 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. CIP240 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP241 CIP.003.241 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP242 CIP.003.242 CLAIM-LINE-STATUS 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. CIP242 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP243 CIP.003.243 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP244 CIP.003.244 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP245 CIP.003.245 REVENUE-CODE 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. CIP245 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP249 CIP.003.249 REVENUE-CENTER-QUANTITY-ACTUAL On facility claims/encounters, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP250 CIP.003.250 REVENUE-CENTER-QUANTITY-ALLOWED 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/encounter records use Service Quantity Allowed and CLAIMRX claims/encounter records use the Prescription Quantity Allowed field. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP251 CIP.003.251 REVENUE-CHARGE The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP252 CIP.003.252 ALLOWED-AMT The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP254 CIP.003.254 MEDICAID-PAID-AMT The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP255 CIP.003.255 MEDICAID-FFS-EQUIVALENT-AMT The amount that would have been paid had the services been provided on a Fee for Service basis. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP256 CIP.003.256 BILLING-UNIT Unit of billing that is used for billing services by the facility. CIP256 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP257 CIP.003.257 TYPE-OF-SERVICE A code to categorize the services provided to a Medicaid or CHIP enrollee. CIP257 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP260 CIP.003.260 SERVICING-PROV-NUM A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The value is conditional as its usage varies by state. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP261 CIP.003.261 SERVICING-PROV-NPI-NUM The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP263 CIP.003.263 SERVICING-PROV-TYPE A code to describe the type of provider being reported. CIP263 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP264 CIP.003.264 SERVICING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CIP264 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP265 CIP.003.265 OPERATING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP266 CIP.003.266 OTHER-TPL-COLLECTION 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. CIP266 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP267 CIP.003.267 PROV-FACILITY-TYPE 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. CIP267 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP269 CIP.003.269 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. CIP269 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP272 CIP.003.272 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP278 CIP.003.278 NDC-QUANTITY This field is to capture the actual quantity of the National Drug Code being prescribed on the claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP284 CIP.003.284 NATIONAL-DRUG-CODE A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP285 CIP.003.285 NDC-UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the National Drug Code is expressed. CIP285 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP286 CIP.003.286 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP287 CIP.003.287 SELF-DIRECTION-TYPE This data element is not applicable to this file type. CIP287 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP288 CIP.003.288 PRE-AUTHORIZATION-NUM A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP296 CIP.003.296 IHS-SERVICE-IND To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. CIP296 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP314 CIP.003.314 UNIQUE-DEVICE-IDENTIFIER An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP340 CIP.003.340 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). CIP340 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP316 CIP.003.316 MBESCBES-FORM 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. CIP316 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP315 CIP.003.315 MBESCBES-CATEGORY-OF-SERVICE 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. CIP315 Values CIP00003 CLAIM-LINE-RECORD-IP
CIP317 CIP.003.317 GME-AMOUNT-PAID The amount included in the Medicaid Amount (CIP.003.254) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP318 CIP.003.318 REFERRING-PROV-NUM A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP319 CIP.003.319 REFERRING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP336 CIP.003.336 SDP-ALLOWED-AMT The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP337 CIP.003.337 SDP-PAID-AMT The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP273 CIP.003.273 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CIP00003 CLAIM-LINE-RECORD-IP
CIP322 CIP.004.322 RECORD-ID 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.). CIP322 Values CIP00004 CLAIM-DX-IP
CIP323 CIP.004.323 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CIP323 Values CIP00004 CLAIM-DX-IP
CIP324 CIP.004.324 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CIP00004 CLAIM-DX-IP
CIP325 CIP.004.325 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CIP00004 CLAIM-DX-IP
CIP326 CIP.004.326 ICN-ADJ 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
CIP327 CIP.004.327 ADJUSTMENT-IND Indicates the type of adjustment record. CIP327 Values CIP00004 CLAIM-DX-IP
CIP328 CIP.004.328 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CIP00004 CLAIM-DX-IP
CIP329 CIP.004.329 DIAGNOSIS-TYPE 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. CIP329 Values CIP00004 CLAIM-DX-IP
CIP330 CIP.004.330 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 CIP00004 CLAIM-DX-IP
CIP331 CIP.004.331 DIAGNOSIS-CODE-FLAG Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. CIP331 Values CIP00004 CLAIM-DX-IP
CIP332 CIP.004.332 DIAGNOSIS-CODE ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '21051'. CIP332 Values CIP00004 CLAIM-DX-IP
CIP333 CIP.004.333 DIAGNOSIS-POA-FLAG 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. CIP333 Values CIP00004 CLAIM-DX-IP
CIP334 CIP.004.334 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CIP00004 CLAIM-DX-IP
CLT001 CLT.001.001 RECORD-ID 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.). CLT001 Values CLT00001 FILE-HEADER-RECORD-LT
CLT002 CLT.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. CLT002 Values CLT00001 FILE-HEADER-RECORD-LT
CLT003 CLT.001.003 SUBMISSION-TRANSACTION-TYPE 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. CLT003 Values CLT00001 FILE-HEADER-RECORD-LT
CLT004 CLT.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. CLT004 Values CLT00001 FILE-HEADER-RECORD-LT
CLT005 CLT.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A CLT00001 FILE-HEADER-RECORD-LT
CLT006 CLT.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A CLT00001 FILE-HEADER-RECORD-LT
CLT007 CLT.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CLT007 Values CLT00001 FILE-HEADER-RECORD-LT
CLT008 CLT.001.008 DATE-FILE-CREATED The date on which the file was created. N/A CLT00001 FILE-HEADER-RECORD-LT
CLT009 CLT.001.009 START-OF-TIME-PERIOD This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. N/A CLT00001 FILE-HEADER-RECORD-LT
CLT010 CLT.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A CLT00001 FILE-HEADER-RECORD-LT
CLT011 CLT.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. CLT011 Values CLT00001 FILE-HEADER-RECORD-LT
CLT012 CLT.001.012 SSN-INDICATOR 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. CLT012 Values CLT00001 FILE-HEADER-RECORD-LT
CLT013 CLT.001.013 TOT-REC-CNT A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. N/A CLT00001 FILE-HEADER-RECORD-LT
CLT227 CLT.001.227 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A CLT00001 FILE-HEADER-RECORD-LT
CLT014 CLT.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CLT00001 FILE-HEADER-RECORD-LT
CLT016 CLT.002.016 RECORD-ID 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.). CLT016 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT017 CLT.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CLT017 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT018 CLT.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT019 CLT.002.019 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT020 CLT.002.020 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT021 CLT.002.021 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT022 CLT.002.022 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT023 CLT.002.023 CROSSOVER-INDICATOR An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. CLT023 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT024 CLT.002.024 1115A-DEMONSTRATION-IND 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. CLT024 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT025 CLT.002.025 ADJUSTMENT-IND Indicates the type of adjustment record. CLT025 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT026 CLT.002.026 ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a claim was paid differently than it was billed. CLT026 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT044 CLT.002.044 ADMISSION-DATE The date on which the recipient was admitted to a psychiatric or long-term care facility. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT045 CLT.002.045 ADMISSION-HOUR The time of admission to a psychiatric or long-term care facility. CLT045 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT046 CLT.002.046 DISCHARGE-DATE The date on which the recipient was discharged from a psychiatric or long-term care facility. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT047 CLT.002.047 DISCHARGE-HOUR The time of discharge from a psychiatric or long-term care facility. CLT047 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT048 CLT.002.048 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT049 CLT.002.049 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT050 CLT.002.050 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT051 CLT.002.051 MEDICAID-PAID-DATE The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT052 CLT.002.052 TYPE-OF-CLAIM A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C' or an S-CHIP sub-capitated encounter record. CLT052 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT053 CLT.002.053 TYPE-OF-BILL 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.) CLT053 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT054 CLT.002.054 CLAIM-STATUS 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. CLT054 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT055 CLT.002.055 CLAIM-STATUS-CATEGORY 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. CLT055 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT056 CLT.002.056 SOURCE-LOCATION The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. CLT056 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT057 CLT.002.057 CHECK-NUM The check or electronic funds transfer number. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT058 CLT.002.058 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT059 CLT.002.059 CLAIM-PYMT-REM-CODE-1 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). CLT059 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT060 CLT.002.060 CLAIM-PYMT-REM-CODE-2 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). CLT060 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT061 CLT.002.061 CLAIM-PYMT-REM-CODE-3 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). CLT061 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT062 CLT.002.062 CLAIM-PYMT-REM-CODE-4 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). CLT062 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT063 CLT.002.063 TOT-BILLED-AMT The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT064 CLT.002.064 TOT-ALLOWED-AMT The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT065 CLT.002.065 TOT-MEDICAID-PAID-AMT The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT067 CLT.002.067 TOT-MEDICARE-DEDUCTIBLE-AMT 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 CLT00002 CLAIM-HEADER-RECORD-LT
CLT068 CLT.002.068 TOT-MEDICARE-COINS-AMT 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-HEADER-RECORD-LT
CLT069 CLT.002.069 TOT-TPL-AMT 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 CLT00002 CLAIM-HEADER-RECORD-LT
CLT070 CLT.002.070 TOT-OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT071 CLT.002.071 OTHER-INSURANCE-IND The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. CLT071 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT072 CLT.002.072 OTHER-TPL-COLLECTION 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. CLT072 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT075 CLT.002.075 FIXED-PAYMENT-IND 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. CLT075 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT076 CLT.002.076 FUNDING-CODE A code to indicate the source of non-federal share funds. CLT076 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT077 CLT.002.077 FUNDING-SOURCE-NONFEDERAL-SHARE 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. CLT077 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT078 CLT.002.078 MEDICARE-COMB-DED-IND 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. CLT078 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT079 CLT.002.079 PROGRAM-TYPE A code to indicate special Medicaid program under which the service was provided. CLT079 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT080 CLT.002.080 PLAN-ID-NUMBER A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT082 CLT.002.082 PAYMENT-LEVEL-IND The field denotes whether the payment amount was determined at the claim header or line/detail level. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. CLT082 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT083 CLT.002.083 MEDICARE-REIM-TYPE A code to indicate the type of Medicare reimbursement. CLT083 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT084 CLT.002.084 NON-COV-DAYS The number of days of institutional long-term care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered days does not refer to days not covered for any other service. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT085 CLT.002.085 NON-COV-CHARGES The charges for institutional long-term care, which are not reimbursable by the primary payer. The non-covered charges do not refer to charges not covered for any other service. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT086 CLT.002.086 MEDICAID-COV-INPATIENT-DAYS The number of inpatient psychiatric days covered by Medicaid on this claim. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT087 CLT.002.087 CLAIM-LINE-COUNT The total number of lines on the claim. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT090 CLT.002.090 FORCED-CLAIM-IND Indicates if the claim was processed by forcing it through a manual override process. CLT090 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT091 CLT.002.091 HEALTH-CARE-ACQUIRED-CONDITION-IND This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage CLT091 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT092 CLT.002.092 OCCURRENCE-CODE-01 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT092 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT093 CLT.002.093 OCCURRENCE-CODE-02 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT093 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT094 CLT.002.094 OCCURRENCE-CODE-03 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT094 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT095 CLT.002.095 OCCURRENCE-CODE-04 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT095 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT096 CLT.002.096 OCCURRENCE-CODE-05 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT096 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT097 CLT.002.097 OCCURRENCE-CODE-06 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT097 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT098 CLT.002.098 OCCURRENCE-CODE-07 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT098 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT099 CLT.002.099 OCCURRENCE-CODE-08 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT099 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT100 CLT.002.100 OCCURRENCE-CODE-09 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT100 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT101 CLT.002.101 OCCURRENCE-CODE-10 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. CLT101 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT102 CLT.002.102 OCCURRENCE-CODE-EFF-DATE-01 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT103 CLT.002.103 OCCURRENCE-CODE-EFF-DATE-02 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT104 CLT.002.104 OCCURRENCE-CODE-EFF-DATE-03 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT105 CLT.002.105 OCCURRENCE-CODE-EFF-DATE-04 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT106 CLT.002.106 OCCURRENCE-CODE-EFF-DATE-05 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT107 CLT.002.107 OCCURRENCE-CODE-EFF-DATE-06 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT108 CLT.002.108 OCCURRENCE-CODE-EFF-DATE-07 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT109 CLT.002.109 OCCURRENCE-CODE-EFF-DATE-08 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT110 CLT.002.110 OCCURRENCE-CODE-EFF-DATE-09 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT111 CLT.002.111 OCCURRENCE-CODE-EFF-DATE-10 The start date of the corresponding occurrence code or occurrence span codes. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT112 CLT.002.112 OCCURRENCE-CODE-END-DATE-01 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT113 CLT.002.113 OCCURRENCE-CODE-END-DATE-02 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT114 CLT.002.114 OCCURRENCE-CODE-END-DATE-03 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT115 CLT.002.115 OCCURRENCE-CODE-END-DATE-04 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT116 CLT.002.116 OCCURRENCE-CODE-END-DATE-05 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT117 CLT.002.117 OCCURRENCE-CODE-END-DATE-06 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT118 CLT.002.118 OCCURRENCE-CODE-END-DATE-07 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT119 CLT.002.119 OCCURRENCE-CODE-END-DATE-08 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT120 CLT.002.120 OCCURRENCE-CODE-END-DATE-09 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT121 CLT.002.121 OCCURRENCE-CODE-END-DATE-10 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT122 CLT.002.122 PATIENT-CONTROL-NUM A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT123 CLT.002.123 ELIGIBLE-LAST-NAME The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT124 CLT.002.124 ELIGIBLE-FIRST-NAME The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT125 CLT.002.125 ELIGIBLE-MIDDLE-INIT Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT126 CLT.002.126 DATE-OF-BIRTH An individual's date of birth. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT127 CLT.002.127 HEALTH-HOME-PROV-IND 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. CLT127 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT128 CLT.002.128 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. CLT128 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT129 CLT.002.129 WAIVER-ID Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT130 CLT.002.130 BILLING-PROV-NUM A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT131 CLT.002.131 BILLING-PROV-NPI-NUM The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT132 CLT.002.132 BILLING-PROV-TAXONOMY The taxonomy code for the institution billing for the beneficiary. CLT132 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT133 CLT.002.133 BILLING-PROV-TYPE A code to describe the type of provider being reported. CLT133 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT134 CLT.002.134 BILLING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CLT134 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT135 CLT.002.135 REFERRING-PROV-NUM A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT136 CLT.002.136 REFERRING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT140 CLT.002.140 MEDICARE-HIC-NUM The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT141 CLT.002.141 PATIENT-STATUS 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 CLT141 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT144 CLT.002.144 REMITTANCE-NUM The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT145 CLT.002.145 LTC-RCP-LIAB-AMT The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT147 CLT.002.147 ICF-IID-DAYS The number of days of intermediate care for individuals with an intellectual disability that were paid for in whole or in part by Medicaid. If value exceeds 99998 days, code as 99998. (e.g., code 100023 as 99998). N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT148 CLT.002.148 LEAVE-DAYS The number of days, during the period covered by Medicaid, on which the patient did not reside in the long term care facility. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT149 CLT.002.149 NURSING-FACILITY-DAYS The number of days of nursing care included in this claim that were paid for, in whole or in part, by Medicaid. Includes days during which nursing facility received partial payment for holding a bed during patient leave days. If value exceeds 99998 days, code as 99998. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT150 CLT.002.150 SPLIT-CLAIM-IND 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. CLT150 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT151 CLT.002.151 BORDER-STATE-IND 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.) CLT151 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT153 CLT.002.153 TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT154 CLT.002.154 BENEFICIARY-COINSURANCE-DATE-PAID The date the beneficiary paid the coinsurance amount. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT155 CLT.002.155 TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary.. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT156 CLT.002.156 BENEFICIARY-COPAYMENT-DATE-PAID The date the beneficiary paid the copayment amount. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT157 CLT.002.157 TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT158 CLT.002.158 BENEFICIARY-DEDUCTIBLE-DATE-PAID The date the beneficiary paid the deductible amount. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT159 CLT.002.159 CLAIM-DENIED-INDICATOR An indicator to identify a claim that the state refused pay in its entirety. CLT159 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT160 CLT.002.160 COPAY-WAIVED-IND An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. CLT160 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT161 CLT.002.161 HEALTH-HOME-ENTITY-NAME A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT163 CLT.002.163 THIRD-PARTY-COINSURANCE-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT164 CLT.002.164 THIRD-PARTY-COINSURANCE-DATE-PAID The date the third party paid the coinsurance amount N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT165 CLT.002.165 THIRD-PARTY-COPAYMENT-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards copayment. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT166 CLT.002.166 THIRD-PARTY-COPAYMENT-DATE-PAID The date the third party paid the copayment amount. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT167 CLT.002.167 HEALTH-HOME-PROVIDER-NPI The National Provider ID (NPI) of the health home provider. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT168 CLT.002.168 MEDICARE-BENEFICIARY-IDENTIFIER 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 identity theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT174 CLT.002.174 ADMITTING-PROV-NPI-NUM The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT175 CLT.002.175 ADMITTING-PROV-NUM The Medicaid ID of the doctor responsible for admitting a patient to a hospital or other inpatient health facility. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT176 CLT.002.176 ADMITTING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CLT176 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT177 CLT.002.177 ADMITTING-PROV-TAXONOMY Taxonomic classification (code) for a given healthcare provider, as defined by the National Uniform Claim Committee. CLT177 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT178 CLT.002.178 ADMITTING-PROV-TYPE A code to describe the type of provider being reported. CLT178 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT179 CLT.002.179 MEDICARE-PAID-AMT The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT237 CLT.002.237 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT239 CLT.002.239 TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT240 CLT.002.240 TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT241 CLT.002.241 TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT242 CLT.002.242 COMBINED-BENE-COST-SHARING-PAID-AMOUNT The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT244 CLT.002.244 BILLING-PROV-ADDR-LN-1 Billing provider address line 1 from X12 837I loop 2010AA. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT245 CLT.002.245 BILLING-PROV-ADDR-LN-2 Billing provider address line 2 from X12 837I loop 2010AA. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT246 CLT.002.246 BILLING-PROV-CITY Billing provider address city name from X12 837I loop 2010AA. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT247 CLT.002.247 BILLING-PROV-STATE Billing provider address state code from X12 837I loop 2010AA. CLT247 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT248 CLT.002.248 BILLING-PROV-ZIP-CODE Billing provider address ZIP code from X12 837I loop 2010AA. CLT248 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT249 CLT.002.249 SERVICE-FACILITY-LOCATION-ORG-NPI Service facility location organization NPI from X12 837I loop 2310E. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT250 CLT.002.250 SERVICE-FACILITY-LOCATION-ADDR-LN-1 Service facility location address line 1 from X12 837I loop 2310E. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT251 CLT.002.251 SERVICE-FACILITY-LOCATION-ADDR-LN-2 Service facility location address line 2 from X12 837I loop 2310E. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT252 CLT.002.252 SERVICE-FACILITY-LOCATION-CITY Service facility location address city name from X12 837I loop 2310E. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT253 CLT.002.253 SERVICE-FACILITY-LOCATION-STATE Service facility location address state code from X12 837I loop 2310E. CLT253 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT254 CLT.002.254 SERVICE-FACILITY-LOCATION-ZIP-CODE Service facility location address ZIP code from X12 837I loop 2310E. CLT254 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT255 CLT.002.255 PROVIDER-CLAIM-FORM-CODE A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". CLT255 Values CLT00002 CLAIM-HEADER-RECORD-LT
CLT256 CLT.002.256 PROVIDER-CLAIM-FORM-OTHER-TEXT A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT257 CLT.002.257 TOT-GME-AMOUNT-PAID The amount included in the Total Medicaid Amount (CLT.002.065) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT258 CLT.002.258 TOT-SDP-ALLOWED-AMT The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT259 CLT.002.259 TOT-SDP-PAID-AMT The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT173 CLT.002.173 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CLT00002 CLAIM-HEADER-RECORD-LT
