CLT.003.188

ICN-ORIG

Data Element

DE Number

CLT188

System DE Number

CLT.003.188

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

CLT00003

File Segment Name

CLAIM-LINE-RECORD-LT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A unique number assigned by the state's payment system that identifies an original or adjustment claim.
Size	X(50)
FLF Start Position	42
FLF Stop Position	91
Segment Key Field Identifier	2
Coding Requirements	1. Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. Mandatory

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

RULE ID	RULE Definition
RULE-1204	All non-denied LT claim line records must have a corresponding parent record.
RULE-1205	If the icn orig is populated on a non-denied claim line from an LT file, then the icn orig reported must not contain any pipe or asterisk characters.
RULE-6617	If an LT claim line, the icn orig value must be specified in the T-MSIS picture format: X(50).
RULE-7188	If a claim line is from an LT file, then submitting state, original ICN, adjustment ICN, adjudication date, line adjustment indicator, original line ICN, and adjustment line ICN values reported must be unique across all LT claim lines.
RULE-7331	If a segment is an LT claim line, icn orig must be populated.
RULE-7575	All denied LT claim line records must have a corresponding claim header record.

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP019	CIP.002.019	ICN-ORIG	CIP00002	CLAIM-HEADER-RECORD-IP
CIP235	CIP.003.235	ICN-ORIG	CIP00003	CLAIM-LINE-RECORD-IP
CIP325	CIP.004.325	ICN-ORIG	CIP00004	CLAIM-DX-IP
CLT019	CLT.002.019	ICN-ORIG	CLT00002	CLAIM-HEADER-RECORD-LT
CLT271	CLT.004.271	ICN-ORIG	CLT00004	CLAIM-DX-LT
COT019	COT.002.019	ICN-ORIG	COT00002	CLAIM-HEADER-RECORD-OT
COT158	COT.003.158	ICN-ORIG	COT00003	CLAIM-LINE-RECORD-OT
COT277	COT.004.277	ICN-ORIG	COT00004	CLAIM-DX-OT
CRX019	CRX.002.019	ICN-ORIG	CRX00002	CLAIM-HEADER-RECORD-RX
CRX112	CRX.003.112	ICN-ORIG	CRX00003	CLAIM-LINE-RECORD-RX
CRX199	CRX.004.199	ICN-ORIG	CRX00004	CLAIM-DX-RX
FTX020	FTX.002.020	ICN-ORIG	FTX00002	INDIVIDUAL-CAPITATION-PMPM
FTX067	FTX.003.067	ICN-ORIG	FTX00003	INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX108	FTX.004.108	ICN-ORIG	FTX00004	GROUP-INSURANCE-PREMIUM-PAYMENT
FTX152	FTX.005.152	ICN-ORIG	FTX00005	COST-SHARING-OFFSET
FTX195	FTX.006.195	ICN-ORIG	FTX00006	VALUE-BASED-PAYMENT
FTX239	FTX.007.239	ICN-ORIG	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX282	FTX.008.282	ICN-ORIG	FTX00008	COST-SETTLEMENT-PAYMENT
FTX321	FTX.009.321	ICN-ORIG	FTX00009	FQHC-WRAP-PAYMENT
FTX360	FTX.095.360	ICN-ORIG	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	CLT.003.188	UPDATE	File segment	None	31
09/16/2024	4.0.0	CLT.003.188	ADD	N/A		Created