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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

PROVIDER-CLAIM-FORM-CODE

Data Element

DE Number

CLT255

System DE Number

CLT.002.255

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

CLT00002

File Segment Name

CLAIM-HEADER-RECORD-LT

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 1512
FLF Stop Position 1513
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
CIP309 CIP.002.309 PROVIDER-CLAIM-FORM-CODE CIP00002 CLAIM-HEADER-RECORD-IP
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