CLT184 CLT.003.184 RECORD-ID 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.). CLT184 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT185 CLT.003.185 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CLT185 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT186 CLT.003.186 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT187 CLT.003.187 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT188 CLT.003.188 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT189 CLT.003.189 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT190 CLT.003.190 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT191 CLT.003.191 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT192 CLT.003.192 LINE-ADJUSTMENT-IND A code to indicate the type of adjustment record claim/encounter represents at claim detail level. CLT192 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT193 CLT.003.193 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. CLT193 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT194 CLT.003.194 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT195 CLT.003.195 CLAIM-LINE-STATUS 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. CLT195 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT196 CLT.003.196 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT197 CLT.003.197 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT198 CLT.003.198 REVENUE-CODE 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. CLT198 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT202 CLT.003.202 REVENUE-CENTER-QUANTITY-ACTUAL On facility claims/encounters, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT203 CLT.003.203 REVENUE-CENTER-QUANTITY-ALLOWED 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/encounter records use Service Quantity Allowed and CLAIMRX claims/encounter records use the Prescription Quantity Allowed field. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT204 CLT.003.204 REVENUE-CHARGE The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT205 CLT.003.205 ALLOWED-AMT The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT206 CLT.003.206 TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT207 CLT.003.207 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT208 CLT.003.208 MEDICAID-PAID-AMT The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT209 CLT.003.209 MEDICAID-FFS-EQUIVALENT-AMT The amount that would have been paid had the services been provided on a Fee for Service basis. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT210 CLT.003.210 BILLING-UNIT Unit of billing that is used for billing services by the facility. CLT210 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT211 CLT.003.211 TYPE-OF-SERVICE A code to categorize the services provided to a Medicaid or CHIP enrollee. CLT211 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT212 CLT.003.212 SERVICING-PROV-NUM A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The value is conditional as its usage varies by state. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT213 CLT.003.213 SERVICING-PROV-NPI-NUM The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT215 CLT.003.215 SERVICING-PROV-TYPE A code to describe the type of provider being reported. CLT215 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT216 CLT.003.216 SERVICING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CLT216 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT217 CLT.003.217 OTHER-TPL-COLLECTION 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. CLT217 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT219 CLT.003.219 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. CLT219 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT221 CLT.003.221 PROV-FACILITY-TYPE 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. CLT221 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT228 CLT.003.228 NATIONAL-DRUG-CODE A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT229 CLT.003.229 NDC-UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the National Drug Code is expressed. CLT229 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT230 CLT.003.230 NDC-QUANTITY This field is to capture the actual quantity of the National Drug Code being prescribed on the claim/encounter. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT233 CLT.003.233 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT234 CLT.003.234 SELF-DIRECTION-TYPE This data element is not applicable to this file type. CLT234 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT235 CLT.003.235 PRE-AUTHORIZATION-NUM A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT243 CLT.003.243 IHS-SERVICE-IND To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. CLT243 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT260 CLT.003.260 UNIQUE-DEVICE-IDENTIFIER An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT282 CLT.003.282 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). CLT282 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT262 CLT.003.262 MBESCBES-FORM 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. CLT262 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT261 CLT.003.261 MBESCBES-CATEGORY-OF-SERVICE 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. CLT261 Values CLT00003 CLAIM-LINE-RECORD-LT
CLT263 CLT.003.263 GME-AMOUNT-PAID The amount included in the Medicaid Amount (CLT.003.208) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT264 CLT.003.264 REFERRING-PROV-NUM A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT265 CLT.003.265 REFERRING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT266 CLT.003.266 SDP-ALLOWED-AMT The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT267 CLT.003.267 SDP-PAID-AMT The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT226 CLT.003.226 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CLT00003 CLAIM-LINE-RECORD-LT
CLT268 CLT.004.268 RECORD-ID 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.). CLT268 Values CLT00004 CLAIM-DX-LT
CLT269 CLT.004.269 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CLT269 Values CLT00004 CLAIM-DX-LT
CLT270 CLT.004.270 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CLT00004 CLAIM-DX-LT
CLT271 CLT.004.271 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CLT00004 CLAIM-DX-LT
CLT272 CLT.004.272 ICN-ADJ 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
CLT273 CLT.004.273 ADJUSTMENT-IND Indicates the type of adjustment record. CLT273 Values CLT00004 CLAIM-DX-LT
CLT274 CLT.004.274 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CLT00004 CLAIM-DX-LT
CLT275 CLT.004.275 DIAGNOSIS-TYPE 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. CLT275 Values CLT00004 CLAIM-DX-LT
CLT276 CLT.004.276 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
CLT277 CLT.004.277 DIAGNOSIS-CODE-FLAG Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. CLT277 Values CLT00004 CLAIM-DX-LT
CLT278 CLT.004.278 DIAGNOSIS-CODE ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'. CLT278 Values CLT00004 CLAIM-DX-LT
CLT279 CLT.004.279 DIAGNOSIS-POA-FLAG 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. CLT279 Values CLT00004 CLAIM-DX-LT
CLT280 CLT.004.280 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CLT00004 CLAIM-DX-LT
COT001 COT.001.001 RECORD-ID 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.). COT001 Values COT00001 FILE-HEADER-RECORD-OT
COT002 COT.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. COT002 Values COT00001 FILE-HEADER-RECORD-OT
COT003 COT.001.003 SUBMISSION-TRANSACTION-TYPE 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. COT003 Values COT00001 FILE-HEADER-RECORD-OT
COT004 COT.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. COT004 Values COT00001 FILE-HEADER-RECORD-OT
COT005 COT.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A COT00001 FILE-HEADER-RECORD-OT
COT006 COT.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A COT00001 FILE-HEADER-RECORD-OT
COT007 COT.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. COT007 Values COT00001 FILE-HEADER-RECORD-OT
COT008 COT.001.008 DATE-FILE-CREATED The date on which the file was created. N/A COT00001 FILE-HEADER-RECORD-OT
COT009 COT.001.009 START-OF-TIME-PERIOD This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. N/A COT00001 FILE-HEADER-RECORD-OT
COT010 COT.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A COT00001 FILE-HEADER-RECORD-OT
COT011 COT.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. COT011 Values COT00001 FILE-HEADER-RECORD-OT
COT012 COT.001.012 SSN-INDICATOR 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. COT012 Values COT00001 FILE-HEADER-RECORD-OT
COT013 COT.001.013 TOT-REC-CNT A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. N/A COT00001 FILE-HEADER-RECORD-OT
COT216 COT.001.216 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A COT00001 FILE-HEADER-RECORD-OT
COT014 COT.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A COT00001 FILE-HEADER-RECORD-OT
COT016 COT.002.016 RECORD-ID 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.). COT016 Values COT00002 CLAIM-HEADER-RECORD-OT
COT017 COT.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. COT017 Values COT00002 CLAIM-HEADER-RECORD-OT
COT018 COT.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT019 COT.002.019 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT020 COT.002.020 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT021 COT.002.021 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT022 COT.002.022 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A COT00002 CLAIM-HEADER-RECORD-OT
COT023 COT.002.023 CROSSOVER-INDICATOR An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. COT023 Values COT00002 CLAIM-HEADER-RECORD-OT
COT024 COT.002.024 1115A-DEMONSTRATION-IND 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. COT024 Values COT00002 CLAIM-HEADER-RECORD-OT
COT025 COT.002.025 ADJUSTMENT-IND Indicates the type of adjustment record. COT025 Values COT00002 CLAIM-HEADER-RECORD-OT
COT026 COT.002.026 ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a claim was paid differently than it was billed. COT026 Values COT00002 CLAIM-HEADER-RECORD-OT
COT033 COT.002.033 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT034 COT.002.034 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT035 COT.002.035 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT036 COT.002.036 MEDICAID-PAID-DATE The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT037 COT.002.037 TYPE-OF-CLAIM A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C' or an S-CHIP sub-capitated encounter record COT037 Values COT00002 CLAIM-HEADER-RECORD-OT
COT038 COT.002.038 TYPE-OF-BILL 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.) COT038 Values COT00002 CLAIM-HEADER-RECORD-OT
COT039 COT.002.039 CLAIM-STATUS 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. COT039 Values COT00002 CLAIM-HEADER-RECORD-OT
COT040 COT.002.040 CLAIM-STATUS-CATEGORY 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. COT040 Values COT00002 CLAIM-HEADER-RECORD-OT
COT041 COT.002.041 SOURCE-LOCATION The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. COT041 Values COT00002 CLAIM-HEADER-RECORD-OT
COT042 COT.002.042 CHECK-NUM The check or electronic funds transfer number. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT043 COT.002.043 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT044 COT.002.044 CLAIM-PYMT-REM-CODE-1 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). COT044 Values COT00002 CLAIM-HEADER-RECORD-OT
COT045 COT.002.045 CLAIM-PYMT-REM-CODE-2 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). COT045 Values COT00002 CLAIM-HEADER-RECORD-OT
COT046 COT.002.046 CLAIM-PYMT-REM-CODE-3 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). COT046 Values COT00002 CLAIM-HEADER-RECORD-OT
COT047 COT.002.047 CLAIM-PYMT-REM-CODE-4 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). COT047 Values COT00002 CLAIM-HEADER-RECORD-OT
COT048 COT.002.048 TOT-BILLED-AMT The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT049 COT.002.049 TOT-ALLOWED-AMT The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT050 COT.002.050 TOT-MEDICAID-PAID-AMT The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT052 COT.002.052 TOT-MEDICARE-DEDUCTIBLE-AMT 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 COT00002 CLAIM-HEADER-RECORD-OT
COT053 COT.002.053 TOT-MEDICARE-COINS-AMT 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-HEADER-RECORD-OT
COT054 COT.002.054 TOT-TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT056 COT.002.056 TOT-OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT057 COT.002.057 OTHER-INSURANCE-IND The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. COT057 Values COT00002 CLAIM-HEADER-RECORD-OT
COT058 COT.002.058 OTHER-TPL-COLLECTION 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. COT058 Values COT00002 CLAIM-HEADER-RECORD-OT
COT061 COT.002.061 FIXED-PAYMENT-IND 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. COT061 Values COT00002 CLAIM-HEADER-RECORD-OT
COT062 COT.002.062 FUNDING-CODE A code to indicate the source of non-federal share funds. COT062 Values COT00002 CLAIM-HEADER-RECORD-OT
COT063 COT.002.063 FUNDING-SOURCE-NONFEDERAL-SHARE 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. COT063 Values COT00002 CLAIM-HEADER-RECORD-OT
COT064 COT.002.064 MEDICARE-COMB-DED-IND 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. COT064 Values COT00002 CLAIM-HEADER-RECORD-OT
COT065 COT.002.065 PROGRAM-TYPE A code to indicate special Medicaid program under which the service was provided. COT065 Values COT00002 CLAIM-HEADER-RECORD-OT
COT066 COT.002.066 PLAN-ID-NUMBER A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT068 COT.002.068 PAYMENT-LEVEL-IND The field denotes whether the payment amount was determined at the claim header or line/detail level. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. COT068 Values COT00002 CLAIM-HEADER-RECORD-OT
COT069 COT.002.069 MEDICARE-REIM-TYPE A code to indicate the type of Medicare reimbursement. COT069 Values COT00002 CLAIM-HEADER-RECORD-OT
COT070 COT.002.070 CLAIM-LINE-COUNT The total number of lines on the claim. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT072 COT.002.072 FORCED-CLAIM-IND Indicates if the claim was processed by forcing it through a manual override process. COT072 Values COT00002 CLAIM-HEADER-RECORD-OT
COT073 COT.002.073 HEALTH-CARE-ACQUIRED-CONDITION-IND This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage COT073 Values COT00002 CLAIM-HEADER-RECORD-OT
COT074 COT.002.074 OCCURRENCE-CODE-01 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT074 Values COT00002 CLAIM-HEADER-RECORD-OT
COT075 COT.002.075 OCCURRENCE-CODE-02 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT075 Values COT00002 CLAIM-HEADER-RECORD-OT
COT076 COT.002.076 OCCURRENCE-CODE-03 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT076 Values COT00002 CLAIM-HEADER-RECORD-OT
COT077 COT.002.077 OCCURRENCE-CODE-04 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT077 Values COT00002 CLAIM-HEADER-RECORD-OT
COT078 COT.002.078 OCCURRENCE-CODE-05 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT078 Values COT00002 CLAIM-HEADER-RECORD-OT
COT079 COT.002.079 OCCURRENCE-CODE-06 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT079 Values COT00002 CLAIM-HEADER-RECORD-OT
COT080 COT.002.080 OCCURRENCE-CODE-07 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT080 Values COT00002 CLAIM-HEADER-RECORD-OT
COT081 COT.002.081 OCCURRENCE-CODE-08 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT081 Values COT00002 CLAIM-HEADER-RECORD-OT
COT082 COT.002.082 OCCURRENCE-CODE-09 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT082 Values COT00002 CLAIM-HEADER-RECORD-OT
COT083 COT.002.083 OCCURRENCE-CODE-10 A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. COT083 Values COT00002 CLAIM-HEADER-RECORD-OT
COT084 COT.002.084 OCCURRENCE-CODE-EFF-DATE-01 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT085 COT.002.085 OCCURRENCE-CODE-EFF-DATE-02 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT086 COT.002.086 OCCURRENCE-CODE-EFF-DATE-03 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT087 COT.002.087 OCCURRENCE-CODE-EFF-DATE-04 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT088 COT.002.088 OCCURRENCE-CODE-EFF-DATE-05 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT089 COT.002.089 OCCURRENCE-CODE-EFF-DATE-06 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT090 COT.002.090 OCCURRENCE-CODE-EFF-DATE-07 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT091 COT.002.091 OCCURRENCE-CODE-EFF-DATE-08 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT092 COT.002.092 OCCURRENCE-CODE-EFF-DATE-09 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT093 COT.002.093 OCCURRENCE-CODE-EFF-DATE-10 The start date of the corresponding occurrence code or occurrence span codes. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT094 COT.002.094 OCCURRENCE-CODE-END-DATE-01 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT095 COT.002.095 OCCURRENCE-CODE-END-DATE-02 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT096 COT.002.096 OCCURRENCE-CODE-END-DATE-03 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT097 COT.002.097 OCCURRENCE-CODE-END-DATE-04 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT098 COT.002.098 OCCURRENCE-CODE-END-DATE-05 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT099 COT.002.099 OCCURRENCE-CODE-END-DATE-06 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT100 COT.002.100 OCCURRENCE-CODE-END-DATE-07 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT101 COT.002.101 OCCURRENCE-CODE-END-DATE-08 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT102 COT.002.102 OCCURRENCE-CODE-END-DATE-09 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT103 COT.002.103 OCCURRENCE-CODE-END-DATE-10 The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT104 COT.002.104 PATIENT-CONTROL-NUM A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment N/A COT00002 CLAIM-HEADER-RECORD-OT
COT105 COT.002.105 ELIGIBLE-LAST-NAME The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A COT00002 CLAIM-HEADER-RECORD-OT
COT106 COT.002.106 ELIGIBLE-FIRST-NAME The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A COT00002 CLAIM-HEADER-RECORD-OT
COT107 COT.002.107 ELIGIBLE-MIDDLE-INIT Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A COT00002 CLAIM-HEADER-RECORD-OT
COT108 COT.002.108 DATE-OF-BIRTH An individual's date of birth. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT109 COT.002.109 HEALTH-HOME-PROV-IND 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. COT109 Values COT00002 CLAIM-HEADER-RECORD-OT
COT110 COT.002.110 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. COT110 Values COT00002 CLAIM-HEADER-RECORD-OT
COT111 COT.002.111 WAIVER-ID Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT112 COT.002.112 BILLING-PROV-NUM A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT113 COT.002.113 BILLING-PROV-NPI-NUM The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT114 COT.002.114 BILLING-PROV-TAXONOMY The taxonomy code for the provider billing for the service. COT114 Values COT00002 CLAIM-HEADER-RECORD-OT
COT115 COT.002.115 BILLING-PROV-TYPE A code to describe the type of provider being reported. COT115 Values COT00002 CLAIM-HEADER-RECORD-OT
COT116 COT.002.116 BILLING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. COT116 Values COT00002 CLAIM-HEADER-RECORD-OT
COT117 COT.002.117 REFERRING-PROV-NUM A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT118 COT.002.118 REFERRING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT122 COT.002.122 MEDICARE-HIC-NUM The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) N/A COT00002 CLAIM-HEADER-RECORD-OT
COT123 COT.002.123 PLACE-OF-SERVICE A pass-through data element meaning that the state should report the field in T-MSIS as reported by the provider on the claim form (i.e., 837P or 837D - Place of Service is only captured at the line level of the CMS-1500). 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 (UB-04) institutional claims form, the PLACE-OF-SERVICE field should be blank or space-filled. Otherwise, if the claim is submitted with the place of service populated with any value other than the valid values listed in T-MSIS Data Guide for PLACE-OF-SERVICE values, that value should still be reported in the PLACE-OF-SERVICE data element. If the claim is submitted by a provider with the place of service fields blank, then the PLACE-OF-SERVICE on the T-MSIS OT claims file should be blank or space-filled. COT123 Values COT00002 CLAIM-HEADER-RECORD-OT
COT126 COT.002.126 REMITTANCE-NUM The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT127 COT.002.127 DAILY-RATE The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as a flat rate. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT128 COT.002.128 BORDER-STATE-IND 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.) COT128 Values COT00002 CLAIM-HEADER-RECORD-OT
COT130 COT.002.130 TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT131 COT.002.131 BENEFICIARY-COINSURANCE-DATE-PAID The date the beneficiary paid the coinsurance amount. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT132 COT.002.132 TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT133 COT.002.133 BENEFICIARY-COPAYMENT-DATE-PAID The date the beneficiary paid the copayment amount. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT134 COT.002.134 TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT135 COT.002.135 BENEFICIARY-DEDUCTIBLE-DATE-PAID The date the beneficiary paid the deductible amount. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT136 COT.002.136 CLAIM-DENIED-INDICATOR An indicator to identify a claim that the state refused pay in its entirety. COT136 Values COT00002 CLAIM-HEADER-RECORD-OT
COT137 COT.002.137 COPAY-WAIVED-IND An indicator signifying that the copay was waived by the provider COT137 Values COT00002 CLAIM-HEADER-RECORD-OT
COT138 COT.002.138 HEALTH-HOME-ENTITY-NAME A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT140 COT.002.140 THIRD-PARTY-COINSURANCE-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT141 COT.002.141 THIRD-PARTY-COINSURANCE-DATE-PAID The date the third party paid the coinsurance amount N/A COT00002 CLAIM-HEADER-RECORD-OT
COT142 COT.002.142 THIRD-PARTY-COPAYMENT-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards copayment. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT143 COT.002.143 THIRD-PARTY-COPAYMENT-DATE-PAID The date the third party paid the copayment amount. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT146 COT.002.146 HEALTH-HOME-PROVIDER-NPI The National Provider ID (NPI) of the health home provider. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT147 COT.002.147 MEDICARE-BENEFICIARY-IDENTIFIER 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 identity theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT226 COT.002.226 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT230 COT.002.230 TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT231 COT.002.231 TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT232 COT.002.232 TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT233 COT.002.233 COMBINED-BENE-COST-SHARING-PAID-AMOUNT The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT235 COT.002.235 LTC-RCP-LIAB-AMT The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT236 COT.002.236 BILLING-PROV-ADDR-LN-1 Billing provider address line 1 from X12 837I, 837P, and 837D loop 2010AA. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT237 COT.002.237 BILLING-PROV-ADDR-LN-2 Billing provider address line 2 from X12 837I, 837P, and 837D loop 2010AA. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT238 COT.002.238 BILLING-PROV-CITY Billing provider address city name from X12 837I, 837P, and 837D loop 2010AA. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT239 COT.002.239 BILLING-PROV-STATE Billing provider address state code from X12 837I, 837P, and 837D loop 2010AA. COT239 Values COT00002 CLAIM-HEADER-RECORD-OT
COT240 COT.002.240 BILLING-PROV-ZIP-CODE Billing provider address ZIP code from X12 837I, 837P, and 837D loop 2010AA. COT240 Values COT00002 CLAIM-HEADER-RECORD-OT
COT241 COT.002.241 SERVICE-FACILITY-LOCATION-ORG-NPI Service facility location organization NPI from X12 837I loop 2310E or 837P and 837D loop 2310C. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT242 COT.002.242 SERVICE-FACILITY-LOCATION-ADDR-LN-1 Service facility location address line 1 from X12 837I loop 2310E or 837P and 837D loop 2310C. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT243 COT.002.243 SERVICE-FACILITY-LOCATION-ADDR-LN-2 Service facility location address line 2 from X12 837I loop 2310E or 837P and 837D loop 2310C. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT244 COT.002.244 SERVICE-FACILITY-LOCATION-CITY Service facility location address city name from X12 837I loop 2310E or 837P and 837D loop 2310C. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT245 COT.002.245 SERVICE-FACILITY-LOCATION-STATE Service facility location address state code from X12 837I loop 2310E or 837P and 837D loop 2310C. COT245 Values COT00002 CLAIM-HEADER-RECORD-OT
COT246 COT.002.246 SERVICE-FACILITY-LOCATION-ZIP-CODE Service facility location address ZIP code from X12 837I loop 2310E or 837P and 837D loop 2310C. COT246 Values COT00002 CLAIM-HEADER-RECORD-OT
COT247 COT.002.247 PROVIDER-CLAIM-FORM-CODE A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". COT247 Values COT00002 CLAIM-HEADER-RECORD-OT
COT248 COT.002.248 PROVIDER-CLAIM-FORM-OTHER-TEXT A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT249 COT.002.249 TOT-GME-AMOUNT-PAID The amount included in the Total Medicaid Amount (COT.002.050) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT250 COT.002.250 REFERRING-PROV-NUM-2 A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT251 COT.002.251 REFERRING-PROV-NPI-NUM-2 The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the header of their claim. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT252 COT.002.252 TOT-SDP-ALLOWED-AMT The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A COT00002 CLAIM-HEADER-RECORD-OT
COT253 COT.002.253 TOT-SDP-PAID-AMT The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A COT00002 CLAIM-HEADER-RECORD-OT
COT152 COT.002.152 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A COT00002 CLAIM-HEADER-RECORD-OT
COT154 COT.003.154 RECORD-ID 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.). COT154 Values COT00003 CLAIM-LINE-RECORD-OT
COT155 COT.003.155 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. COT155 Values COT00003 CLAIM-LINE-RECORD-OT
COT156 COT.003.156 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A COT00003 CLAIM-LINE-RECORD-OT
COT157 COT.003.157 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A COT00003 CLAIM-LINE-RECORD-OT
COT158 COT.003.158 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT159 COT.003.159 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A COT00003 CLAIM-LINE-RECORD-OT
COT160 COT.003.160 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT161 COT.003.161 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT162 COT.003.162 LINE-ADJUSTMENT-IND A code to indicate the type of adjustment record claim/encounter represents at claim detail level. COT162 Values COT00003 CLAIM-LINE-RECORD-OT
COT163 COT.003.163 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. COT163 Values COT00003 CLAIM-LINE-RECORD-OT
COT164 COT.003.164 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A COT00003 CLAIM-LINE-RECORD-OT
COT165 COT.003.165 CLAIM-LINE-STATUS 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. COT165 Values COT00003 CLAIM-LINE-RECORD-OT
COT166 COT.003.166 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. N/A COT00003 CLAIM-LINE-RECORD-OT
COT167 COT.003.167 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. N/A COT00003 CLAIM-LINE-RECORD-OT
COT168 COT.003.168 REVENUE-CODE 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. COT168 Values COT00003 CLAIM-LINE-RECORD-OT
COT169 COT.003.169 PROCEDURE-CODE A field to capture the CPT or HCPCS code that describes a service or good rendered by the provider to an enrollee on the specified date of service. COT169 Values COT00003 CLAIM-LINE-RECORD-OT
COT170 COT.003.170 PROCEDURE-CODE-DATE The date upon which a reported medical procedure was performed. N/A COT00003 CLAIM-LINE-RECORD-OT
COT171 COT.003.171 PROCEDURE-CODE-FLAG A flag that identifies the coding system used for an associated procedure code. COT171 Values COT00003 CLAIM-LINE-RECORD-OT
COT172 COT.003.172 PROCEDURE-CODE-MOD-1 The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. COT172 Values COT00003 CLAIM-LINE-RECORD-OT
COT174 COT.003.174 BILLED-AMT The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00003 CLAIM-LINE-RECORD-OT
COT175 COT.003.175 ALLOWED-AMT The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00003 CLAIM-LINE-RECORD-OT
COT176 COT.003.176 BENEFICIARY-COPAYMENT-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. N/A COT00003 CLAIM-LINE-RECORD-OT
COT177 COT.003.177 TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. N/A COT00003 CLAIM-LINE-RECORD-OT
COT178 COT.003.178 MEDICAID-PAID-AMT The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A COT00003 CLAIM-LINE-RECORD-OT
COT179 COT.003.179 MEDICAID-FFS-EQUIVALENT-AMT The amount that would have been paid had the services been provided on a Fee for Service basis. N/A COT00003 CLAIM-LINE-RECORD-OT
COT182 COT.003.182 MEDICARE-PAID-AMT The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines. N/A COT00003 CLAIM-LINE-RECORD-OT
COT183 COT.003.183 SERVICE-QUANTITY-ACTUAL The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim/encounter line. For use with CLAIMOT claims/encounters. For CLAIMRX claims/encounters, use the Prescription Quantity Actual field. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. N/A COT00003 CLAIM-LINE-RECORD-OT
COT184 COT.003.184 SERVICE-QUANTITY-ALLOWED The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. N/A COT00003 CLAIM-LINE-RECORD-OT
COT186 COT.003.186 TYPE-OF-SERVICE A code to categorize the services provided to a Medicaid or CHIP enrollee. COT186 Values COT00003 CLAIM-LINE-RECORD-OT
COT187 COT.003.187 HCBS-SERVICE-CODE A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services). COT187 Values COT00003 CLAIM-LINE-RECORD-OT
COT188 COT.003.188 HCBS-TAXONOMY A code to classify the home and community based services listed on the claim into the HCBS taxonomy. The HCBS Taxonomic classification system was adopted by CMS in August 2012. To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting. Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as 'extended state plan' services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment. The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state's service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc. Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf COT188 Values COT00003 CLAIM-LINE-RECORD-OT
COT189 COT.003.189 SERVICING-PROV-NUM A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The value is conditional as its usage varies by state. N/A COT00003 CLAIM-LINE-RECORD-OT
COT190 COT.003.190 SERVICING-PROV-NPI-NUM The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The SERVICING-PROV-NPI-NUM is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims. N/A COT00003 CLAIM-LINE-RECORD-OT
COT191 COT.003.191 SERVICING-PROV-TAXONOMY The taxonomy code for the provider who treated the recipient. COT191 Values COT00003 CLAIM-LINE-RECORD-OT
