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Data Element
CIP310
CIP.002.310
Definition | 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. |
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Size | X(50) |
FLF Start Position | 1700 |
FLF Stop Position | 1749 |
Segment Key Field Identifier | Not Applicable |
Coding Requirements | 1. Value must not be more than 50 characters long 2. Conditional 3. Value must be provided when corresponding Provider Claim Form Code is "Other" |
Valid Value Code Set | Valid Value Code | Valid Value Name | Valid Value Description | Effective Start Date | Effective End Date |
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DE Number | System DE Number | DE Name | File Segment Number | File Segment Name |
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CLT256 | CLT.002.256 | PROVIDER-CLAIM-FORM-OTHER-TEXT | CLT00002 | CLAIM-HEADER-RECORD-LT |
COT248 | COT.002.248 | PROVIDER-CLAIM-FORM-OTHER-TEXT | COT00002 | CLAIM-HEADER-RECORD-OT |
CRX175 | CRX.002.175 | PROVIDER-CLAIM-FORM-OTHER-TEXT | CRX00002 | CLAIM-HEADER-RECORD-RX |