CLT.002.025

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TMSIS Dataguide

Medicaid.gov

Version:

ADJUSTMENT-IND

Data Element

DE Number

CLT025

System DE Number

CLT.002.025

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-LT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	Indicates the type of adjustment record.
Size	X(1)
FLF Start Position	156
FLF Stop Position	156
Segment Key Field Identifier	4
Coding Requirements	1. Value must be 1 character 2. Value must be in Adjustment Indicator List (VVL) 3. Value must be in [0,1,4] 4. Mandatory 5. If value equals "0", then associated Adjustment ICN must not be populated 6. Value must equal "1", when associated Claim Status equals "686"

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-7571	All denied LT claim header records must have a corresponding claim line record.
RULE-888	If the adjustment indicator is populated on a claim header from an LT file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7982	If a claim in a non-denied, original or adjustment FFS crossover claim from an LT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7869	If the type of claim is a fee-for-service and adjustment indicator is populated on a claim header from an LT file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7845	If a segment is an LT claim header, and the type of claim is a fee for service, the adjustment indicator must be populated.
RULE-7743	If a claim in a non-denied, original or adjustment Encounter crossover claim from an LT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7668	If the type of claim is an encounter and adjustment indicator is populated on a claim header from an LT file, then the adjustment indicator value reported must be in the list of valid values for adjustment indicator.
RULE-7648	If a segment is an LT claim header, and the type of claim is an encounter, the adjustment indicator must be populated.
RULE-7634	All non-denied, paid LT claim header records must have a corresponding non-denied claim line record.
RULE-6191	If a claim is from an LT file, then the adjustment indicator value reported must be compatible with the specified T-MSIS picture format: X(1).
RULE-7542	If a segment is an LT claim header, and claim status is equal to '686' (void claim), then adjustment indicator must be equal to '1' (void).
RULE-7465	If a segment is an LT claim header, adjustment indicator must be populated.
RULE-7432	All non-denied LT claim header records must have a corresponding claim line record.
RULE-7413	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an LT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7346	If a segment is an LT claim header and icn adj is populated, then adjustment indicator is a replacement or resubmission payment or a void, reversal or canceled payment.
RULE-7338	If a segment is an LT claim header and icn adj is not populated, then the adjustment indicator is an original claim/encounter payment, credit gross adjustment or a debit gross adjustment payment.
RULE-7184	If a claim header is from an LT file, then submitting state, original ICN, adjustment ICN, adjudication date, and adjustment indicator values reported must be unique across all LT claim headers.

Measure ID	Measure Name
EL-8-001-1	Enrollment, capitation payments, and encounters by Plan Type
FFS-S-011-5	% of claim headers that are original
FFS-S-015-16	% of claim headers that are original
MCR-27-001-1	Encounters (by Claim File Type)
MCR-27-002-2	Encounters (by Claims file type) by Plan ID (non-PCCM)
MCR-S-014-5	% of claim headers that are original
MCR-S-018-16	% of claim headers that are original
FFS-26-011-11	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
FFS-28-001-1	Adjustment Indicator values
FFS-36-001-1	Adjustment Indicator values
MCR-32-003-3	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
MCR-32-013-13	% of claim headers without a valid Adjustment Indicator (ADJ-IND is 2, 3, 9, other invalid value, or missing)
MCR-34-001-1	Adjustment Indicator values
MCR-44-001-1	Adjustment Indicator values
RULE-7465	% of claim headers with a missing Adjustment Indicator
RULE-888	% of claim headers with an invalid Adjustment Indicator (ADJUSTMENT-IND is 2, 3, 9, other invalid value)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP026	CIP.002.026	ADJUSTMENT-IND	CIP00002	CLAIM-HEADER-RECORD-IP
CIP327	CIP.004.327	ADJUSTMENT-IND	CIP00004	CLAIM-DX-IP
CLT273	CLT.004.273	ADJUSTMENT-IND	CLT00004	CLAIM-DX-LT
COT025	COT.002.025	ADJUSTMENT-IND	COT00002	CLAIM-HEADER-RECORD-OT
COT279	COT.004.279	ADJUSTMENT-IND	COT00004	CLAIM-DX-OT
CRX025	CRX.002.025	ADJUSTMENT-IND	CRX00002	CLAIM-HEADER-RECORD-RX
CRX201	CRX.004.201	ADJUSTMENT-IND	CRX00004	CLAIM-DX-RX
FTX023	FTX.002.023	ADJUSTMENT-IND	FTX00002	INDIVIDUAL-CAPITATION-PMPM
FTX070	FTX.003.070	ADJUSTMENT-IND	FTX00003	INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX111	FTX.004.111	ADJUSTMENT-IND	FTX00004	GROUP-INSURANCE-PREMIUM-PAYMENT
FTX155	FTX.005.155	ADJUSTMENT-IND	FTX00005	COST-SHARING-OFFSET
FTX198	FTX.006.198	ADJUSTMENT-IND	FTX00006	VALUE-BASED-PAYMENT
FTX242	FTX.007.242	ADJUSTMENT-IND	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX285	FTX.008.285	ADJUSTMENT-IND	FTX00008	COST-SETTLEMENT-PAYMENT
FTX324	FTX.009.324	ADJUSTMENT-IND	FTX00009	FQHC-WRAP-PAYMENT
FTX363	FTX.095.363	ADJUSTMENT-IND	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
12/19/2024	4.0.1	CLT.002.025	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in Adjustment Indicator List (VVL)3. Value must be in [0,1,4]4. Mandatory5. If value equals "0", then associated Adjustment ICN must not be populated6. Value must equal "1", when associated Claim Status equals "686"7. Value must match the adjustment indicator in the header (CIP.002.026)	1. Value must be 1 character2. Value must be in Adjustment Indicator List (VVL)3. Value must be in [0,1,4]4. Mandatory5. If value equals "0", then associated Adjustment ICN must not be populated6. Value must equal "1", when associated Claim Status equals "686"
09/16/2024	4.0.0	CLT.002.025	UPDATE	File segment	None	30
09/16/2024	4.0.0	CLT.002.025	ADD	N/A		Created