COT192 COT.003.192 SERVICING-PROV-TYPE A code to describe the type of provider being reported. COT192 Values COT00003 CLAIM-LINE-RECORD-OT
COT193 COT.003.193 SERVICING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. COT193 Values COT00003 CLAIM-LINE-RECORD-OT
COT194 COT.003.194 OTHER-TPL-COLLECTION 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. COT194 Values COT00003 CLAIM-LINE-RECORD-OT
COT195 COT.003.195 TOOTH-DESIGNATION-SYSTEM A code to identify the tooth numbering system being used. COT195 Values COT00003 CLAIM-LINE-RECORD-OT
COT196 COT.003.196 TOOTH-NUM The tooth number serviced based on the tooth numbering system identified in the TOOTH-DESIGNATION-SYSTEM field. COT196 Values COT00003 CLAIM-LINE-RECORD-OT
COT197 COT.003.197 TOOTH-QUAD-CODE The area of the oral cavity is designated by a two-digit code. COT197 Values COT00003 CLAIM-LINE-RECORD-OT
COT198 COT.003.198 TOOTH-SURFACE-CODE A code to identify the tooth's surface on which the service was performed. COT198 Values COT00003 CLAIM-LINE-RECORD-OT
COT199 COT.003.199 ORIGINATION-ADDR-LN1 The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. N/A COT00003 CLAIM-LINE-RECORD-OT
COT200 COT.003.200 ORIGINATION-ADDR-LN2 The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. N/A COT00003 CLAIM-LINE-RECORD-OT
COT201 COT.003.201 ORIGINATION-CITY The name of the origination city from which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional. N/A COT00003 CLAIM-LINE-RECORD-OT
COT202 COT.003.202 ORIGINATION-STATE The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a health care provider to a health care provider for healthcare services or vice versa. COT202 Values COT00003 CLAIM-LINE-RECORD-OT
COT203 COT.003.203 ORIGINATION-ZIP-CODE 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. COT203 Values COT00003 CLAIM-LINE-RECORD-OT
COT204 COT.003.204 DESTINATION-ADDR-LN1 The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. N/A COT00003 CLAIM-LINE-RECORD-OT
COT205 COT.003.205 DESTINATION-ADDR-LN2 The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. N/A COT00003 CLAIM-LINE-RECORD-OT
COT206 COT.003.206 DESTINATION-CITY The name of the destination city to which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. N/A COT00003 CLAIM-LINE-RECORD-OT
COT207 COT.003.207 DESTINATION-STATE The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. COT207 Values COT00003 CLAIM-LINE-RECORD-OT
COT208 COT.003.208 DESTINATION-ZIP-CODE The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. COT208 Values COT00003 CLAIM-LINE-RECORD-OT
COT210 COT.003.210 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. COT210 Values COT00003 CLAIM-LINE-RECORD-OT
COT213 COT.003.213 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT217 COT.003.217 NATIONAL-DRUG-CODE A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT227 COT.003.227 PROCEDURE-CODE-MOD-2 The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. COT227 Values COT00003 CLAIM-LINE-RECORD-OT
COT218 COT.003.218 PROCEDURE-CODE-MOD-3 The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. COT218 Values COT00003 CLAIM-LINE-RECORD-OT
COT219 COT.003.219 PROCEDURE-CODE-MOD-4 The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services. COT219 Values COT00003 CLAIM-LINE-RECORD-OT
COT221 COT.003.221 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A COT00003 CLAIM-LINE-RECORD-OT
COT222 COT.003.222 SELF-DIRECTION-TYPE A data element to identify how the beneficiary self-directed the service, i.e. hiring authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services), budget authority (The beneficiary has decision-making authority over how the Medicaid funds in a budget are spent), or both hiring and budget authority. COT222 Values COT00003 CLAIM-LINE-RECORD-OT
COT223 COT.003.223 PRE-AUTHORIZATION-NUM A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). N/A COT00003 CLAIM-LINE-RECORD-OT
COT224 COT.003.224 NDC-UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the National Drug Code is expressed. COT224 Values COT00003 CLAIM-LINE-RECORD-OT
COT225 COT.003.225 NDC-QUANTITY This field is to capture the actual quantity of the National Drug Code being prescribed on the claim/encounter. N/A COT00003 CLAIM-LINE-RECORD-OT
COT234 COT.003.234 IHS-SERVICE-IND To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. COT234 Values COT00003 CLAIM-LINE-RECORD-OT
COT254 COT.003.254 DIAGNOSIS-CODE-POINTER-1 A pointer to the diagnosis code in the order of importance to this service. N/A COT00003 CLAIM-LINE-RECORD-OT
COT287 COT.003.287 DIAGNOSIS-CODE-POINTER-2 A pointer to the diagnosis code in the order of importance to this service. N/A COT00003 CLAIM-LINE-RECORD-OT
COT288 COT.003.288 DIAGNOSIS-CODE-POINTER-3 A pointer to the diagnosis code in the order of importance to this service. N/A COT00003 CLAIM-LINE-RECORD-OT
COT289 COT.003.289 DIAGNOSIS-CODE-POINTER-4 A pointer to the diagnosis code in the order of importance to this service. N/A COT00003 CLAIM-LINE-RECORD-OT
COT255 COT.003.255 UNIQUE-DEVICE-IDENTIFIER An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. N/A COT00003 CLAIM-LINE-RECORD-OT
COT290 COT.003.290 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). COT290 Values COT00003 CLAIM-LINE-RECORD-OT
COT257 COT.003.257 MBESCBES-FORM 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. COT257 Values COT00003 CLAIM-LINE-RECORD-OT
COT256 COT.003.256 MBESCBES-CATEGORY-OF-SERVICE 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. COT256 Values COT00003 CLAIM-LINE-RECORD-OT
COT258 COT.003.258 SERVICE-FACILITY-LOCATION-ORG-NPI Service facility location organization NPI from X12 837P loop 2420C and 837D loop 2420D. N/A COT00003 CLAIM-LINE-RECORD-OT
COT259 COT.003.259 SERVICE-FACILITY-LOCATION-ADDR-LN-1 Service facility location address line 1 from X12 837P loop 2420C and 837D loop 2420D. N/A COT00003 CLAIM-LINE-RECORD-OT
COT260 COT.003.260 SERVICE-FACILITY-LOCATION-ADDR-LN-2 Service facility location address line 2 from X12 837P loop 2420C and 837D loop 2420D. N/A COT00003 CLAIM-LINE-RECORD-OT
COT261 COT.003.261 SERVICE-FACILITY-LOCATION-CITY Service facility location address city name from X12 837P loop 2420C and 837D loop 2420D. N/A COT00003 CLAIM-LINE-RECORD-OT
COT262 COT.003.262 SERVICE-FACILITY-LOCATION-STATE Service facility location address state code from X12 837P loop 2420C and 837D loop 2420D. COT262 Values COT00003 CLAIM-LINE-RECORD-OT
COT263 COT.003.263 SERVICE-FACILITY-LOCATION-ZIP-CODE Service facility location address ZIP code from X12 837P loop 2420C and 837D loop 2420D. COT263 Values COT00003 CLAIM-LINE-RECORD-OT
COT264 COT.003.264 PLACE-OF-SERVICE A pass-through data element meaning that the state should report the field in T-MSIS as reported by the provider on the claim form (i.e., 837P or 837D - Place of Service is only captured at the line level of the CMS-1500). 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 (UB-04) institutional claims form, the PLACE-OF-SERVICE field should be blank or space-filled. Otherwise, if the claim is submitted with the place of service populated with any value other than the valid values listed in T-MSIS Data Guide for PLACE-OF-SERVICE values, that value should still be reported in the PLACE-OF-SERVICE data element. If the claim is submitted by a provider with the place of service fields blank, then the PLACE-OF-SERVICE on the T-MSIS OT claims file should be blank or space-filled. COT264 Values COT00003 CLAIM-LINE-RECORD-OT
COT265 COT.003.265 GME-AMOUNT-PAID The amount included in the Medicaid Amount (COT.003.178) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT266 COT.003.266 REFERRING-PROV-NUM A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT267 COT.003.267 REFERRING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. N/A COT00003 CLAIM-LINE-RECORD-OT
COT268 COT.003.268 REFERRING-PROV-NUM-2 A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT269 COT.003.269 REFERRING-PROV-NPI-NUM-2 The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the line/detail of their claim. N/A COT00003 CLAIM-LINE-RECORD-OT
COT270 COT.003.270 ORDERING-PROV-NUM The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. N/A COT00003 CLAIM-LINE-RECORD-OT
COT271 COT.003.271 ORDERING-PROV-NPI-NUM The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. N/A COT00003 CLAIM-LINE-RECORD-OT
COT272 COT.003.272 SDP-ALLOWED-AMT The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A COT00003 CLAIM-LINE-RECORD-OT
COT273 COT.003.273 SDP-PAID-AMT The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A COT00003 CLAIM-LINE-RECORD-OT
COT214 COT.003.214 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A COT00003 CLAIM-LINE-RECORD-OT
COT274 COT.004.274 RECORD-ID 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.). COT274 Values COT00004 CLAIM-DX-OT
COT275 COT.004.275 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. COT275 Values COT00004 CLAIM-DX-OT
COT276 COT.004.276 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A COT00004 CLAIM-DX-OT
COT277 COT.004.277 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A COT00004 CLAIM-DX-OT
COT278 COT.004.278 ICN-ADJ 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
COT279 COT.004.279 ADJUSTMENT-IND Indicates the type of adjustment record. COT279 Values COT00004 CLAIM-DX-OT
COT280 COT.004.280 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A COT00004 CLAIM-DX-OT
COT281 COT.004.281 DIAGNOSIS-TYPE 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. COT281 Values COT00004 CLAIM-DX-OT
COT282 COT.004.282 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 837P claim can have up to 12 external cause of injury diagnosis codes and up to 24 other diagnosis codes). N/A COT00004 CLAIM-DX-OT
COT283 COT.004.283 DIAGNOSIS-CODE-FLAG Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. COT283 Values COT00004 CLAIM-DX-OT
COT284 COT.004.284 DIAGNOSIS-CODE ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'. COT284 Values COT00004 CLAIM-DX-OT
COT285 COT.004.285 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A COT00004 CLAIM-DX-OT
CRX001 CRX.001.001 RECORD-ID 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.). CRX001 Values CRX00001 FILE-HEADER-RECORD-RX
CRX002 CRX.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. CRX002 Values CRX00001 FILE-HEADER-RECORD-RX
CRX003 CRX.001.003 SUBMISSION-TRANSACTION-TYPE 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. CRX003 Values CRX00001 FILE-HEADER-RECORD-RX
CRX004 CRX.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. CRX004 Values CRX00001 FILE-HEADER-RECORD-RX
CRX005 CRX.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A CRX00001 FILE-HEADER-RECORD-RX
CRX006 CRX.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A CRX00001 FILE-HEADER-RECORD-RX
CRX007 CRX.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CRX007 Values CRX00001 FILE-HEADER-RECORD-RX
CRX008 CRX.001.008 DATE-FILE-CREATED The date on which the file was created. N/A CRX00001 FILE-HEADER-RECORD-RX
CRX009 CRX.001.009 START-OF-TIME-PERIOD This value must be the first day of the reporting month, regardless of the actual date span of the data in the file. N/A CRX00001 FILE-HEADER-RECORD-RX
CRX010 CRX.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A CRX00001 FILE-HEADER-RECORD-RX
CRX011 CRX.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. CRX011 Values CRX00001 FILE-HEADER-RECORD-RX
CRX012 CRX.001.012 SSN-INDICATOR 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. CRX012 Values CRX00001 FILE-HEADER-RECORD-RX
CRX013 CRX.001.013 TOT-REC-CNT A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. N/A CRX00001 FILE-HEADER-RECORD-RX
CRX155 CRX.001.155 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A CRX00001 FILE-HEADER-RECORD-RX
CRX014 CRX.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CRX00001 FILE-HEADER-RECORD-RX
CRX016 CRX.002.016 RECORD-ID 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.). CRX016 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX017 CRX.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CRX017 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX018 CRX.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX019 CRX.002.019 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX020 CRX.002.020 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX021 CRX.002.021 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX022 CRX.002.022 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX023 CRX.002.023 CROSSOVER-INDICATOR An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. CRX023 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX024 CRX.002.024 1115A-DEMONSTRATION-IND 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. CRX024 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX025 CRX.002.025 ADJUSTMENT-IND Indicates the type of adjustment record. CRX025 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX026 CRX.002.026 ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a claim was paid differently than it was billed. CRX026 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX027 CRX.002.027 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX028 CRX.002.028 MEDICAID-PAID-DATE The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX029 CRX.002.029 TYPE-OF-CLAIM A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C' or an S-CHIP sub-capitated encounter record. CRX029 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX030 CRX.002.030 CLAIM-STATUS 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. CRX030 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX031 CRX.002.031 CLAIM-STATUS-CATEGORY 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. CRX031 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX032 CRX.002.032 SOURCE-LOCATION The field denotes the claims payment system from which the claim was extracted. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis. For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. CRX032 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX033 CRX.002.033 CHECK-NUM The check or electronic funds transfer number. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX034 CRX.002.034 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX035 CRX.002.035 CLAIM-PYMT-REM-CODE-1 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). CRX035 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX036 CRX.002.036 CLAIM-PYMT-REM-CODE-2 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). CRX036 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX037 CRX.002.037 CLAIM-PYMT-REM-CODE-3 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). CRX037 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX038 CRX.002.038 CLAIM-PYMT-REM-CODE-4 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). CRX038 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX039 CRX.002.039 TOT-BILLED-AMT The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX040 CRX.002.040 TOT-ALLOWED-AMT The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX041 CRX.002.041 TOT-MEDICAID-PAID-AMT The total amount paid to the provider 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 to the provider by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX043 CRX.002.043 TOT-MEDICARE-DEDUCTIBLE-AMT 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 CRX00002 CLAIM-HEADER-RECORD-RX
CRX044 CRX.002.044 TOT-MEDICARE-COINS-AMT 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 CRX00002 CLAIM-HEADER-RECORD-RX
CRX045 CRX.002.045 TOT-TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX047 CRX.002.047 TOT-OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX048 CRX.002.048 OTHER-INSURANCE-IND The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. CRX048 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX049 CRX.002.049 OTHER-TPL-COLLECTION 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. CRX049 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX052 CRX.002.052 FIXED-PAYMENT-IND 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. CRX052 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX053 CRX.002.053 FUNDING-CODE A code to indicate the source of non-federal share funds. CRX053 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX054 CRX.002.054 FUNDING-SOURCE-NONFEDERAL-SHARE 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. CRX054 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX055 CRX.002.055 PROGRAM-TYPE A code to indicate special Medicaid program under which the service was provided. CRX055 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX056 CRX.002.056 PLAN-ID-NUMBER A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX058 CRX.002.058 PAYMENT-LEVEL-IND The field denotes whether the payment amount was determined at the claim header or line/detail level. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header. For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed. For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. CRX058 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX059 CRX.002.059 MEDICARE-REIM-TYPE A code to indicate the type of Medicare reimbursement. CRX059 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX060 CRX.002.060 CLAIM-LINE-COUNT The total number of lines on the claim. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX061 CRX.002.061 FORCED-CLAIM-IND Indicates if the claim was processed by forcing it through a manual override process. CRX061 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX062 CRX.002.062 PATIENT-CONTROL-NUM A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX063 CRX.002.063 ELIGIBLE-LAST-NAME The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX064 CRX.002.064 ELIGIBLE-FIRST-NAME The first name of the individual to whom the services were provided.(The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX065 CRX.002.065 ELIGIBLE-MIDDLE-INIT Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX066 CRX.002.066 DATE-OF-BIRTH An individual's date of birth. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX067 CRX.002.067 HEALTH-HOME-PROV-IND 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. CRX067 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX068 CRX.002.068 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. CRX068 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX069 CRX.002.069 WAIVER-ID Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX070 CRX.002.070 BILLING-PROV-NUM A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX071 CRX.002.071 BILLING-PROV-NPI-NUM The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX072 CRX.002.072 BILLING-PROV-TAXONOMY The taxonomy code for the provider billing for the service. CRX072 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX073 CRX.002.073 BILLING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CRX073 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX074 CRX.002.074 PRESCRIBING-PROV-NUM A unique identification number assigned by the state to the provider who prescribed the drug, device, or supply. This must be the individual's ID number, not a group identification number. If the prescribing physician provider ID is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the state file, then the State should use the DEA ID for this data element N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX075 CRX.002.075 PRESCRIBING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who prescribed a medication to a patient. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX079 CRX.002.079 MEDICARE-HIC-NUM The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX081 CRX.002.081 REMITTANCE-NUM The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX082 CRX.002.082 BORDER-STATE-IND 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.) CRX082 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX084 CRX.002.084 DATE-PRESCRIBED The date the drug, device, or supply was prescribed by the physician or other practitioner. This should not be confused with the Prescription Fill Date, which represents the date the prescription was actually filled by the provider. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX085 CRX.002.085 PRESCRIPTION-FILL-DATE Date the drug, device, or supply was dispensed by the provider. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX086 CRX.002.086 COMPOUND-DRUG-IND Indicator to specify if the drug is compound or not. CRX086 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX087 CRX.002.087 TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX088 CRX.002.088 BENEFICIARY-COINSURANCE-DATE-PAID The date the beneficiary paid the coinsurance amount. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX089 CRX.002.089 TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX090 CRX.002.090 BENEFICIARY-COPAYMENT-DATE-PAID The date the beneficiary paid the copayment amount. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX092 CRX.002.092 TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX093 CRX.002.093 BENEFICIARY-DEDUCTIBLE-DATE-PAID The date the beneficiary paid the deductible amount. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX094 CRX.002.094 CLAIM-DENIED-INDICATOR An indicator to identify a claim that the state refused pay in its entirety. CRX094 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX095 CRX.002.095 COPAY-WAIVED-IND An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. CRX095 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX096 CRX.002.096 HEALTH-HOME-ENTITY-NAME A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX098 CRX.002.098 THIRD-PARTY-COINSURANCE-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX099 CRX.002.099 THIRD-PARTY-COINSURANCE-DATE-PAID The date the third party paid the coinsurance amount N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX100 CRX.002.100 THIRD-PARTY-COPAYMENT-AMOUNT-PAID The amount of money paid by a third party on behalf of the beneficiary towards copayment. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX101 CRX.002.101 THIRD-PARTY-COPAYMENT-DATE-PAID The date the third party paid the copayment amount. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX102 CRX.002.102 DISPENSING-PRESCRIPTION-DRUG-PROV-NPI The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX104 CRX.002.104 HEALTH-HOME-PROVIDER-NPI The National Provider ID (NPI) of the health home provider. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX105 CRX.002.105 MEDICARE-BENEFICIARY-IDENTIFIER 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 identity theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX156 CRX.002.156 DISPENSING-PRESCRIPTION-DRUG-PROV-NUM The state-specific provider id of the provider who actually dispensed the prescription medication. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX160 CRX.002.160 MEDICARE-COMB-DED-IND 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. CRX160 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX161 CRX.002.161 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX162 CRX.002.162 PRESCRIPTION-ORIGIN-CODE How the prescription was sent to the pharmacy. CRX162 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX163 CRX.002.163 TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX164 CRX.002.164 TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX165 CRX.002.165 TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX166 CRX.002.166 COMBINED-BENE-COST-SHARING-PAID-AMOUNT The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX173 CRX.002.173 LTC-RCP-LIAB-AMT The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX174 CRX.002.174 PROVIDER-CLAIM-FORM-CODE A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". CRX174 Values CRX00002 CLAIM-HEADER-RECORD-RX
CRX175 CRX.002.175 PROVIDER-CLAIM-FORM-OTHER-TEXT A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX176 CRX.002.176 TOT-GME-AMOUNT-PAID The amount included in the Total Medicaid Amount (CRX.002.041) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX177 CRX.002.177 TOT-SDP-ALLOWED-AMT The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX178 CRX.002.178 TOT-SDP-PAID-AMT The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX106 CRX.002.106 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CRX00002 CLAIM-HEADER-RECORD-RX
CRX108 CRX.003.108 RECORD-ID 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.). CRX108 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX109 CRX.003.109 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CRX109 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX110 CRX.003.110 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX111 CRX.003.111 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX112 CRX.003.112 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX113 CRX.003.113 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX114 CRX.003.114 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX115 CRX.003.115 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX116 CRX.003.116 LINE-ADJUSTMENT-IND A code to indicate the type of adjustment record claim/encounter represents at claim detail level. CRX116 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX117 CRX.003.117 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. CRX117 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX118 CRX.003.118 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX119 CRX.003.119 CLAIM-LINE-STATUS 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. CRX119 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX120 CRX.003.120 NATIONAL-DRUG-CODE A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX121 CRX.003.121 BILLED-AMT The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX122 CRX.003.122 ALLOWED-AMT The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity allowed at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX123 CRX.003.123 BENEFICIARY-COPAYMENT-PAID-AMOUNT The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX124 CRX.003.124 TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX125 CRX.003.125 MEDICAID-PAID-AMT The amount paid to the provider by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX126 CRX.003.126 MEDICAID-FFS-EQUIVALENT-AMT The amount that would have been paid had the services been provided on a Fee for Service basis. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX127 CRX.003.127 MEDICARE-DEDUCTIBLE-AMT The amount paid by Medicaid/CHIP on this claim at the claim line level toward the beneficiary's Medicare deductible. If the Medicare 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 and Medicare Coinsurance Payment is not required. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX128 CRX.003.128 MEDICARE-COINS-AMT The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the Medicare Deductible Amount. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX129 CRX.003.129 MEDICARE-PAID-AMT The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX131 CRX.003.131 PRESCRIPTION-QUANTITY-ALLOWED The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed. For use with CLAIMRX claims/encounters. For CLAIMOT claims/encounter records, use the Service Quantity Allowed field. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Allowed field. One prescription for 100 250 milligram tablets results in Prescription Quantity Allowed =100. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX132 CRX.003.132 PRESCRIPTION-QUANTITY-ACTUAL The quantity of a drug that is dispensed for a prescription as reported ny National Drug Code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMLT claims/encounter records, use the Revenue Center Quantity Actual field. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX133 CRX.003.133 UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the drug or supply is expressed. CRX133 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX134 CRX.003.134 TYPE-OF-SERVICE A code to categorize the services provided to a Medicaid or CHIP enrollee. CRX134 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX135 CRX.003.135 HCBS-SERVICE-CODE A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services). CRX135 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX136 CRX.003.136 HCBS-TAXONOMY A code to classify the home and community based services listed on the claim into the HCBS taxonomy. The HCBS Taxonomic classification system was adopted by CMS in August 2012. To acknowledge state variation, services and categories are defined based on the minimum definition necessary to establish mutually distinct categories and services. Some services are defined in part by characteristics that are NOT in that service. For example, the difference between companion services and personal care is that companion services do not include assistance with activities of daily living (ADLs) such as bathing, dressing, eating, and toileting. Some of the services reflected by the HCBS Taxonomy including, but not limited to personal care, case management, home health aide, and physician services, may (and in some case, must) also be covered under the Medicaid State Plan. The definitions below only define these services for purposes of Section 1915(c) Waivers and the State Plan Home and Community-Based Services benefit authorized by Section 1915(i). States interested in reflecting services as 'extended state plan' services must offer them in accordance with state plan service definitions. Consult with the CMS Division of Benefits and Coverage in those instances to ensure definition alignment. The services and categories are arranged in order of consideration for placing a particular state service in the taxonomy. If one is not sure how to map a state's service to the taxonomy, one should first consider Case Management, then Round-the-Clock Services, then Supported Employment, etc. Documentation of the HCBS Taxonomy from the CMS Waiver Management System can be found here: https://wms-mmdl.cms.gov/WMS/help/TaxonomyCategoryDefinitions.pdf CRX136 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX137 CRX.003.137 OTHER-TPL-COLLECTION 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. CRX137 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX138 CRX.003.138 DAYS-SUPPLY Number of days supply dispensed. