An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide Medicaid.gov

Version:

3.39.0

PROVIDER-CLAIM-FORM-CODE

Data Element

DE Number

CIP309

System DE Number

CIP.002.309

File Name

CIP - CLAIM INPATIENT

File Segment Number

CIP00002

File Segment Name

CLAIM-HEADER-RECORD-IP

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances
Definition A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other".
Size X(2)
FLF Start Position 1698
FLF Stop Position 1699
Segment Key Field Identifier Not Applicable
Coding Requirements 1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code List (VVL)
3. Mandatory
Valid Value Code Set Valid Value Code Valid Value Name Valid Value Description Effective Start Date Effective End Date
DE Number System DE Number DE Name File Segment Number File Segment Name
CLT255 CLT.002.255 PROVIDER-CLAIM-FORM-CODE CLT00002 CLAIM-HEADER-RECORD-LT
COT247 COT.002.247 PROVIDER-CLAIM-FORM-CODE COT00002 CLAIM-HEADER-RECORD-OT
CRX174 CRX.002.174 PROVIDER-CLAIM-FORM-CODE CRX00002 CLAIM-HEADER-RECORD-RX