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX139 CRX.003.139 NEW-REFILL-IND Indicator showing whether the prescription being filled was a new prescription or a refill. If it is a refill, the indicator will indicate the number of refills. CRX139 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX140 CRX.003.140 BRAND-GENERIC-IND Indicates whether the drug is a brand name, generic, single-source, or multi-source drug. CRX140 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX141 CRX.003.141 DISPENSE-FEE-SUBMITTED The charge to cover the cost of the professional dispensing fee for the prescription. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX142 CRX.003.142 PRESCRIPTION-NUM The unique identification number assigned by the pharmacy or supplier to the prescription. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX143 CRX.003.143 DRUG-UTILIZATION-CODE A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: 'Reason for Service Code' (439-E4); 'Professional Service Code' (440-E5); and 'Result of Service Code' (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP 'Reasons of Service Code' (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP 'Professional Service Code' (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP 'Result of Service Code' (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. CRX143 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX144 CRX.003.144 DTL-METRIC-DEC-QTY Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter). N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX145 CRX.003.145 COMPOUND-DOSAGE-FORM The physical form of a dose of medication, such as a capsule or injection. CRX145 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX146 CRX.003.146 REBATE-ELIGIBLE-INDICATOR An indicator to identify claim lines with an NDC that is eligible for the drug rebate program. CRX146 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX149 CRX.003.149 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. CRX149 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX152 CRX.003.152 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX157 CRX.003.157 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX158 CRX.003.158 SELF-DIRECTION-TYPE This data element is not applicable to this file type. CRX158 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX159 CRX.003.159 PRE-AUTHORIZATION-NUM A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX167 CRX.003.167 INGREDIENT-COST-SUBMITTED The charge to cover the cost of ingredients for the prescription or drug. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX168 CRX.003.168 INGREDIENT-COST-PAID-AMT The amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level towards the cost of ingredients for the prescription or drug. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX169 CRX.003.169 DISPENSE-FEE-PAID-AMT The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the cost of the pharmacy's professional dispensing fee for the prescription. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX170 CRX.003.170 PROFESSIONAL-SERVICE-FEE-SUBMITTED The charge to cover the clinical services, not otherwise covered under the professional dispensing fee. (Example - not filling a prescription because of therapeutic duplication). N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX171 CRX.003.171 PROFESSIONAL-SERVICE-FEE-PAID-AMT The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the costs of clinical services not otherwise covered under the professional dispensing fee. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX172 CRX.003.172 IHS-SERVICE-IND To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. CRX172 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX179 CRX.003.179 UNIQUE-DEVICE-IDENTIFIER An unique identifier assigned to every medical device that meets the requirements of 21 CFR 801 and 830. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX209 CRX.003.209 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). CRX209 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX181 CRX.003.181 MBESCBES-FORM 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. CRX181 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX180 CRX.003.180 MBESCBES-CATEGORY-OF-SERVICE 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. CRX180 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX182 CRX.003.182 PROCEDURE-CODE The procedure code (e.g., CPT, HCPCS, or other procedure code that is not an NDC or UDI) reported by a pharmacy on their NCPDP transaction. CRX182 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX183 CRX.003.183 PROCEDURE-CODE-MOD-1 The first modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX183 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX184 CRX.003.184 PROCEDURE-CODE-MOD-2 The second modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX184 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX185 CRX.003.185 PROCEDURE-CODE-MOD-3 The third modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX185 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX186 CRX.003.186 PROCEDURE-CODE-MOD-4 The fourth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX186 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX187 CRX.003.187 PROCEDURE-CODE-MOD-5 The fifth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX187 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX188 CRX.003.188 PROCEDURE-CODE-MOD-6 The sixth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX188 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX189 CRX.003.189 PROCEDURE-CODE-MOD-7 The seventh modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX189 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX190 CRX.003.190 PROCEDURE-CODE-MOD-8 The eighth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX190 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX191 CRX.003.191 PROCEDURE-CODE-MOD-9 The ninth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX191 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX192 CRX.003.192 PROCEDURE-CODE-MOD-10 The tenth modifier associated with the procedure code (or if procedure code is missing, then the modifier may be associated with an NDC or Unique Device Identifier). CRX192 Values CRX00003 CLAIM-LINE-RECORD-RX
CRX193 CRX.003.193 GME-AMOUNT-PAID The amount included in the Medicaid Amount (CRX.003.125) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX194 CRX.003.194 SDP-ALLOWED-AMT The component (in dollar and cents) of the allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX195 CRX.003.195 SDP-PAID-AMT The component (in dollar and cents) of the paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX153 CRX.003.153 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CRX00003 CLAIM-LINE-RECORD-RX
CRX196 CRX.004.196 RECORD-ID 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.). CRX196 Values CRX00004 CLAIM-DX-RX
CRX197 CRX.004.197 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CRX197 Values CRX00004 CLAIM-DX-RX
CRX198 CRX.004.198 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A CRX00004 CLAIM-DX-RX
CRX199 CRX.004.199 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A CRX00004 CLAIM-DX-RX
CRX200 CRX.004.200 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A CRX00004 CLAIM-DX-RX
CRX201 CRX.004.201 ADJUSTMENT-IND Indicates the type of adjustment record. CRX201 Values CRX00004 CLAIM-DX-RX
CRX202 CRX.004.202 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A CRX00004 CLAIM-DX-RX
CRX203 CRX.004.203 DIAGNOSIS-TYPE Indicates the context of the diagnosis code from the provider's claim (i.e., an NCPDP claim can have up to 5 diagnosis codes). The type of diagnosis code (e.g., principal, admitting, external cause of injury, or other) is captured here. The order in which the diagnosis code was reported is captured in the Diagnosis Sequence Number. CRX203 Values CRX00004 CLAIM-DX-RX
CRX204 CRX.004.204 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 NCPDP claim can have up to 5 diagnosis codes). N/A CRX00004 CLAIM-DX-RX
CRX205 CRX.004.205 DIAGNOSIS-CODE-FLAG Flag used to identify wither the associated Diagnosis Code value is a ICD-9 or ICD-10 code. CRX205 Values CRX00004 CLAIM-DX-RX
CRX206 CRX.004.206 DIAGNOSIS-CODE ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as '2105'. CRX206 Values CRX00004 CLAIM-DX-RX
CRX207 CRX.004.207 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A CRX00004 CLAIM-DX-RX
ELG001 ELG.001.001 RECORD-ID 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.). ELG001 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG002 ELG.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. ELG002 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG003 ELG.001.003 SUBMISSION-TRANSACTION-TYPE 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. ELG003 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG004 ELG.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. ELG004 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG005 ELG.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG006 ELG.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG007 ELG.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG007 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG008 ELG.001.008 DATE-FILE-CREATED The date on which the file was created. N/A ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG009 ELG.001.009 START-OF-TIME-PERIOD 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 ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG010 ELG.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG011 ELG.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. ELG011 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG012 ELG.001.012 SSN-INDICATOR 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. ELG012 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG013 ELG.001.013 TOT-REC-CNT 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 ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG272 ELG.001.272 FILE-SUBMISSION-METHOD The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. ELG272 Values ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG247 ELG.001.247 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG014 ELG.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00001 FILE-HEADER-RECORD-ELIGIBILITY
ELG016 ELG.002.016 RECORD-ID 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.). ELG016 Values ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG017 ELG.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG017 Values ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG018 ELG.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG019 ELG.002.019 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG020 ELG.002.020 ELIGIBLE-FIRST-NAME Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG021 ELG.002.021 ELIGIBLE-LAST-NAME Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG022 ELG.002.022 ELIGIBLE-MIDDLE-INIT Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG024 ELG.002.024 DATE-OF-BIRTH An individual's date of birth. N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG025 ELG.002.025 DATE-OF-DEATH The date an individual died on. N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG026 ELG.002.026 PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG027 ELG.002.027 PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG028 ELG.002.028 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY
ELG030 ELG.003.030 RECORD-ID 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.). ELG030 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG031 ELG.003.031 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG031 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG032 ELG.003.032 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG033 ELG.003.033 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG034 ELG.003.034 MARITAL-STATUS A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state's marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. ELG034 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG035 ELG.003.035 MARITAL-STATUS-OTHER-EXPLANATION A free-text field to capture the description of the marital/domestic-relationship status when Marital Status =14 (Other) is selected. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG036 ELG.003.036 SSN The eligible individual's social security number. For newborns when value is unknown it is not required. For SSN states, in instances where the social security number is not known and a temporary MSIS Identification Number is used, the MSIS Identification Number field should be populated with the temporary MSIS Identification Number and the SSN field should be space-filled, or blank. When the SSN becomes known, the MSIS Identification Number field should continue to be populated with the temporary MSIS Identification Number and the SSN field should be populated with the newly acquired SSN for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS Identification Number and the social security number. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG037 ELG.003.037 SSN-VERIFICATION-FLAG A code describing whether the state has verified the social security number (SSN) with the Social Security Administration (SSA). ELG037 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG038 ELG.003.038 INCOME-CODE A code indicating the federal poverty level range in which the family income falls. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group. A beneficiary's income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. ELG038 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG039 ELG.003.039 VETERAN-IND A flag indicating if a non-citizen is exempt from the 5-year bar on benefits because they are a veteran or an active member of the military, naval or air service. ELG039 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG040 ELG.003.040 CITIZENSHIP-IND Indicates if the individual is identified as a U.S. Citizen. ELG040 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG041 ELG.003.041 CITIZENSHIP-VERIFICATION-FLAG Indicates the individual is enrolled in Medicaid pending citizenship verification. ELG041 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG042 ELG.003.042 IMMIGRATION-STATUS The immigration status of the individual. ELG042 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG043 ELG.003.043 IMMIGRATION-VERIFICATION-FLAG Indicates the individual is enrolled in Medicaid pending immigration verification. ELG043 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG044 ELG.003.044 IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified noncitizen." N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG045 ELG.003.045 ENGL-PROF-CODE A code indicating the level of spoken English proficiency by the individual. ELG045 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG046 ELG.003.046 PREFERRED-LANGUAGE-CODE A code indicating the language that is the individuals' preferred spoken or written language. ELG046 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG047 ELG.003.047 HOUSEHOLD-SIZE Household Size used in the Medicaid or CHIP eligibility determination process. ELG047 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG049 ELG.003.049 PREGNANCY-IND A flag indicating the individual is pregnant at the time of application based on self-attestation. ELG049 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG050 ELG.003.050 MEDICARE-HIC-NUM The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG051 ELG.003.051 MEDICARE-BENEFICIARY-IDENTIFIER 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 identity 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 ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG054 ELG.003.054 CHIP-CODE A code used to distinguish among Medicaid, Medicaid Expansion CHIP, and Separate CHIP populations. ELG054 Values ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG057 ELG.003.057 VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG058 ELG.003.058 VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG269 ELG.003.269 ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group. A beneficiary�s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG273 ELG.003.273 APPLICATION-SIGNATURE-DATE The date that a beneficiary signed their Medicaid or CHIP application. If the beneficiary was deemed eligible via an administrative determination then a signature may not be applicable/available. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG059 ELG.003.059 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00003 VARIABLE-DEMOGRAPHICS-ELIGIBILITY
ELG061 ELG.004.061 RECORD-ID 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.). ELG061 Values ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG062 ELG.004.062 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG062 Values ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG063 ELG.004.063 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG064 ELG.004.064 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG065 ELG.004.065 ELIGIBLE-ADDR-TYPE The type of address and contact information for the eligible submitted in the record segment. ELG065 Values ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG066 ELG.004.066 ELIGIBLE-ADDR-LN1 The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG067 ELG.004.067 ELIGIBLE-ADDR-LN2 The second line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG068 ELG.004.068 ELIGIBLE-ADDR-LN3 The third line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG069 ELG.004.069 ELIGIBLE-CITY The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG070 ELG.004.070 ELIGIBLE-STATE The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code for where the individual eligible to receive healthcare services resides. (The state for the type of address indicated in Address Type.) ELG070 Values ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG071 ELG.004.071 ELIGIBLE-ZIP-CODE U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) ELG071 Values ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG072 ELG.004.072 ELIGIBLE-COUNTY-CODE Standard ANSI code used to identify a specific U.S. County. ELG072 Values ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG073 ELG.004.073 ELIGIBLE-PHONE-NUM Phone number for a given entity (e.g. person, organization, agency). N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG074 ELG.004.074 TYPE-OF-LIVING-ARRANGEMENT A free-form text field to describe the type of living arrangement used for the eligibility determination process. N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG075 ELG.004.075 ELIGIBLE-ADDR-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG076 ELG.004.076 ELIGIBLE-ADDR-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG077 ELG.004.077 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00004 ELIGIBLE-CONTACT-INFORMATION
ELG079 ELG.005.079 RECORD-ID 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.). ELG079 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG080 ELG.005.080 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG080 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG081 ELG.005.081 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG082 ELG.005.082 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG083 ELG.005.083 MSIS-CASE-NUM The state-assigned number which uniquely identifies the Medicaid case to which the enrollee belongs. The definition of a case varies. There are single-person cases (mostly aged and blind/disabled) and multi-person cases (mostly TANF) in which all members of the case have the same case number, but a unique identification number. A warning for longitudinal research efforts: a case numbers associated with an individual may change over time. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG085 ELG.005.085 DUAL-ELIGIBLE-CODE Indicates coverage for individuals entitled to Medicare (Part A and/or B benefits) and eligible for some category of Medicaid benefits. ELG085 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG086 ELG.005.086 PRIMARY-ELIGIBILITY-GROUP-IND A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollees' eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0. ELG086 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG087 ELG.005.087 ELIGIBILITY-GROUP The eligibility group applicable to the individual based on the eligibility determination process. The valid value list of eligibility groups aligns with those being used in the Medicaid and CHIP Program Data System (MACPro). ELG087 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG088 ELG.005.088 LEVEL-OF-CARE-STATUS The level of care required to meet an individual's needs and to determine LTSS program eligibility. ELG088 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG089 ELG.005.089 SSDI-IND A flag indicating if the individual is enrolled in Social Security Disability Insurance (SSDI) administered via the Social Security Administration (SSA). ELG089 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG090 ELG.005.090 SSI-IND A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA). ELG090 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG091 ELG.005.091 SSI-STATE-SUPPLEMENT-STATUS-CODE Indicates the individual's State Supplemental Income Status. ELG091 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG092 ELG.005.092 SSI-STATUS Indicates the individual's SSI Status. ELG092 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG093 ELG.005.093 STATE-SPEC-ELIG-GROUP The composite of eligibility mapping factors used to create the corresponding Maintenance Assistance Status (MAS) and Basis of Eligibility (BOE) values (before January 1, 2014) and Eligibility Group values (on or after January 1, 2014). This field should not include information that already appears elsewhere on the Eligible File record even if it is part of the MAS and BOE or Eligibility Group algorithm (e.g., age information computed from Date of Birth or County Code). N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG094 ELG.005.094 CONCEPTION-TO-BIRTH-IND A flag to identify children eligible through the conception to birth option, which is available only through a separate State CHIP Program. ELG094 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG095 ELG.005.095 ELIGIBILITY-TERMINATION-REASON The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21'; (Other) '22'; (Unknown), then the state should not report the co-occurring value '21'; and/or '22'; to T-MSIS. If there are multiple co-occurring distinct values between '01'; and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01'; through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. ELG095 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG097 ELG.005.097 RESTRICTED-BENEFITS-CODE A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to. ELG097 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG098 ELG.005.098 TANF-CASH-CODE A flag that indicates whether the individual received Federal Temporary Assistance for Needy Families (TANF) benefits. ELG098 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG099 ELG.005.099 ELIGIBILITY-DETERMINANT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG100 ELG.005.100 ELIGIBILITY-DETERMINANT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG274 ELG.005.274 ELIGIBILITY-REDETERMINATION-DATE The date by which a person's Medicaid or CHIP eligibility must be redetermined, per 1915(i)(1)(I), 42 CFR 435.916, 435.926, any other applicable regulations, or waiver of these regulations. This is effectively the "expiration date" of the eligibility characteristics with which the date is being reported. Upon this date the state is required to perform a renewal or redetermination of the individual's eligibility. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG275 ELG.005.275 ELIGIBILITY-EXTENSION-CODE A code to identify the authority used to extend eligibility during the period of coverage. This code should correspond to the eligibility characteristics, including eligibility redetermination date, with which the code is being reported. ELG275 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG276 ELG.005.276 ELIGIBILITY-EXTENSION-OTHER-TEXT A free-form text field where a state can identify the 'Other' authority used to extend eligibility. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG277 ELG.005.277 CONTINUOUS-ELIGIBILITY-CODE A code to identify the authority used to provide continuous eligibility during the period of coverage ELG277 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG278 ELG.005.278 CONTINUOUS-ELIGIBILITY-OTHER-TEXT A free-form text field where a state can identify the "other" authority used to provide continuous eligibility. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG279 ELG.005.279 INCOME-STANDARD-CODE An indicator that identifies the income standard used by the state to assign the corresponding primary eligibility group. ELG279 Values ELG00005 ELIGIBILITY-DETERMINANTS
ELG280 ELG.005.280 INCOME-STANDARD-OTHER-TEXT A free-form text field where a state can identify the "other" income standard used to assign the corresponding primary eligibility group. Required when "Other" is reported to Income Standard Code. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG281 ELG.005.281 ELIGIBILITY-TERMINATION-REASON-OTHER-TYPE-TEXT Value must be populated with a state-specific reason for termination when the ELIGIBILITY-TERMINATION-REASON value is 'Other'. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG101 ELG.005.101 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00005 ELIGIBILITY-DETERMINANTS
ELG103 ELG.006.103 RECORD-ID 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.). ELG103 Values ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG104 ELG.006.104 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG104 Values ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG105 ELG.006.105 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG106 ELG.006.106 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG107 ELG.006.107 HEALTH-HOME-SPA-NAME A free-form text field for the name of the health home program approved by CMS. This name needs to be consistent across files to be used for linking. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG108 ELG.006.108 HEALTH-HOME-ENTITY-NAME A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG109 ELG.006.109 HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG110 ELG.006.110 HEALTH-HOME-SPA-PARTICIPATION-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG111 ELG.006.111 HEALTH-HOME-ENTITY-EFF-DATE The date on which the health home entity was approved by CMS to participate in the Health Home Program. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG112 ELG.006.112 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00006 HEALTH-HOME-SPA-PARTICIPATION-INFORMATION
ELG114 ELG.007.114 RECORD-ID 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.). ELG114 Values ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG115 ELG.007.115 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG115 Values ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG116 ELG.007.116 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG117 ELG.007.117 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG118 ELG.007.118 HEALTH-HOME-SPA-NAME A free-form text field for the name of the health home program approved by CMS. This name needs to be consistent across files to be used for linking. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG119 ELG.007.119 HEALTH-HOME-ENTITY-NAME A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG120 ELG.007.120 HEALTH-HOME-PROV-NUM The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG121 ELG.007.121 HEALTH-HOME-SPA-PROVIDER-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG122 ELG.007.122 HEALTH-HOME-SPA-PROVIDER-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG123 ELG.007.123 HEALTH-HOME-ENTITY-EFF-DATE The date on which the health home entity was approved by CMS to participate in the Health Home Program. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG124 ELG.007.124 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00007 HEALTH-HOME-SPA-PROVIDERS
ELG126 ELG.008.126 RECORD-ID 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.). ELG126 Values ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG127 ELG.008.127 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG127 Values ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG128 ELG.008.128 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG129 ELG.008.129 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG130 ELG.008.130 HEALTH-HOME-CHRONIC-CONDITION The chronic condition used to determine the individual's eligibility for the health home provision. ELG130 Values ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG131 ELG.008.131 HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION A free-text field to capture the description of the other chronic condition (or conditions) when value "H" (Other) appears in the Health Home Chronic Condition data element. N/A ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG132 ELG.008.132 HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG133 ELG.008.133 HEALTH-HOME-CHRONIC-CONDITION-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG134 ELG.008.134 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00008 HEALTH-HOME-CHRONIC-CONDITIONS
ELG136 ELG.009.136 RECORD-ID 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.). ELG136 Values ELG00009 LOCK-IN-INFORMATION
ELG137 ELG.009.137 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG137 Values ELG00009 LOCK-IN-INFORMATION
ELG138 ELG.009.138 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00009 LOCK-IN-INFORMATION
ELG139 ELG.009.139 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00009 LOCK-IN-INFORMATION
ELG140 ELG.009.140 LOCKIN-PROV-NUM The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A ELG00009 LOCK-IN-INFORMATION
ELG141 ELG.009.141 LOCKIN-PROV-TYPE A code describing the provider type classification for which the provider/beneficiary lock-in relationship exists. ELG141 Values ELG00009 LOCK-IN-INFORMATION
ELG142 ELG.009.142 LOCKIN-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00009 LOCK-IN-INFORMATION
ELG143 ELG.009.143 LOCKIN-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00009 LOCK-IN-INFORMATION
ELG270 ELG.009.270 LOCKED-IN-SRVCS The type(s) of services that are locked-in. ELG270 Values ELG00009 LOCK-IN-INFORMATION
ELG144 ELG.009.144 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00009 LOCK-IN-INFORMATION
ELG146 ELG.010.146 RECORD-ID 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.). ELG146 Values ELG00010 MFP-INFORMATION
ELG147 ELG.010.147 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG147 Values ELG00010 MFP-INFORMATION
ELG148 ELG.010.148 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00010 MFP-INFORMATION
ELG149 ELG.010.149 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00010 MFP-INFORMATION
ELG150 ELG.010.150 MFP-LIVES-WITH-FAMILY A code indicating if the individual lives with his/her family or is not a participant in the MFP program. ELG150 Values ELG00010 MFP-INFORMATION
ELG151 ELG.010.151 MFP-QUALIFIED-INSTITUTION A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant. ELG151 Values ELG00010 MFP-INFORMATION
ELG152 ELG.010.152 MFP-QUALIFIED-RESIDENCE A code indicating the type of qualified residence. ELG152 Values ELG00010 MFP-INFORMATION
ELG153 ELG.010.153 MFP-REASON-PARTICIPATION-ENDED A code describing why an individual's participation in Money Follows the Person demonstration ended. ELG153 Values ELG00010 MFP-INFORMATION
ELG154 ELG.010.154 MFP-REINSTITUTIONALIZED-REASON A code describing why the individual was reinstitutionalized after participation in the Money Follows the Person Demonstration. ELG154 Values ELG00010 MFP-INFORMATION
ELG155 ELG.010.155 MFP-ENROLLMENT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00010 MFP-INFORMATION
ELG156 ELG.010.156 MFP-ENROLLMENT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00010 MFP-INFORMATION
ELG157 ELG.010.157 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00010 MFP-INFORMATION
ELG159 ELG.011.159 RECORD-ID 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.). ELG159 Values ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG160 ELG.011.160 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG160 Values ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG161 ELG.011.161 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG162 ELG.011.162 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG163 ELG.011.163 STATE-PLAN-OPTION-TYPE This field specifies the State Plan Options in which the individual is enrolled. Use on occurrence for each State Plan Option enrollment. ELG163 Values ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG164 ELG.011.164 STATE-PLAN-OPTION-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG165 ELG.011.165 STATE-PLAN-OPTION-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG166 ELG.011.166 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00011 STATE-PLAN-OPTION-PARTICIPATION
ELG168 ELG.012.168 RECORD-ID 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.). ELG168 Values ELG00012 WAIVER-PARTICIPATION
ELG169 ELG.012.169 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG169 Values ELG00012 WAIVER-PARTICIPATION
ELG170 ELG.012.170 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00012 WAIVER-PARTICIPATION
ELG171 ELG.012.171 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00012 WAIVER-PARTICIPATION
ELG172 ELG.012.172 WAIVER-ID Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A ELG00012 WAIVER-PARTICIPATION
ELG173 ELG.012.173 WAIVER-TYPE Code for specifying waiver types under which the eligible individual is covered during the month. ELG173 Values ELG00012 WAIVER-PARTICIPATION
ELG174 ELG.012.174 WAIVER-ENROLLMENT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00012 WAIVER-PARTICIPATION
ELG175 ELG.012.175 WAIVER-ENROLLMENT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00012 WAIVER-PARTICIPATION
ELG176 ELG.012.176 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00012 WAIVER-PARTICIPATION
ELG178 ELG.013.178 RECORD-ID 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.). ELG178 Values ELG00013 LTSS-PARTICIPATION
ELG179 ELG.013.179 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG179 Values ELG00013 LTSS-PARTICIPATION
ELG180 ELG.013.180 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00013 LTSS-PARTICIPATION
ELG181 ELG.013.181 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00013 LTSS-PARTICIPATION
ELG182 ELG.013.182 LTSS-LEVEL-CARE The level of care provided to the individual by the long term care facility. ELG182 Values ELG00013 LTSS-PARTICIPATION
ELG183 ELG.013.183 LTSS-PROV-NUM A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual. N/A ELG00013 LTSS-PARTICIPATION
ELG184 ELG.013.184 LTSS-ELIGIBILITY-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00013 LTSS-PARTICIPATION
ELG185 ELG.013.185 LTSS-ELIGIBILITY-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00013 LTSS-PARTICIPATION
ELG186 ELG.013.186 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00013 LTSS-PARTICIPATION
ELG188 ELG.014.188 RECORD-ID 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.). ELG188 Values ELG00014 MANAGED-CARE-PARTICIPATION
ELG189 ELG.014.189 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG189 Values ELG00014 MANAGED-CARE-PARTICIPATION
ELG190 ELG.014.190 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00014 MANAGED-CARE-PARTICIPATION
ELG191 ELG.014.191 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00014 MANAGED-CARE-PARTICIPATION
ELG192 ELG.014.192 MANAGED-CARE-PLAN-ID The managed care plan identification number under which the eligible individual is enrolled. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed-Care-Plan-ID in the Eligible File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-eligible-file-managed-care/ See T-MSIS Guidance Document, "CMS Guidance: Preliminary guidance for Primary Care Case Management Reporting". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-guidance-primary-care-case-management-reporting-updated/ N/A ELG00014 MANAGED-CARE-PARTICIPATION
ELG193 ELG.014.193 MANAGED-CARE-PLAN-TYPE A model of health care delivery organized to provide a defined set of services. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/ ELG193 Values ELG00014 MANAGED-CARE-PARTICIPATION
ELG196 ELG.014.196 MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00014 MANAGED-CARE-PARTICIPATION
ELG197 ELG.014.197 MANAGED-CARE-PLAN-ENROLLMENT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00014 MANAGED-CARE-PARTICIPATION
ELG198 ELG.014.198 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00014 MANAGED-CARE-PARTICIPATION
ELG200 ELG.015.200 RECORD-ID 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.). ELG200 Values ELG00015 ETHNICITY-INFORMATION
ELG201 ELG.015.201 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG201 Values ELG00015 ETHNICITY-INFORMATION
ELG202 ELG.015.202 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00015 ETHNICITY-INFORMATION
ELG203 ELG.015.203 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00015 ETHNICITY-INFORMATION
ELG204 ELG.015.204 ETHNICITY-CODE A code indicating that the individual's ethnicity is Hispanic, Latino/a, or Spanish ethnicity of a Medicaid/CHIP enrolled individual. Ethnicity Code clarifications: If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified." NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. ELG204 Values ELG00015 ETHNICITY-INFORMATION
ELG205 ELG.015.205 ETHNICITY-DECLARATION-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00015 ETHNICITY-INFORMATION
ELG206 ELG.015.206 ETHNICITY-DECLARATION-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00015 ETHNICITY-INFORMATION
ELG271 ELG.015.271 ETHNICITY-OTHER A freeform field to document the ethnicity of the beneficiary when the beneficiary identifies themselves as Another Hispanic, Latino, or Spanish origin (ethnicity code 4). N/A ELG00015 ETHNICITY-INFORMATION
ELG207 ELG.015.207 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00015 ETHNICITY-INFORMATION
ELG209 ELG.016.209 RECORD-ID 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.). ELG209 Values ELG00016 RACE-INFORMATION
ELG210 ELG.016.210 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG210 Values ELG00016 RACE-INFORMATION
ELG211 ELG.016.211 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00016 RACE-INFORMATION
ELG212 ELG.016.212 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00016 RACE-INFORMATION
ELG213 ELG.016.213 RACE A code indicating the individual's race either in accordance with requirements of Section 4302 of the Affordable Care Act classifications. Race Code clarifications: If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown". If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," "Unspecified" or "Unknown". If state has beneficiaries coded in their database as "Other" with no additional detail or in a category that is not available in the code set provided, then code them in T-MSIS as "Other" (valid value "018"), but only use "Other" if the use of "Other Asian" or "Other Pacific Islander" are not appropriate. DO NOT USE "Unspecified" or "Unknown". The "Other" valid value was added to T-MSIS to better align T-MSIS with the single-streamlined application and to accommodate some atypical states, despite the requirements of Section 4302 of the ACA. NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese). NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question. ELG213 Values ELG00016 RACE-INFORMATION
ELG214 ELG.016.214 RACE-OTHER A freeform field to document the race of the beneficiary when the beneficiary identifies themselves as Other Asian, Other Pacific Islander (race codes 010 or 015). N/A ELG00016 RACE-INFORMATION
ELG215 ELG.016.215 AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR 'American Indian or Alaska Native' means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the 'Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? ELG215 Values ELG00016 RACE-INFORMATION
ELG216 ELG.016.216 RACE-DECLARATION-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00016 RACE-INFORMATION
ELG217 ELG.016.217 RACE-DECLARATION-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00016 RACE-INFORMATION
ELG218 ELG.016.218 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00016 RACE-INFORMATION
ELG220 ELG.017.220 RECORD-ID 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.). ELG220 Values ELG00017 DISABILITY-INFORMATION
ELG221 ELG.017.221 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG221 Values ELG00017 DISABILITY-INFORMATION
ELG222 ELG.017.222 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00017 DISABILITY-INFORMATION
ELG223 ELG.017.223 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00017 DISABILITY-INFORMATION
ELG224 ELG.017.224 DISABILITY-TYPE-CODE A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act. ELG224 Values ELG00017 DISABILITY-INFORMATION
ELG225 ELG.017.225 DISABILITY-TYPE-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00017 DISABILITY-INFORMATION
ELG226 ELG.017.226 DISABILITY-TYPE-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00017 DISABILITY-INFORMATION
ELG227 ELG.017.227 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00017 DISABILITY-INFORMATION
ELG229 ELG.018.229 RECORD-ID 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.). ELG229 Values ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG230 ELG.018.230 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG230 Values ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG231 ELG.018.231 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG232 ELG.018.232 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG233 ELG.018.233 1115A-DEMONSTRATION-IND Indicates that the individual participates in an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation (CMMI) demonstration. ELG233 Values ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG234 ELG.018.234 1115A-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG235 ELG.018.235 1115A-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG236 ELG.018.236 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00018 1115A-DEMONSTRATION-INFORMATION
ELG238 ELG.020.238 RECORD-ID 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.). ELG238 Values ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG239 ELG.020.239 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG239 Values ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG240 ELG.020.240 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG241 ELG.020.241 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG242 ELG.020.242 HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE The chronic condition for which the eligible person is receiving non-Health-Home home and community based care. ELG242 Values ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG243 ELG.020.243 HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG244 ELG.020.244 HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG245 ELG.020.245 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00020 HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME
ELG248 ELG.021.248 RECORD-ID 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.). ELG248 Values ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG249 ELG.021.249 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG249 Values ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG250 ELG.021.250 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG251 ELG.021.251 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG252 ELG.021.252 ENROLLMENT-TYPE Identify the type of enrollment that the eligible person has been enrolled into as either Medicaid/Medicaid Expansion CHIP or Separate CHIP. ELG252 Values ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG253 ELG.021.253 ENROLLMENT-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG254 ELG.021.254 ENROLLMENT-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG255 ELG.021.255 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00021 ENROLLMENT-TIME-SPAN-SEGMENT
ELG257 ELG.022.257 RECORD-ID 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.). ELG257 Values ELG00022 ELG-IDENTIFIERS
ELG258 ELG.022.258 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. ELG258 Values ELG00022 ELG-IDENTIFIERS
ELG259 ELG.022.259 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A ELG00022 ELG-IDENTIFIERS
ELG260 ELG.022.260 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A ELG00022 ELG-IDENTIFIERS
ELG261 ELG.022.261 ELG-IDENTIFIER-TYPE A code to identify the kind of eligible identifier that is captured in the Eligible Identifier data element. ELG261 Values ELG00022 ELG-IDENTIFIERS
ELG262 ELG.022.262 ELG-IDENTIFIER-ISSUING-ENTITY-ID This data element is reserved for future use. N/A ELG00022 ELG-IDENTIFIERS
ELG263 ELG.022.263 ELG-IDENTIFIER-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A ELG00022 ELG-IDENTIFIERS
ELG264 ELG.022.264 ELG-IDENTIFIER-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A ELG00022 ELG-IDENTIFIERS
ELG265 ELG.022.265 ELG-IDENTIFIER A data element to capture the various identifiers assigned to Medicaid and CHIP beneficiary by various entities. The specific type of identifier is shown in the corresponding value in the Eligible Identifier Type data element. States should provide all Old MSIS Identification Number with Eligible Identifier Type = 2 to T-MSIS in case the state changes the MSIS Identification Number of a beneficiary. The state should submit updates to T-MSIS whenever an identifier is retired or issued. States should provide Old MSIS Identification Number with Reason for Change = 'MERGE' to T-MSIS if the state was reporting multiple MSIS Identification Numbers for a single beneficiary and merges them under a single MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = 'UNMERGE' to T-MSIS if the state unmerges a beneficiary from another beneficiary. For example, if a newborn child is originally reported with the mother's MSIS Identification Number and is then assigned a different MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = 'LSE' to T-MSIS if the state assigns a new MSIS Identification Number to any beneficiaries during large system enhancement in state MMIS. States should provide Old MSIS Identification Number with Reason for Change = 'TCAM' to T-MSIS if the Medicaid and Separate CHIP programs use different MSIS Identifier Number schemas and beneficiaries are transferred from CHIP to Medicaid or from Medicaid to CHIP and a new MSIS Identification Number is issued. N/A ELG00022 ELG-IDENTIFIERS
ELG266 ELG.022.266 REASON-FOR-CHANGE A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligible Identifier Type = '2-Old MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID' or 'Unmerge'. ELG266 Values ELG00022 ELG-IDENTIFIERS
ELG267 ELG.022.267 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A ELG00022 ELG-IDENTIFIERS
FTX001 FTX.001.001 RECORD-ID 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.). FTX001 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX002 FTX.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. FTX002 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX003 FTX.001.003 SUBMISSION-TRANSACTION-TYPE 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. FTX003 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX004 FTX.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. FTX004 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX005 FTX.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX006 FTX.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX007 FTX.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX007 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX008 FTX.001.008 DATE-FILE-CREATED The date on which the file was created. N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX009 FTX.001.009 START-OF-TIME-PERIOD newly acquired SSN for at least one monthly submission of the Eligible File so that T-MSIS can associated the temporary MSIS Identification Number and the social security number. N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX010 FTX.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX011 FTX.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. FTX011 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX012 FTX.001.012 SSN-INDICATOR with the temporary MSIS Identification Number and the SSN field should be space-filled, or blank. When the SSN becomes known, the MSIS Identification Number field should continue to be populated with the temporary MSIS Identification Number and the SSN field should be populated with the FTX012 Values FTX00001 FILE-HEADER-RECORD-FTX
FTX013 FTX.001.013 TOT-REC-CNT A count of all records in the file except for the file header record. This count will be used as a control total to help assure that the file did not become corrupted during transmission. N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX014 FTX.001.014 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e. update files, replace files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX015 FTX.001.015 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00001 FILE-HEADER-RECORD-FTX
FTX017 FTX.002.017 RECORD-ID 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.). FTX017 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX018 FTX.002.018 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX018 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX019 FTX.002.019 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX020 FTX.002.020 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX021 FTX.002.021 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX023 FTX.002.023 ADJUSTMENT-IND Indicates the type of adjustment record. FTX023 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX024 FTX.002.024 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX025 FTX.002.025 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX026 FTX.002.026 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX027 FTX.002.027 CHECK-NUM The check or electronic funds transfer number. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX028 FTX.002.028 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX029 FTX.002.029 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX029 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX030 FTX.002.030 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX031 FTX.002.031 PAYER-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX031 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX032 FTX.002.032 PAYER-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other". N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX033 FTX.002.033 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically correspond to the X12 820 Premium Receiver. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX034 FTX.002.034 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX034 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX035 FTX.002.035 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX036 FTX.002.036 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX036 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX037 FTX.002.037 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX038 FTX.002.038 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. This will typically belong to the entity identified as the X12 820 Premium Receiver. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX039 FTX.002.039 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX039 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX040 FTX.002.040 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX041 FTX.002.041 CONTRACT-ID Managed care plan contract ID N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX042 FTX.002.042 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX043 FTX.002.043 CAPITATION-PERIOD-START-DATE The date representing the beginning of the period covered by the capitation or sub-capitation payment or recoupment; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX044 FTX.002.044 CAPITATION-PERIOD-END-DATE The date representing the end of the period covered by the capitation or sub-capitation payment or recoupment; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX045 FTX.002.045 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX045 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX048 FTX.002.048 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX048 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX047 FTX.002.047 MBESCBES-FORM 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. FTX047 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX046 FTX.002.046 MBESCBES-CATEGORY-OF-SERVICE 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. FTX046 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX049 FTX.002.049 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX050 FTX.002.050 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX050 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX051 FTX.002.051 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX051 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX052 FTX.002.052 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX052 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX053 FTX.002.053 SDP-IND Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. FTX053 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX054 FTX.002.054 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX054 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX055 FTX.002.055 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX056 FTX.002.056 SUBCAPITATION-IND Indicates whether the transaction represents a sub-capitation payment between a managed care plan and a sub-capitated entity or sub-capitated network provider or not. A sub-capitation payment could also be between a sub-capitated entity and another sub-capitated entity or sub-capitated network provider. FTX056 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX057 FTX.002.057 PAYMENT-CAT-XREF Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX058 FTX.002.058 RATE-CELL-DESCRIPTION-TEXT This is the description of the rate cell from the rate setting process that applies to the capitation payment. For example, a rate cell may represent the monthly capitation rate paid for adults with chronic conditions who live in a rural area. If the rate paid for this capitation payment is based on the rate cell for adults with chronic conditions who live in a rural area, then the rate cell description could be "Adults with chronic conditions living in a rural area." N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX059 FTX.002.059 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX059 Values FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX060 FTX.002.060 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX061 FTX.002.061 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX062 FTX.002.062 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX064 FTX.003.064 RECORD-ID 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.). FTX064 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX065 FTX.003.065 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX065 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX066 FTX.003.066 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX067 FTX.003.067 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX068 FTX.003.068 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX070 FTX.003.070 ADJUSTMENT-IND Indicates the type of adjustment record. FTX070 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX071 FTX.003.071 PAYMENT-OR-RECOUPMENT-DATE The date that the payment was executed by the payer. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX072 FTX.003.072 PAYMENT-AMOUNT The dollar amount being paid to the payee. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX073 FTX.003.073 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX074 FTX.003.074 CHECK-NUM The check or electronic funds transfer number. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX075 FTX.003.075 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of making a payment, as opposed to the payee who is the object of the transaction. The payer is the entity that is making a payment. The payee is the individual or entity that is receiving a payment. This will typically correspond to the X12 820 Premium Payer. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX076 FTX.003.076 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX076 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX077 FTX.003.077 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX078 FTX.003.078 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is receiving a payment. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of making a payment. This will typically correspond to the X12 820 Premium Receiver. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX079 FTX.003.079 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX079 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX080 FTX.003.080 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX081 FTX.003.081 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is a payment. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of making a payment. This will typically belong to the entity identified as the X12 820 Premium Receiver. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX082 FTX.003.082 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX082 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX083 FTX.003.083 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX084 FTX.003.084 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX085 FTX.003.085 INSURANCE-PLAN-ID The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX086 FTX.003.086 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX087 FTX.003.087 MEMBER-ID Member identification number as it appears on the card issued by the TPL insurance carrier. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX088 FTX.003.088 PREMIUM-PERIOD-START-DATE The date representing the beginning of the period covered by the premium payment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX089 FTX.003.089 PREMIUM-PERIOD-END-DATE The date representing the end of the period covered by the premium payment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX090 FTX.003.090 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX090 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX093 FTX.003.093 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX093 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX092 FTX.003.092 MBESCBES-FORM 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. FTX092 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX091 FTX.003.091 MBESCBES-CATEGORY-OF-SERVICE 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. FTX091 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX094 FTX.003.094 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX095 FTX.003.095 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX095 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX096 FTX.003.096 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX096 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX097 FTX.003.097 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX097 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX098 FTX.003.098 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX098 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX099 FTX.003.099 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX100 FTX.003.100 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX100 Values FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX101 FTX.003.101 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX102 FTX.003.102 MEMO This represents any notes from the state's ledger/accounting system associated with the payment. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX103 FTX.003.103 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX105 FTX.004.105 RECORD-ID 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.). FTX105 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX106 FTX.004.106 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX106 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX107 FTX.004.107 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX108 FTX.004.108 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX109 FTX.004.109 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX111 FTX.004.111 ADJUSTMENT-IND Indicates the type of adjustment record. FTX111 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX112 FTX.004.112 PAYMENT-DATE The date that the payment was executed by the payer. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX113 FTX.004.113 PAYMENT-AMOUNT The dollar amount being paid to the payee. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX114 FTX.004.114 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX115 FTX.004.115 CHECK-NUM The check or electronic funds transfer number. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX116 FTX.004.116 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of making a payment, as opposed to the payee who is the object of the transaction. The payer is the entity that is making a payment. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. This will typically correspond to the X12 820 Premium Payer. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX117 FTX.004.117 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX117 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX118 FTX.004.118 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX119 FTX.004.119 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is receiving a payment. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of making a payment. This will typically correspond to the X12 820 Premium Receiver. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX120 FTX.004.120 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX120 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX121 FTX.004.121 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX122 FTX.004.122 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is receiving a payment. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of making a payment. This will typically belong to the entity identified as the X12 820 Premium Receiver. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX123 FTX.004.123 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX123 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX124 FTX.004.124 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX125 FTX.004.125 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX126 FTX.004.126 INSURANCE-PLAN-ID The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX127 FTX.004.127 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ MSIS-IDENTIFICATION-NUM is conditional in the FTX00004 segment because some members of a private group policy may not be eligible for Medicaid or CHIP, though at least one member of the group policy must be eligible for Medicaid or CHIP. There should be one FTX00004 segment for each member of the group policy for which the premium assistance payment is being paid, regardless of whether the member of the group policy was eligible for and enrolled in Medicaid or CHIP. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX128 FTX.004.128 SSN The SSN of the member of the group insurance policy. Each FTX00004 segment represents a different member of a given group insurance policy. Typically all members of the group insurance policy will have both an MSIS ID and an SSN. Under some circumstances, it's possible that or more members of a group insurance policy do not have an MSIS ID, but do have an SSN, if they are included on the group insurance policy but not eligible for Medicaid or CHIP. It�s also possible that one or more members of a group insurance policy do not have an SSN. If a member of a group insurance policy does not have an SSN, leave this field blank. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX129 FTX.004.129 MEMBER-ID Member identification number as it appears on the card issued by the TPL insurance carrier. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX130 FTX.004.130 GROUP-NUM The group number of the TPL health insurance policy. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX131 FTX.004.131 POLICY-OWNER-CODE This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary. FTX131 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX132 FTX.004.132 PREMIUM-PERIOD-START-DATE The date representing the beginning of the period covered by the premium payment; for example, the first day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX133 FTX.004.133 PREMIUM-PERIOD-END-DATE The date representing the end of the period covered by the premium payment; for example, the last day of the calendar month of beneficiary coverage in the insurance plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month). N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX134 FTX.004.134 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX134 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX137 FTX.004.137 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX137 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX136 FTX.004.136 MBESCBES-FORM 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. FTX136 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX135 FTX.004.135 MBESCBES-CATEGORY-OF-SERVICE 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. FTX135 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX138 FTX.004.138 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX139 FTX.004.139 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX139 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX140 FTX.004.140 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX140 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX141 FTX.004.141 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX141 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX142 FTX.004.142 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX142 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX143 FTX.004.143 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX144 FTX.004.144 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX144 Values FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX145 FTX.004.145 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX146 FTX.004.146 MEMO This represents any notes from the state's ledger/accounting system associated with the payment. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX147 FTX.004.147 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX149 FTX.005.149 RECORD-ID 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.). FTX149 Values FTX00005 COST-SHARING-OFFSET
FTX150 FTX.005.150 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX150 Values FTX00005 COST-SHARING-OFFSET
FTX151 FTX.005.151 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00005 COST-SHARING-OFFSET
FTX152 FTX.005.152 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00005 COST-SHARING-OFFSET
FTX153 FTX.005.153 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00005 COST-SHARING-OFFSET
FTX155 FTX.005.155 ADJUSTMENT-IND Indicates the type of adjustment record. FTX155 Values FTX00005 COST-SHARING-OFFSET
FTX156 FTX.005.156 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00005 COST-SHARING-OFFSET
FTX157 FTX.005.157 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00005 COST-SHARING-OFFSET
FTX158 FTX.005.158 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00005 COST-SHARING-OFFSET
FTX159 FTX.005.159 CHECK-NUM The check or electronic funds transfer number. N/A FTX00005 COST-SHARING-OFFSET
FTX160 FTX.005.160 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. For beneficiary Cost Sharing Offset, the payer is always the state and the payee is always a beneficiary. N/A FTX00005 COST-SHARING-OFFSET
FTX161 FTX.005.161 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX161 Values FTX00005 COST-SHARING-OFFSET
FTX162 FTX.005.162 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00005 COST-SHARING-OFFSET
FTX163 FTX.005.163 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. For beneficiary Cost Sharing Offset, the beneficiary is always the payee. N/A FTX00005 COST-SHARING-OFFSET
FTX164 FTX.005.164 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX164 Values FTX00005 COST-SHARING-OFFSET
FTX165 FTX.005.165 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00005 COST-SHARING-OFFSET
FTX166 FTX.005.166 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX166 Values FTX00005 COST-SHARING-OFFSET
FTX167 FTX.005.167 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00005 COST-SHARING-OFFSET
FTX168 FTX.005.168 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00005 COST-SHARING-OFFSET
FTX169 FTX.005.169 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX169 Values FTX00005 COST-SHARING-OFFSET
FTX170 FTX.005.170 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00005 COST-SHARING-OFFSET
FTX171 FTX.005.171 CONTRACT-ID Managed care plan contract ID N/A FTX00005 COST-SHARING-OFFSET
FTX172 FTX.005.172 INSURANCE-PLAN-ID The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. N/A FTX00005 COST-SHARING-OFFSET
FTX173 FTX.005.173 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A FTX00005 COST-SHARING-OFFSET
FTX174 FTX.005.174 COVERAGE-PERIOD-START-DATE The date representing the beginning of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the beginning of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them. N/A FTX00005 COST-SHARING-OFFSET
FTX175 FTX.005.175 COVERAGE-PERIOD-END-DATE The date representing the end of the period covered by the capitation payment or premium payment that the beneficiary is offsetting; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan to which the off-setting amount is applied. If returning money to the beneficiary, this is the date representing the end of the period for which the beneficiary had previously made an offsetting payment that is now being returned to them. N/A FTX00005 COST-SHARING-OFFSET
FTX176 FTX.005.176 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX176 Values FTX00005 COST-SHARING-OFFSET
FTX179 FTX.005.179 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX179 Values FTX00005 COST-SHARING-OFFSET
FTX178 FTX.005.178 MBESCBES-FORM 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. FTX178 Values FTX00005 COST-SHARING-OFFSET
FTX177 FTX.005.177 MBESCBES-CATEGORY-OF-SERVICE 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. FTX177 Values FTX00005 COST-SHARING-OFFSET
FTX180 FTX.005.180 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00005 COST-SHARING-OFFSET
FTX181 FTX.005.181 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX181 Values FTX00005 COST-SHARING-OFFSET
FTX182 FTX.005.182 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX182 Values FTX00005 COST-SHARING-OFFSET
FTX183 FTX.005.183 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX183 Values FTX00005 COST-SHARING-OFFSET
FTX184 FTX.005.184 OFFSET-TRANS-TYPE This indicates the type of payment that the beneficiary cost-sharing is/was offsetting. FTX184 Values FTX00005 COST-SHARING-OFFSET
FTX185 FTX.005.185 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX185 Values FTX00005 COST-SHARING-OFFSET
FTX186 FTX.005.186 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00005 COST-SHARING-OFFSET
FTX187 FTX.005.187 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX187 Values FTX00005 COST-SHARING-OFFSET
FTX188 FTX.005.188 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00005 COST-SHARING-OFFSET
FTX189 FTX.005.189 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00005 COST-SHARING-OFFSET
FTX190 FTX.005.190 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00005 COST-SHARING-OFFSET
FTX192 FTX.006.192 RECORD-ID 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.). FTX192 Values FTX00006 VALUE-BASED-PAYMENT
FTX193 FTX.006.193 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX193 Values FTX00006 VALUE-BASED-PAYMENT
FTX194 FTX.006.194 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00006 VALUE-BASED-PAYMENT
FTX195 FTX.006.195 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00006 VALUE-BASED-PAYMENT
FTX196 FTX.006.196 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00006 VALUE-BASED-PAYMENT
FTX198 FTX.006.198 ADJUSTMENT-IND Indicates the type of adjustment record. FTX198 Values FTX00006 VALUE-BASED-PAYMENT
FTX199 FTX.006.199 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00006 VALUE-BASED-PAYMENT
FTX200 FTX.006.200 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00006 VALUE-BASED-PAYMENT
FTX201 FTX.006.201 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00006 VALUE-BASED-PAYMENT
FTX202 FTX.006.202 CHECK-NUM The check or electronic funds transfer number. N/A FTX00006 VALUE-BASED-PAYMENT
FTX203 FTX.006.203 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. N/A FTX00006 VALUE-BASED-PAYMENT
FTX204 FTX.006.204 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX204 Values FTX00006 VALUE-BASED-PAYMENT
FTX205 FTX.006.205 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00006 VALUE-BASED-PAYMENT
FTX206 FTX.006.206 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00006 VALUE-BASED-PAYMENT
FTX207 FTX.006.207 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX207 Values FTX00006 VALUE-BASED-PAYMENT
FTX208 FTX.006.208 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00006 VALUE-BASED-PAYMENT
FTX209 FTX.006.209 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX209 Values FTX00006 VALUE-BASED-PAYMENT
FTX210 FTX.006.210 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00006 VALUE-BASED-PAYMENT
FTX211 FTX.006.211 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00006 VALUE-BASED-PAYMENT
FTX212 FTX.006.212 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX212 Values FTX00006 VALUE-BASED-PAYMENT
FTX213 FTX.006.213 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00006 VALUE-BASED-PAYMENT
FTX214 FTX.006.214 CONTRACT-ID Managed care plan contract ID N/A FTX00006 VALUE-BASED-PAYMENT
FTX215 FTX.006.215 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A FTX00006 VALUE-BASED-PAYMENT
FTX216 FTX.006.216 PERFORMANCE-PERIOD-START-DATE The date representing the beginning of the performance period that the value-based dollar amount is rewarding or penalizing. N/A FTX00006 VALUE-BASED-PAYMENT
FTX217 FTX.006.217 PERFORMANCE-PERIOD-END-DATE The date representing the end of the performance period that the value-based dollar amount is rewarding or penalizing. N/A FTX00006 VALUE-BASED-PAYMENT
FTX218 FTX.006.218 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX218 Values FTX00006 VALUE-BASED-PAYMENT
FTX221 FTX.006.221 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX221 Values FTX00006 VALUE-BASED-PAYMENT
FTX220 FTX.006.220 MBESCBES-FORM 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. FTX220 Values FTX00006 VALUE-BASED-PAYMENT
FTX219 FTX.006.219 MBESCBES-CATEGORY-OF-SERVICE 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. FTX219 Values FTX00006 VALUE-BASED-PAYMENT
FTX222 FTX.006.222 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00006 VALUE-BASED-PAYMENT
FTX223 FTX.006.223 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX223 Values FTX00006 VALUE-BASED-PAYMENT
FTX224 FTX.006.224 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX224 Values FTX00006 VALUE-BASED-PAYMENT
FTX225 FTX.006.225 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX225 Values FTX00006 VALUE-BASED-PAYMENT
FTX226 FTX.006.226 SDP-IND Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. FTX226 Values FTX00006 VALUE-BASED-PAYMENT
FTX227 FTX.006.227 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX227 Values FTX00006 VALUE-BASED-PAYMENT
FTX228 FTX.006.228 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00006 VALUE-BASED-PAYMENT
FTX229 FTX.006.229 VALUE-BASED-PAYMENT-MODEL-TYPE This is the type of value-based payment model to which the financial transaction applies. These values come from the 'Alternative Payment Model (APM) Framework Final White Paper', produced by the Healthcare Learning and Action Network. https://hcp-lan.org/work products/apm-whitepaper.pdf FTX229 Values FTX00006 VALUE-BASED-PAYMENT
FTX230 FTX.006.230 PAYMENT-CAT-XREF Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. N/A FTX00006 VALUE-BASED-PAYMENT
FTX231 FTX.006.231 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX231 Values FTX00006 VALUE-BASED-PAYMENT
FTX232 FTX.006.232 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00006 VALUE-BASED-PAYMENT
FTX233 FTX.006.233 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00006 VALUE-BASED-PAYMENT
FTX234 FTX.006.234 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00006 VALUE-BASED-PAYMENT
FTX236 FTX.007.236 RECORD-ID 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.). FTX236 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX237 FTX.007.237 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX237 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX238 FTX.007.238 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX239 FTX.007.239 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX240 FTX.007.240 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX242 FTX.007.242 ADJUSTMENT-IND Indicates the type of adjustment record. FTX242 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX243 FTX.007.243 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX244 FTX.007.244 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX245 FTX.007.245 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX246 FTX.007.246 CHECK-NUM The check or electronic funds transfer number. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX247 FTX.007.247 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX248 FTX.007.248 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX248 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX249 FTX.007.249 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX250 FTX.007.250 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX251 FTX.007.251 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX251 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX252 FTX.007.252 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX253 FTX.007.253 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX253 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX254 FTX.007.254 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX255 FTX.007.255 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX256 FTX.007.256 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX256 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX257 FTX.007.257 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX258 FTX.007.258 CONTRACT-ID Managed care plan contract ID N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX259 FTX.007.259 PAYMENT-PERIOD-START-DATE The date representing the start of the time period that the payment is expected to be used by the provider. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX260 FTX.007.260 PAYMENT-PERIOD-END-DATE The date representing the end of the time period that the payment is expected to be used by the provider. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX261 FTX.007.261 PAYMENT-PERIOD-TYPE A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment. FTX261 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX262 FTX.007.262 PAYMENT-PERIOD-TYPE-OTHER-TEXT This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other". N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX263 FTX.007.263 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX263 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX266 FTX.007.266 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX266 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX265 FTX.007.265 MBESCBES-FORM 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. FTX265 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX264 FTX.007.264 MBESCBES-CATEGORY-OF-SERVICE 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. FTX264 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX267 FTX.007.267 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX268 FTX.007.268 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX268 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX269 FTX.007.269 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX269 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX270 FTX.007.270 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX270 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX271 FTX.007.271 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX271 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX272 FTX.007.272 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX273 FTX.007.273 PAYMENT-CAT-XREF Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX274 FTX.007.274 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX274 Values FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX275 FTX.007.275 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX276 FTX.007.276 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX277 FTX.007.277 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX279 FTX.008.279 RECORD-ID 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.). FTX279 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX280 FTX.008.280 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX280 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX281 FTX.008.281 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX282 FTX.008.282 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX283 FTX.008.283 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX285 FTX.008.285 ADJUSTMENT-IND Indicates the type of adjustment record. FTX285 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX286 FTX.008.286 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX287 FTX.008.287 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX288 FTX.008.288 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX289 FTX.008.289 CHECK-NUM The check or electronic funds transfer number. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX290 FTX.008.290 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX291 FTX.008.291 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX291 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX292 FTX.008.292 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX293 FTX.008.293 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX294 FTX.008.294 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX294 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX295 FTX.008.295 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX296 FTX.008.296 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX296 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX297 FTX.008.297 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX298 FTX.008.298 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX299 FTX.008.299 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX299 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX300 FTX.008.300 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX301 FTX.008.301 COST-SETTLEMENT-PERIOD-START-DATE The date representing the beginning of the cost settlement period. For example, if the cost settlement is for the first calendar quarter of the year then the Cost Settlement Period Start Date would be January 1 of that year and the Cost Settlement Period End Date would be March 31 of that year. Likewise, if the cost settlement is for the first calendar month of the year then the Cost Settlement Period Start Date would be January 1 of that year and the Cost Settlement Period End Date would be January 31 of that year. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX302 FTX.008.302 COST-SETTLEMENT-PERIOD-END-DATE The date representing the end of the cost-settlement period. For example, if the cost-settlement is for the first calendar quarter of the year, then the cost settlement end date would be March 31 of that year. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX303 FTX.008.303 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX303 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX306 FTX.008.306 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX306 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX305 FTX.008.305 MBESCBES-FORM 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. FTX305 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX304 FTX.008.304 MBESCBES-CATEGORY-OF-SERVICE 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. FTX304 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX307 FTX.008.307 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX308 FTX.008.308 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX308 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX309 FTX.008.309 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX309 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX310 FTX.008.310 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX310 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX311 FTX.008.311 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX311 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX312 FTX.008.312 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX313 FTX.008.313 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX313 Values FTX00008 COST-SETTLEMENT-PAYMENT
FTX314 FTX.008.314 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX315 FTX.008.315 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX316 FTX.008.316 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00008 COST-SETTLEMENT-PAYMENT
FTX318 FTX.009.318 RECORD-ID 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.). FTX318 Values FTX00009 FQHC-WRAP-PAYMENT
FTX319 FTX.009.319 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX319 Values FTX00009 FQHC-WRAP-PAYMENT
FTX320 FTX.009.320 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX321 FTX.009.321 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX322 FTX.009.322 ICN-ADJ A unique claim/transaction number assigned by the state's payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX324 FTX.009.324 ADJUSTMENT-IND Indicates the type of adjustment record. FTX324 Values FTX00009 FQHC-WRAP-PAYMENT
FTX325 FTX.009.325 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX326 FTX.009.326 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX327 FTX.009.327 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX328 FTX.009.328 CHECK-NUM The check or electronic funds transfer number. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX329 FTX.009.329 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX330 FTX.009.330 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX330 Values FTX00009 FQHC-WRAP-PAYMENT
FTX331 FTX.009.331 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00009 FQHC-WRAP-PAYMENT
FTX332 FTX.009.332 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX333 FTX.009.333 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX333 Values FTX00009 FQHC-WRAP-PAYMENT
FTX334 FTX.009.334 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00009 FQHC-WRAP-PAYMENT
FTX335 FTX.009.335 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX335 Values FTX00009 FQHC-WRAP-PAYMENT
FTX336 FTX.009.336 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00009 FQHC-WRAP-PAYMENT
FTX337 FTX.009.337 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX338 FTX.009.338 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX338 Values FTX00009 FQHC-WRAP-PAYMENT
FTX339 FTX.009.339 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00009 FQHC-WRAP-PAYMENT
FTX340 FTX.009.340 WRAP-PERIOD-START-DATE The date representing the beginning of the FQHC wrap payment or recoupment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year then the Wrap Period Start Date would be January 1 of that year and the Wrap Period End Date would be March 31 of that year. Likewise, if the FQHC wrap payment is for the first calendar month of the year then the Wrap Period Start Date would be January 1 of that year and the Wrap Period End Date would be January 31 of that year. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX341 FTX.009.341 WRAP-PERIOD-END-DATE The date representing the end of the FQHC wrap payment period. For example, if the FQHC wrap payment is for the first calendar quarter of the year, then the FQHC wrap payment end date would be March 31 of that year. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX342 FTX.009.342 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX342 Values FTX00009 FQHC-WRAP-PAYMENT
FTX345 FTX.009.345 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX345 Values FTX00009 FQHC-WRAP-PAYMENT
FTX344 FTX.009.344 MBESCBES-FORM 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. FTX344 Values FTX00009 FQHC-WRAP-PAYMENT
FTX343 FTX.009.343 MBESCBES-CATEGORY-OF-SERVICE 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. FTX343 Values FTX00009 FQHC-WRAP-PAYMENT
FTX346 FTX.009.346 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX347 FTX.009.347 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX347 Values FTX00009 FQHC-WRAP-PAYMENT
FTX348 FTX.009.348 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX348 Values FTX00009 FQHC-WRAP-PAYMENT
FTX349 FTX.009.349 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX349 Values FTX00009 FQHC-WRAP-PAYMENT
FTX350 FTX.009.350 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX350 Values FTX00009 FQHC-WRAP-PAYMENT
FTX351 FTX.009.351 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered N/A FTX00009 FQHC-WRAP-PAYMENT
FTX352 FTX.009.352 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX352 Values FTX00009 FQHC-WRAP-PAYMENT
FTX353 FTX.009.353 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX354 FTX.009.354 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX355 FTX.009.355 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00009 FQHC-WRAP-PAYMENT
FTX357 FTX.095.357 RECORD-ID 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.). FTX357 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX358 FTX.095.358 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. FTX358 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX359 FTX.095.359 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX360 FTX.095.360 ICN-ORIG A unique item control number assigned by the states payment system that identifies an original or adjustment claim/transaction. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX361 FTX.095.361 ICN-ADJ A unique claim/transaction number assigned by the state�s payment system that identifies the adjustment claim/transaction for an original item control number. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX363 FTX.095.363 ADJUSTMENT-IND Indicates the type of adjustment record. FTX363 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX364 FTX.095.364 PAYMENT-OR-RECOUPMENT-DATE The date that the payment or recoupment was executed by the payer. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX365 FTX.095.365 PAYMENT-OR-RECOUPMENT-AMOUNT The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX366 FTX.095.366 CHECK-EFF-DATE The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX367 FTX.095.367 CHECK-NUM The check or electronic funds transfer number. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX368 FTX.095.368 PAYER-ID This is the identifier that corresponds with the payer's role in relation to the Medicaid/CHIP system. The payer is the subject taking the action of either making a payment or taking a recoupment, as opposed to the payee who is the object of the transaction. The payer is the entity that is either making a payment or recouping a payment from another entity or individual. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX369 FTX.095.369 PAYER-ID-TYPE This is a qualifier that indicates what type of ID the payer ID is. For example, if the payer ID represents the state Medicaid or CHIP agency, then the payer ID type will indicate that the payer ID should be interpreted as a submitting state code. FTX369 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX370 FTX.095.370 PAYER-ID-TYPE-OTHER-TEXT This is a description of what the payer ID represents when the payer ID was reported with a payer type of "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX371 FTX.095.371 PAYER-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payer, when applicable. The valid value list is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX371 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX372 FTX.095.372 PAYER-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payer ID was reported with a PAYER-MCR-PLAN-OR-OTHER-TYPE of "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX373 FTX.095.373 PAYEE-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX374 FTX.095.374 PAYEE-ID-TYPE This is a qualifier that indicates what type of ID the payee ID is. For example, if the payee ID represents a provider ID, then the payee ID type will indicate that the payee ID should be interpreted as a provider ID. FTX374 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX375 FTX.095.375 PAYEE-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-ID-TYPE represents when the PAYEE-ID-TYPE was reported with a payee ID type of "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX376 FTX.095.376 PAYEE-MCR-PLAN-TYPE This describes the type of managed care plan or care coordination model of the payee, when applicable. The valid value code set is comprised of the standard managed care plan type list from the MCR and ELG files and a complementary list of care coordination models. FTX376 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX377 FTX.095.377 PAYEE-MCR-PLAN-TYPE-OTHER-TEXT This is a description of what type of managed care plan or care coordination model the payee ID was reported with a payee MCR plan or other care coordination model type of "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX378 FTX.095.378 PAYEE-TAX-ID This is the identifier that corresponds with the payee's role in relation to the Medicaid/CHIP system. The payee is the individual or entity that is either receiving a payment or having a previous payment recouped. The payee is the object of the transaction, as opposed to the payer who is the subject taking the action of either making a payment or taking a recoupment. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX379 FTX.095.379 PAYEE-TAX-ID-TYPE This is a qualifier that indicates what type of tax ID the payee tax ID is. For example, if the payee tax ID represents a SSN, then the payee tax ID type will indicate that the payee tax ID should be interpreted as a SSN. FTX379 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX380 FTX.095.380 PAYEE-TAX-ID-TYPE-OTHER-TEXT This is a description of what the PAYEE-TAX-ID-TYPE represents when the PAYEE-TAX-ID-TYPE was reported with a payee tax ID type of "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX381 FTX.095.381 CONTRACT-ID Managed care plan contract ID N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX382 FTX.095.382 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX383 FTX.095.383 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique 'key' value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX384 FTX.095.384 PAYMENT-PERIOD-START-DATE The date representing the start of the time period that the payment is expected to be used by the provider. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX385 FTX.095.385 PAYMENT-PERIOD-END-DATE The date representing the end of the time period that the payment is expected to be used by the provider. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX386 FTX.095.386 PAYMENT-PERIOD-TYPE A qualifier that identifies what the payment period begin and end dates represent. For example, the payment period begin an end dates may correspond to a range of service dates from claims or encounters or they may represent a period of beneficiary eligibility or enrollment. FTX386 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX387 FTX.095.387 PAYMENT-PERIOD-TYPE-OTHER-TEXT This is a description of the type of financial transaction when the PAYMENT-PERIOD-TYPE is "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX388 FTX.095.388 TRANSACTION-TYPE This is a code that classifies the type of financial transaction when the financial transaction does not fit into any other financial transaction segment type (e.g., FTX00002, FTX00003, FTX00004, etc.). FTX388 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX389 FTX.095.389 TRANSACTION-TYPE-OTHER-TEXT This is a description of the type of financial transaction when the TRANSACTION-TYPE is "Other". N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX390 FTX.095.390 CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. FTX390 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX393 FTX.095.393 MBESCBES-FORM-GROUP Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). FTX393 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX392 FTX.095.392 MBESCBES-FORM 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. FTX392 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX391 FTX.095.391 MBESCBES-CATEGORY-OF-SERVICE 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. FTX391 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX394 FTX.095.394 WAIVER-ID Field specifying the waiver or demonstration which authorized payment. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX395 FTX.095.395 WAIVER-TYPE A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which transaction is submitted. FTX395 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX396 FTX.095.396 FUNDING-CODE A code to indicate the source of non-federal share funds. FTX396 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX397 FTX.095.397 FUNDING-SOURCE-NONFEDERAL-SHARE 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. FTX397 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX398 FTX.095.398 SDP-IND Indicates whether the financial transaction from an MC plan to a provider or other entity is a type of State Directed Payment. FTX398 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX399 FTX.095.399 SOURCE-LOCATION The field denotes the claims/transaction processing system in which the claims/transactions were originally processed. FTX399 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX400 FTX.095.400 SPA-NUMBER State plan amendment (SPA) ID number using the following format: SS-YY-NNNN-xxxx where: SS = State (use the two character postal abbreviation for your state); YY = Calendar Year (last two characters of the calendar year of the state plan amendment); NNNN = SPA number (a four character number beginning with 0001) States should track their submissions to assign sequential numbers to their submissions. xxxx = Optional, 1 to 4 characters alpha/numeric modifier (Suffix) States should use the specific SPA that covered the services rendered. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX401 FTX.095.401 PAYMENT-CAT-XREF Cross-reference to the applicable payment category in the managed care plan's contract with the state Medicaid/CHIP agency or their fiscal intermediary. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX402 FTX.095.402 EXPENDITURE-AUTHORITY-TYPE Expenditure Authority Type is the federal statute or regulation under which the expenditure is authorized/justified. The federal statute or regulation is usually referenced in either the Medicaid or CHIP State Plan or waiver documentation. For waivers, do not reference the federal statute or regulation being waived by the waiver. For waivers, referring to the waiver authority is sufficient. If the federal statute or regulation is not available in the list of valid values, choose the value for "Other" and report the authority in the Expenditure Authority Type Text. FTX402 Values FTX00095 MISCELLANEOUS-PAYMENT
FTX403 FTX.095.403 EXPENDITURE-AUTHORITY-TYPE-OTHER-TEXT This field is only to be used if Expenditure Authority Type "Other" valid value is selected. Enter a specific text description of the "Other" expenditure authority type. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX404 FTX.095.404 MEMO This represents any notes from the state's ledger/accounting system associated with the payment/recoupment. N/A FTX00095 MISCELLANEOUS-PAYMENT
FTX405 FTX.095.405 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A FTX00095 MISCELLANEOUS-PAYMENT
MCR001 MCR.001.001 RECORD-ID 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.). MCR001 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR002 MCR.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. MCR002 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR003 MCR.001.003 SUBMISSION-TRANSACTION-TYPE 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. MCR003 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR004 MCR.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. MCR004 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR005 MCR.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR006 MCR.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR007 MCR.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR007 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR008 MCR.001.008 DATE-FILE-CREATED The date on which the file was created. N/A MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR009 MCR.001.009 START-OF-TIME-PERIOD 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 MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR010 MCR.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR011 MCR.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. MCR011 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR013 MCR.001.013 TOT-REC-CNT 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 MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR113 MCR.001.113 FILE-SUBMISSION-METHOD The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. MCR113 Values MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR112 MCR.001.112 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR014 MCR.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00001 FILE-HEADER-RECORD-MANAGED-CARE
MCR016 MCR.002.016 RECORD-ID 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.). MCR016 Values MCR00002 MANAGED-CARE-MAIN
MCR017 MCR.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR017 Values MCR00002 MANAGED-CARE-MAIN
MCR018 MCR.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00002 MANAGED-CARE-MAIN
MCR019 MCR.002.019 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00002 MANAGED-CARE-MAIN
MCR020 MCR.002.020 MANAGED-CARE-CONTRACT-EFF-DATE The start date of the managed care contract period with the state. N/A MCR00002 MANAGED-CARE-MAIN
MCR021 MCR.002.021 MANAGED-CARE-CONTRACT-END-DATE The expiration date of the managed care contract period with the state. N/A MCR00002 MANAGED-CARE-MAIN
MCR022 MCR.002.022 MANAGED-CARE-NAME The name of the managed care entity under contract with the State Medicaid Agency. The name should be as it appears on the contract. N/A MCR00002 MANAGED-CARE-MAIN
MCR023 MCR.002.023 MANAGED-CARE-PROGRAM The state program through which a managed care plan is approved to operate. MCR023 Values MCR00002 MANAGED-CARE-MAIN
MCR024 MCR.002.024 MANAGED-CARE-PLAN-TYPE The type of managed care plan that corresponds to the State Plan Identification Number. The value reported in this data element should match the Managed Care Plan Type value reported on the Eligible file for the corresponding managed care plan number. Assign plan type value "15" for plans that primarily cover non-emergency medical transportation (NEMT). See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Non-Emergency Medical Transportation (NEMT) Prepaid Ambulatory Health Plans (PAHPs) in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-nonemergency-medical-transportation-nemt-prepaid-ambulatory-health-plans-pahps-in-the-tmsis-managed-care-filemanaged-care/ See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File" https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/ MCR024 Values MCR00002 MANAGED-CARE-MAIN
MCR025 MCR.002.025 REIMBURSEMENT-ARRANGEMENT A code indicating the how the managed care entity is reimbursed. MCR025 Values MCR00002 MANAGED-CARE-MAIN
MCR026 MCR.002.026 MANAGED-CARE-PROFIT-STATUS A code denoting the profit status of managed care entity. MCR026 Values MCR00002 MANAGED-CARE-MAIN
MCR027 MCR.002.027 CORE-BASED-STATISTICAL-AREA-CODE A code signifying whether the Managed Care Organization's (MCO) service area falls into one or more metropolitan or micropolitan statistical areas. Whenever a service area straddles two types of areas (e.g., metropolitan & micropolitan, metropolitan & non-CBSA area) classify the service area based on the denser classification. Metropolitan and micropolitan statistical areas (metro and micro areas) are geographic entities defined by the U.S. Office of Management and Budget (OMB). The term "Core Based Statistical Area" (CBSA) is a collective term for both metro and micro areas. A metro area contains a core urban area of 50,000 or more population, and a micro area contains an urban core of at least 10,000 (but less than 50,000) population. Each metro or micro area consists of one or more counties and includes the counties containing the core urban area, as well as any adjacent counties that have a high degree of social and economic integration (as measured by commuting to work) with the urban core. The U.S. Office of Management and Budget (OMB) defines metropolitan or micropolitan statistical areas based on published standards. The standards for defining the areas are reviewed and revised once every ten years, prior to each decennial census. Between censuses, the definitions are updated annually to reflect the most recent Census Bureau population estimates. The current definitions are as of December 2009. See the hyperlink below for further information. http://www.whitehouse.gov/sites/default/files/omb/assets/bulletins/b10-02.pdf MCR027 Values MCR00002 MANAGED-CARE-MAIN
MCR028 MCR.002.028 PERCENT-BUSINESS The percentage of the managed care entity's total revenue that is derived from contracts with Medicare (Part C and D) in the state and State Medicaid agency contract(s) prior calendar year. Include Medicaid and Medicare in calculation of percentage of business in public programs for IRS health insurer tax exemption as required in ACA. N/A MCR00002 MANAGED-CARE-MAIN
MCR029 MCR.002.029 MANAGED-CARE-SERVICE-AREA Identifies the geographic unit under which the managed care entity is under contract to provide services. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareservicearea-in-the-managed-care-file-managed-care/ MCR029 Values MCR00002 MANAGED-CARE-MAIN
MCR030 MCR.002.030 MANAGED-CARE-MAIN-REC-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A MCR00002 MANAGED-CARE-MAIN
MCR031 MCR.002.031 MANAGED-CARE-MAIN-REC-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A MCR00002 MANAGED-CARE-MAIN
MCR032 MCR.002.032 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00002 MANAGED-CARE-MAIN
MCR034 MCR.003.034 RECORD-ID 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.). MCR034 Values MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR035 MCR.003.035 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR035 Values MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR036 MCR.003.036 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR037 MCR.003.037 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR038 MCR.003.038 MANAGED-CARE-LOCATION-ID A field to differentiate a managed care entity's service locations through adding a sequential number in this data element identifier field. Use sequential numbers to indicate additional services locations. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR039 MCR.003.039 MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR040 MCR.003.040 MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR041 MCR.003.041 MANAGED-CARE-ADDR-TYPE The type of address for the managed care organization submitted in the Managed Care Main segment. MCR041 Values MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR042 MCR.003.042 MANAGED-CARE-ADDR-LN1 The managed care entity's address listed on the contract with the state. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR043 MCR.003.043 MANAGED-CARE-ADDR-LN2 The managed care entity's address listed on the contract with the state. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR044 MCR.003.044 MANAGED-CARE-ADDR-LN3 The managed care entity's address listed on the contract with the state. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR045 MCR.003.045 MANAGED-CARE-CITY The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR046 MCR.003.046 MANAGED-CARE-STATE The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the of the managed care entity's address as listed on the contract with the state. MCR046 Values MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR047 MCR.003.047 MANAGED-CARE-ZIP-CODE U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) MCR047 Values MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR048 MCR.003.048 MANAGED-CARE-COUNTY The ANSI County numeric code for the county or county equivalent. One county code should be captured for each of a managed care entity's locations identified. MCR048 Values MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR049 MCR.003.049 MANAGED-CARE-TELEPHONE Phone number for a given entity (e.g. person, organization, agency). N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR050 MCR.003.050 MANAGED-CARE-EMAIL The email address of the managed care entity listed on the contract with the state. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR051 MCR.003.051 MANAGED-CARE-FAX-NUMBER A fax number, including area code, as listed on the contract with the state. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR052 MCR.003.052 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00003 MANAGED-CARE-LOCATION-AND-CONTACT-INFO
MCR054 MCR.004.054 RECORD-ID 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.). MCR054 Values MCR00004 MANAGED-CARE-SERVICE-AREA
MCR055 MCR.004.055 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR055 Values MCR00004 MANAGED-CARE-SERVICE-AREA
MCR056 MCR.004.056 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00004 MANAGED-CARE-SERVICE-AREA
MCR057 MCR.004.057 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00004 MANAGED-CARE-SERVICE-AREA
MCR058 MCR.004.058 MANAGED-CARE-SERVICE-AREA-NAME The specific identifiers for the counties, cities, regions, ZIP Codes and/or other geographic areas that the managed care entity serves. Put each zip code, city, county, region, or other area descriptor on a separate record. Use 5 digit zip codes when service area definition is zip code based. Use ANSI codes when service area is defined by counties or cities. The value reported in Managed Care Service Area should represent the geographical unit of the values reported in the Managed Care Service Area Name. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Service Area in the Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareservicearea-in-the-managed-care-file-managed-care/ MCR058 Values MCR00004 MANAGED-CARE-SERVICE-AREA
MCR059 MCR.004.059 MANAGED-CARE-SERVICE-AREA-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A MCR00004 MANAGED-CARE-SERVICE-AREA
MCR060 MCR.004.060 MANAGED-CARE-SERVICE-AREA-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A MCR00004 MANAGED-CARE-SERVICE-AREA
MCR061 MCR.004.061 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00004 MANAGED-CARE-SERVICE-AREA
MCR063 MCR.005.063 RECORD-ID 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.). MCR063 Values MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR064 MCR.005.064 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR064 Values MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR065 MCR.005.065 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR066 MCR.005.066 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR067 MCR.005.067 OPERATING-AUTHORITY The type of operating authority through which the managed care entity receives its contract authority. The Managed Care Plan Type assigned to the manage care plan in the Managed Care Main segment should be consistent with the Operating Authority value reported. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Managed Care Plan Type in the T-MSIS Managed Care File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-managedcareplantype-in-the-t-msis-managed-care-file-managed-care/ MCR067 Values MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR068 MCR.005.068 WAIVER-ID Field specifying the ID of the waiver, demonstration or other authority which authorizes the state to operate the managed care program. These IDs must be the approved, full federal ID number assigned during the state submission and CMS approval process. N/A MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR069 MCR.005.069 MANAGED-CARE-OP-AUTHORITY-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR070 MCR.005.070 MANAGED-CARE-OP-AUTHORITY-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR071 MCR.005.071 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00005 MANAGED-CARE-OPERATING-AUTHORITY
MCR073 MCR.006.073 RECORD-ID 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.). MCR073 Values MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR074 MCR.006.074 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR074 Values MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR075 MCR.006.075 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR076 MCR.006.076 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR077 MCR.006.077 MANAGED-CARE-PLAN-POP The eligibility group(s) the state is authorized to enroll in managed care plans by its operating authority. Submit a separate record segment for each eligibility group that can be enrolled in the managed care program in which the managed care plan is participating. MCR077 Values MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR078 MCR.006.078 MANAGED-CARE-PLAN-POP-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR079 MCR.006.079 MANAGED-CARE-PLAN-POP-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR080 MCR.006.080 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00006 MANAGED-CARE-PLAN-POPULATION-ENROLLED
MCR082 MCR.007.082 RECORD-ID 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.). MCR082 Values MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR083 MCR.007.083 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR083 Values MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR084 MCR.007.084 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR085 MCR.007.085 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR086 MCR.007.086 ACCREDITATION-ORGANIZATION Identify the accreditation awarded to the managed care entity. MCR086 Values MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR087 MCR.007.087 DATE-ACCREDITATION-ACHIEVED The date the organization achieved accreditation. N/A MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR088 MCR.007.088 DATE-ACCREDITATION-END The date when organization's accreditation ends. N/A MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR089 MCR.007.089 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00007 MANAGED- CARE-ACCREDITATION-ORGANIZATION
MCR114 MCR.010.114 RECORD-ID 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.). MCR114 Values MCR00010 MANAGED-CARE-ID
MCR115 MCR.010.115 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. MCR115 Values MCR00010 MANAGED-CARE-ID
MCR116 MCR.010.116 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A MCR00010 MANAGED-CARE-ID
MCR117 MCR.010.117 STATE-PLAN-ID-NUM The ID number a state issues to a managed care entity N/A MCR00010 MANAGED-CARE-ID
MCR118 MCR.010.118 MANAGED-CARE-PLAN-OTHER-ID-TYPE A code to identify the kind of managed care identifier that is captured in the Managed Care Identifier data element. The state should submit updates to T-MSIS whenever an identifier is retired or issued. N/A MCR00010 MANAGED-CARE-ID
MCR119 MCR.010.119 MANAGED-CARE-PLAN-OTHER-ID A data element to capture the various IDs used to identify a managed care plan, other than the plan ID that is used to link claims, MCR, ELG, and PRV in T-MSIS. The specific type of identifier is defined in the corresponding value in the Managed Care Plan Other Identifier Type data element. N/A MCR00010 MANAGED-CARE-ID
MCR120 MCR.010.120 MANAGED-CARE-ID-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A MCR00010 MANAGED-CARE-ID
MCR121 MCR.010.121 MANAGED-CARE-ID-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A MCR00010 MANAGED-CARE-ID
MCR122 MCR.010.122 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A MCR00010 MANAGED-CARE-ID
PRV001 PRV.001.001 RECORD-ID 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.). PRV001 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV002 PRV.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. PRV002 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV003 PRV.001.003 SUBMISSION-TRANSACTION-TYPE 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. PRV003 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV004 PRV.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. PRV004 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV005 PRV.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV006 PRV.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV007 PRV.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV007 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV008 PRV.001.008 DATE-FILE-CREATED The date on which the file was created. N/A PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV009 PRV.001.009 START-OF-TIME-PERIOD 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 PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV010 PRV.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV011 PRV.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. PRV011 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV013 PRV.001.013 TOT-REC-CNT 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 PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV139 PRV.001.139 FILE-SUBMISSION-METHOD The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. PRV139 Values PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV138 PRV.001.138 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV014 PRV.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00001 FILE-HEADER-RECORD-PROVIDER
PRV016 PRV.002.016 RECORD-ID 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.). PRV016 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV017 PRV.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV017 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV018 PRV.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV019 PRV.002.019 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV020 PRV.002.020 PROV-ATTRIBUTES-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV021 PRV.002.021 PROV-ATTRIBUTES-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV022 PRV.002.022 PROV-DOING-BUSINESS-AS-NAME The provider's name that is commonly used by the public when the "doing-business-as" name is different than the legal name. DBA is an abbreviation for "doing business as." Registering a DBA is required to operate a business under a name that differs from the company's legal name. If DBA name is the same as the legal name, do not populate DBA name. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV023 PRV.002.023 PROV-LEGAL-NAME The name as it appears on the provider agreement between the state and the entity. Both persons and other entities can have a legal name. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV024 PRV.002.024 PROV-ORGANIZATION-NAME The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. Provider Organization Name should be same as provider last name when provider is an individual. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV025 PRV.002.025 PROV-TAX-NAME The name that the provider entity uses on IRS filings. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV026 PRV.002.026 FACILITY-GROUP-INDIVIDUAL-CODE A code to identify whether the Submitting State Provider Identifier is assigned to an individual, group, or a facility. PRV026 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV027 PRV.002.027 TEACHING-IND A code indicating if the provider's organization is a teaching facility. PRV027 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV028 PRV.002.028 PROV-FIRST-NAME Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV029 PRV.002.029 PROV-MIDDLE-INITIAL Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV030 PRV.002.030 PROV-LAST-NAME Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV031 PRV.002.031 SEX The individual's biological sex assigned at birth. PRV031 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV032 PRV.002.032 OWNERSHIP-CODE A code denoting the ownership interest and/or managing control information. The valid values list is a Medicare standard list. PRV032 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV033 PRV.002.033 PROV-PROFIT-STATUS A code denoting the profit status of the provider. PRV033 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV034 PRV.002.034 DATE-OF-BIRTH An individual's date of birth. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV035 PRV.002.035 DATE-OF-DEATH The date an individual died on. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV036 PRV.002.036 ACCEPTING-NEW-PATIENTS-IND An indicator to identify providers who are accepting new patients. PRV036 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV140 PRV.002.140 ATYPICAL-PROV-IND An indicator to identify whether the provider is an atypical provider and therefore not eligible for an NPI. PRV140 Values PRV00002 PROV-ATTRIBUTES-MAIN
PRV037 PRV.002.037 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00002 PROV-ATTRIBUTES-MAIN
PRV039 PRV.003.039 RECORD-ID 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.). PRV039 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV040 PRV.003.040 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV040 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV041 PRV.003.041 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV042 PRV.003.042 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV043 PRV.003.043 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV044 PRV.003.044 PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV045 PRV.003.045 PROV-LOCATION-AND-CONTACT-INFO-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV046 PRV.003.046 PROV-ADDR-TYPE The type of address and contact information for the provider submitted in the record segment. PRV046 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV047 PRV.003.047 ADDR-LN1 The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV048 PRV.003.048 ADDR-LN2 The second line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV049 PRV.003.049 ADDR-LN3 The third line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV050 PRV.003.050 ADDR-CITY The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV051 PRV.003.051 ADDR-STATE The ANSI numeric state code component of an address associated with a given entity (e.g. person, organization, agency, etc.) PRV051 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV052 PRV.003.052 ADDR-ZIP-CODE U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.) PRV052 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV053 PRV.003.053 ADDR-TELEPHONE Phone number for a given entity (e.g. person, organization, agency). N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV054 PRV.003.054 ADDR-EMAIL The email address of the provider for the location being captured on this record N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV055 PRV.003.055 ADDR-FAX-NUM The fax number of the provider for the location being captured on this record. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV056 PRV.003.056 ADDR-BORDER-STATE-IND A code identify an out of state provider enrolled with the state (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) PRV056 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV057 PRV.003.057 ADDR-COUNTY Standard ANSI code used to identify a specific U.S. County. PRV057 Values PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV058 PRV.003.058 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00003 PROV-LOCATION-AND-CONTACT-INFO
PRV060 PRV.004.060 RECORD-ID 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.). PRV060 Values PRV00004 PROV-LICENSING-INFO
PRV061 PRV.004.061 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV061 Values PRV00004 PROV-LICENSING-INFO
PRV062 PRV.004.062 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00004 PROV-LICENSING-INFO
PRV063 PRV.004.063 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00004 PROV-LICENSING-INFO
PRV064 PRV.004.064 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A PRV00004 PROV-LICENSING-INFO
PRV065 PRV.004.065 PROV-LICENSE-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00004 PROV-LICENSING-INFO
PRV066 PRV.004.066 PROV-LICENSE-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00004 PROV-LICENSING-INFO
PRV067 PRV.004.067 LICENSE-TYPE A code to identify the kind of license or accreditation number that is captured in the License or Accreditation Number data element. PRV067 Values PRV00004 PROV-LICENSING-INFO
PRV068 PRV.004.068 LICENSE-ISSUING-ENTITY-ID A free text field to capture the identity of the entity issuing the license or accreditation. Enter the applicable state code, county code, municipality name, "DEA", professional society's name, or the CLIA accreditation body's name. -If associated License Type is equal to 1 and issuing authority is a State, then value must be ANSI State abbreviation code.- If associated License Type is equal to 1 and issuing authority is a county, then value must be a 5-digit, concatenated code consisting of the ANSI state code plus the ANSI county code. A list of codes can be found here: https://www.nrcs.usda.gov/wps/portal/nrcs/detail/national/home/?cid=nrcs143_013697 If associated License Type is equal to 1 and issuing authority is a municipality, then enter a text string with the name of the municipality. If associated License Type is equal to 3, then enter the text string identifying the professional society issuing the accreditation. If associated License Type is equal to 4, then value must be the text string identifying the CLIA accreditation body's name. N/A PRV00004 PROV-LICENSING-INFO
PRV069 PRV.004.069 LICENSE-OR-ACCREDITATION-NUMBER A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the License Issuing Entity ID data element. N/A PRV00004 PROV-LICENSING-INFO
PRV070 PRV.004.070 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00004 PROV-LICENSING-INFO
PRV072 PRV.005.072 RECORD-ID 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.). PRV072 Values PRV00005 PROV-IDENTIFIERS
PRV073 PRV.005.073 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV073 Values PRV00005 PROV-IDENTIFIERS
PRV074 PRV.005.074 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00005 PROV-IDENTIFIERS
PRV075 PRV.005.075 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00005 PROV-IDENTIFIERS
PRV076 PRV.005.076 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A PRV00005 PROV-IDENTIFIERS
PRV077 PRV.005.077 PROV-IDENTIFIER-TYPE A code to identify the kind of provider identifier that is captured in the Provider Identifier data element. The state should submit updates to T-MSIS whenever an identifier is retired or issued. see Provider Identifier Type List (VVL.146) PRV077 Values PRV00005 PROV-IDENTIFIERS
PRV078 PRV.005.078 PROV-IDENTIFIER-ISSUING-ENTITY-ID A free text field to capture the identity of the entity that issued the provider identifier in the Provider Identifier (PRV.005.081) data element. For (State Tax ID), if associated Provider Identifier Type (PRV.005.077) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (PRV.005.077) value is equal to 8, then value must be the name of the entity that issued the identifier. N/A PRV00005 PROV-IDENTIFIERS
PRV079 PRV.005.079 PROV-IDENTIFIER-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00005 PROV-IDENTIFIERS
PRV080 PRV.005.080 PROV-IDENTIFIER-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00005 PROV-IDENTIFIERS
PRV081 PRV.005.081 PROV-IDENTIFIER A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is defined in the corresponding value in the Provider Identifier Type data element. N/A PRV00005 PROV-IDENTIFIERS
PRV082 PRV.005.082 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00005 PROV-IDENTIFIERS
PRV084 PRV.006.084 RECORD-ID 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.). PRV084 Values PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV085 PRV.006.085 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV085 Values PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV086 PRV.006.086 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV087 PRV.006.087 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV088 PRV.006.088 PROV-CLASSIFICATION-TYPE A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/cms-technical-instructions-provider-classification-requirements-in-tmsis/ A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. PRV088 Values PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV089 PRV.006.089 PROV-CLASSIFICATION-CODE The code values from the categorization schema identified in the Provider Classification Type data element. Note: States should apply these classification schemas consistently across all providers. PRV089 Values PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV090 PRV.006.090 PROV-TAXONOMY-CLASSIFICATION-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV091 PRV.006.091 PROV-TAXONOMY-CLASSIFICATION-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV092 PRV.006.092 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00006 PROV-TAXONOMY-CLASSIFICATION
PRV094 PRV.007.094 RECORD-ID 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.). PRV094 Values PRV00007 PROV-MEDICAID-ENROLLMENT
PRV095 PRV.007.095 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV095 Values PRV00007 PROV-MEDICAID-ENROLLMENT
PRV096 PRV.007.096 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00007 PROV-MEDICAID-ENROLLMENT
PRV097 PRV.007.097 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00007 PROV-MEDICAID-ENROLLMENT
PRV098 PRV.007.098 PROV-MEDICAID-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00007 PROV-MEDICAID-ENROLLMENT
PRV099 PRV.007.099 PROV-MEDICAID-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00007 PROV-MEDICAID-ENROLLMENT
PRV100 PRV.007.100 PROV-MEDICAID-ENROLLMENT-STATUS-CODE A code representing the provider's Medicaid and/or CHIP enrollment status for the time span specified by the Provider Medicaid Effective Date and Provider Medicaid End Date data elements. Note: The State Plan Enrollment data element identifies whether the provider is enrolled in Medicaid, CHIP, or both. PRV100 Values PRV00007 PROV-MEDICAID-ENROLLMENT
PRV101 PRV.007.101 STATE-PLAN-ENROLLMENT The state plan with which a provider has an affiliation and is able to provide services to the state's fee for service enrollees. PRV101 Values PRV00007 PROV-MEDICAID-ENROLLMENT
PRV102 PRV.007.102 PROV-ENROLLMENT-METHOD Process by which a provider was enrolled in Medicaid or CHIP. PRV102 Values PRV00007 PROV-MEDICAID-ENROLLMENT
PRV103 PRV.007.103 APPL-DATE The date on which the provider applied for enrollment into the State's Medicaid and/or CHIP program. N/A PRV00007 PROV-MEDICAID-ENROLLMENT
PRV104 PRV.007.104 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00007 PROV-MEDICAID-ENROLLMENT
PRV106 PRV.008.106 RECORD-ID 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.). PRV106 Values PRV00008 PROV-AFFILIATED-GROUPS
PRV107 PRV.008.107 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV107 Values PRV00008 PROV-AFFILIATED-GROUPS
PRV108 PRV.008.108 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00008 PROV-AFFILIATED-GROUPS
PRV109 PRV.008.109 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00008 PROV-AFFILIATED-GROUPS
PRV110 PRV.008.110 SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY The unique, state-assigned identification number for the group or subpart with which the individual or subpart is associated. (The submitting state's unique identifier for the group. (Note: The group will also be in the provider data set as a provider (i.e., the group-as-a-provider). N/A PRV00008 PROV-AFFILIATED-GROUPS
PRV111 PRV.008.111 PROV-AFFILIATED-GROUP-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00008 PROV-AFFILIATED-GROUPS
PRV112 PRV.008.112 PROV-AFFILIATED-GROUP-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00008 PROV-AFFILIATED-GROUPS
PRV113 PRV.008.113 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00008 PROV-AFFILIATED-GROUPS
PRV115 PRV.009.115 RECORD-ID 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.). PRV115 Values PRV00009 PROV-AFFILIATED-PROGRAMS
PRV116 PRV.009.116 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV116 Values PRV00009 PROV-AFFILIATED-PROGRAMS
PRV117 PRV.009.117 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00009 PROV-AFFILIATED-PROGRAMS
PRV118 PRV.009.118 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00009 PROV-AFFILIATED-PROGRAMS
PRV119 PRV.009.119 AFFILIATED-PROGRAM-TYPE A code to identify the category of program that the provider is affiliated. PRV119 Values PRV00009 PROV-AFFILIATED-PROGRAMS
PRV120 PRV.009.120 AFFILIATED-PROGRAM-ID A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. N/A PRV00009 PROV-AFFILIATED-PROGRAMS
PRV121 PRV.009.121 PROV-AFFILIATED-PROGRAM-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00009 PROV-AFFILIATED-PROGRAMS
PRV122 PRV.009.122 PROV-AFFILIATED-PROGRAM-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00009 PROV-AFFILIATED-PROGRAMS
PRV123 PRV.009.123 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00009 PROV-AFFILIATED-PROGRAMS
PRV125 PRV.010.125 RECORD-ID 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.). PRV125 Values PRV00010 PROV-BED-TYPE-INFO
PRV126 PRV.010.126 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. PRV126 Values PRV00010 PROV-BED-TYPE-INFO
PRV127 PRV.010.127 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A PRV00010 PROV-BED-TYPE-INFO
PRV128 PRV.010.128 SUBMITTING-STATE-PROV-ID The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers, practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System. N/A PRV00010 PROV-BED-TYPE-INFO
PRV129 PRV.010.129 PROV-LOCATION-ID A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. N/A PRV00010 PROV-BED-TYPE-INFO
PRV130 PRV.010.130 BED-TYPE-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A PRV00010 PROV-BED-TYPE-INFO
PRV131 PRV.010.131 BED-TYPE-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A PRV00010 PROV-BED-TYPE-INFO
PRV134 PRV.010.134 BED-TYPE-CODE A code to classify beds available at a facility. PRV134 Values PRV00010 PROV-BED-TYPE-INFO
PRV135 PRV.010.135 BED-COUNT A count of the number of beds available at the facility for the category of bed identified in the Bed Type Code data element. Beds should not be counted twice under different bed types. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Bed Information in the T-MSIS Provider File". https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-provider-bed-information-in-the-tmsis-provider-file-provider/ N/A PRV00010 PROV-BED-TYPE-INFO
PRV136 PRV.010.136 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A PRV00010 PROV-BED-TYPE-INFO
TPL001 TPL.001.001 RECORD-ID 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.). TPL001 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL002 TPL.001.002 DATA-DICTIONARY-VERSION A data element to capture the version of the T-MSIS data dictionary that was used to build the file. TPL002 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL003 TPL.001.003 SUBMISSION-TRANSACTION-TYPE 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. TPL003 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL004 TPL.001.004 FILE-ENCODING-SPECIFICATION Denotes which supported file encoding standard was used to create the file. TPL004 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL005 TPL.001.005 DATA-MAPPING-DOCUMENT-VERSION Identifies the version of the T-MSIS data mapping document used to build a state submission file. N/A TPL00001 FILE-HEADER-RECORD-TPL
TPL006 TPL.001.006 FILE-NAME A code to identify the subject area to which the records in its file relate. Each T-MSIS submission file should only contain records for one subject area (i.e., Eligible, Third-party liability, Provider, Managed Care Plan Information, Inpatient, Long-Term Care, Other, Pharmacy Claim, and Financial Transactions). N/A TPL00001 FILE-HEADER-RECORD-TPL
TPL007 TPL.001.007 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. TPL007 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL008 TPL.001.008 DATE-FILE-CREATED The date on which the file was created. N/A TPL00001 FILE-HEADER-RECORD-TPL
TPL009 TPL.001.009 START-OF-TIME-PERIOD 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 TPL00001 FILE-HEADER-RECORD-TPL
TPL010 TPL.001.010 END-OF-TIME-PERIOD This value must be the last day of the reporting month, regardless of the actual date span. N/A TPL00001 FILE-HEADER-RECORD-TPL
TPL011 TPL.001.011 FILE-STATUS-INDICATOR A code to indicate whether the records in the file are test or production records. TPL011 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL012 TPL.001.012 SSN-INDICATOR 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. TPL012 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL013 TPL.001.013 TOT-REC-CNT 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 TPL00001 FILE-HEADER-RECORD-TPL
TPL095 TPL.001.095 FILE-SUBMISSION-METHOD The file submission method (e.g., TFFR, RHFR, IT, or CSO) used by the state to build and submit the file. This should correspond with the state's declared file submission method for the same file type and time period. TPL095 Values TPL00001 FILE-HEADER-RECORD-TPL
TPL088 TPL.001.088 SEQUENCE-NUMBER To enable states to sequentially number files, when related, follow-on files are necessary (i.e., update files, replacement files). This should begin with 1 for the original Create submission type and be incremented by one for each Replacement or Update submission for the same reporting period and file type (subject area). N/A TPL00001 FILE-HEADER-RECORD-TPL
TPL014 TPL.001.014 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A TPL00001 FILE-HEADER-RECORD-TPL
TPL016 TPL.002.016 RECORD-ID 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.). TPL016 Values TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL017 TPL.002.017 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. TPL017 Values TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL018 TPL.002.018 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL019 TPL.002.019 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL020 TPL.002.020 TPL-HEALTH-INSURANCE-COVERAGE-IND A flag to indicate that the Medicaid/CHIP eligible person has some form of third party insurance coverage. TPL020 Values TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL021 TPL.002.021 TPL-OTHER-COVERAGE-IND A flag to indicate that the Medicaid/CHIP eligible person has some other form of third party funding besides insurance coverage. TPL021 Values TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL022 TPL.002.022 ELIGIBLE-FIRST-NAME The first name of the individual to whom the services were provided. N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL023 TPL.002.023 ELIGIBLE-MIDDLE-INIT Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL024 TPL.002.024 ELIGIBLE-LAST-NAME The last name of the individual to whom the services were provided. N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL025 TPL.002.025 ELIG-PRSN-MAIN-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL026 TPL.002.026 ELIG-PRSN-MAIN-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL027 TPL.002.027 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A TPL00002 TPL-MEDICAID-ELIGIBLE-PERSON-MAIN
TPL029 TPL.003.029 RECORD-ID 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.). TPL029 Values TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL030 TPL.003.030 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. TPL030 Values TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL031 TPL.003.031 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL032 TPL.003.032 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL033 TPL.003.033 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL034 TPL.003.034 INSURANCE-PLAN-ID The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL035 TPL.003.035 GROUP-NUM The group number of the TPL health insurance policy. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL036 TPL.003.036 MEMBER-ID Member identification number as it appears on the card issued by the TPL insurance carrier. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL037 TPL.003.037 INSURANCE-PLAN-TYPE Code to classify the type of insurance plan providing TPL coverage. TPL037 Values TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL038 TPL.003.038 ANNUAL-DEDUCTIBLE-AMT Annual amount paid each year by the enrollee in the plan before a health plan benefit begins. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL044 TPL.003.044 POLICY-OWNER-FIRST-NAME Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name). N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL045 TPL.003.045 POLICY-OWNER-LAST-NAME Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name). N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL046 TPL.003.046 POLICY-OWNER-SSN Unique identifier issued to an individual by the SSA for the purpose of identification. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL047 TPL.003.047 POLICY-OWNER-CODE This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary. TPL047 Values TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL048 TPL.003.048 INSURANCE-COVERAGE-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL049 TPL.003.049 INSURANCE-COVERAGE-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL089 TPL.003.089 COVERAGE-TYPE A code to indicate the level of coverage being provided under this policy for the insured by the TPL carrier. TPL089 Values TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL050 TPL.003.050 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A TPL00003 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO
TPL052 TPL.004.052 RECORD-ID 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.). TPL052 Values TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL053 TPL.004.053 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. TPL053 Values TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL054 TPL.004.054 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL055 TPL.004.055 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL056 TPL.004.056 INSURANCE-PLAN-ID The ID number issued by the Insurance carrier providing third party liability insurance coverage to beneficiaries. Typically the Plan ID/Plan Number is on the beneficiaries' insurance card. N/A TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL057 TPL.004.057 INSURANCE-PLAN-TYPE Code to classify the entity providing TPL coverage. TPL057 Values TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL058 TPL.004.058 COVERAGE-TYPE Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier. TPL058 Values TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL059 TPL.004.059 INSURANCE-CATEGORIES-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL060 TPL.004.060 INSURANCE-CATEGORIES-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL061 TPL.004.061 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A TPL00004 TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES
TPL063 TPL.005.063 RECORD-ID 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.). TPL063 Values TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL064 TPL.005.064 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. TPL064 Values TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL065 TPL.005.065 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL066 TPL.005.066 MSIS-IDENTIFICATION-NUM A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number. https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ N/A TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL067 TPL.005.067 TYPE-OF-OTHER-THIRD-PARTY-LIABILITY This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed Insurance Type Plan. TPL067 Values TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL068 TPL.005.068 OTHER-TPL-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL069 TPL.005.069 OTHER-TPL-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL070 TPL.005.070 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A TPL00005 TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION
TPL072 TPL.006.072 RECORD-ID 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.). TPL072 Values TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL073 TPL.006.073 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. TPL073 Values TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL074 TPL.006.074 RECORD-NUMBER A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL075 TPL.006.075 INSURANCE-CARRIER-ID-NUM The state-assigned identification number of the Third Party Liability (TPL) Entity. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL076 TPL.006.076 TPL-ENTITY-ADDR-TYPE The type of address for a TPL Entity submitted in the record segment. TPL076 Values TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL077 TPL.006.077 INSURANCE-CARRIER-ADDR-LN1 The first line of a potentially multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL078 TPL.006.078 INSURANCE-CARRIER-ADDR-LN2 The second line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL079 TPL.006.079 INSURANCE-CARRIER-ADDR-LN3 The third line of a multi-line physical street or mailing address for a given entity (e.g. person, organization, agency, etc.). N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL080 TPL.006.080 INSURANCE-CARRIER-CITY The city component of an address associated with a given entity (e.g. person, organization, agency, etc.). N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL081 TPL.006.081 INSURANCE-CARRIER-STATE The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the TPL Insurance carrier. TPL081 Values TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL082 TPL.006.082 INSURANCE-CARRIER-ZIP-CODE The ZIP Code for the location being captured on the TPL Entity Contact Information record. TPL082 Values TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL083 TPL.006.083 INSURANCE-CARRIER-PHONE-NUM Phone number for a given entity (e.g. person, organization, agency). N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL084 TPL.006.084 TPL-ENTITY-CONTACT-INFO-EFF-DATE The first calendar day on which all of the other data elements in the same segment were effective. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL085 TPL.006.085 TPL-ENTITY-CONTACT-INFO-END-DATE The last calendar day on which all of the other data elements in the same segment were effective. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL090 TPL.006.090 INSURANCE-CARRIER-NAIC-CODE The National Association of Insurance Commissioners (NAIC) code of the TPL Insurance carrier. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL091 TPL.006.091 INSURANCE-CARRIER-NAME The name of the TPL Insurance carrier. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
TPL086 TPL.006.086 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A TPL00006 TPL-ENTITY-CONTACT-INFORMATION
ELG023 ELG.002.023 SEX The individual's biological sex assigned at birth. ELG023 Values ELG00002 PRIMARY-DEMOGRAPHICS-ELIGIBILITY