CLT.003.261

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TMSIS Dataguide

Medicaid.gov

Version:

MBESCBES-CATEGORY-OF-SERVICE

Data Element

DE Number

CLT261

System DE Number

CLT.003.261

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

File Segment Name

CLAIM-LINE-RECORD-LT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A code indicating the category of service for the paid claim. The category of service is the line item from the MBES/CBES expenditure form (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.) that states use to report their expenditures and request federal financial participation.
Size	X(5)
FLF Start Position	535
FLF Stop Position	539
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 5 characters or less 2. When MBESCBES Form Group equals "1", value must be in 64.9COS list (VVL) 3. When MBESCBES Form Group equals "2", value must be in 64.21COS list (VVL) 4. When MBESCBES Form Group equals "3", value must be in 21COS list (VVL) 5. Conditional 6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $0 7. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated

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

RULE ID	RULE Definition
RULE-8908	if a claim is a non-denied claim from a LT file, then the MBESCBES category of service value reported must be compatible with the specified T-MSIS picture format: X(5).
RULE-9086	If the MBESCBES category of service is populated and MBESCBES form is '21BASE' on a non-denied claim line from a LT file, then the MBESCBES category of service reported must be found in the list of valid values for '21BASE-FORM'.
RULE-9087	If the MBESCBES category of service is populated and MBESCBES form is '64.21U' on a non-denied claim line from a LT file, then the MBESCBES category of service reported must be found in the list of valid values for '64.21U-FORM'.
RULE-9088	If the MBESCBES category of service is populated and MBESCBES form is '64.9BASE' on a non-denied claim line from a LT file, then the MBESCBES category of service reported must be found in the list of valid values for '64.9BASE-FORM'.
RULE-9182	If a claim is a non-denied claim from a LT file, and is a Medicaid or Medicaid-expansion CHIP FFS or Separate CHIP FFS claim and claim line medicaid paid amt is non-null and not zero, then the claim line MBESCBES category of service must be populated.

Measure ID	Measure Name
MIS-42-001-1	% missing: MBESCBES-CATEGORY-OF-SERVICE (CLT00003)
MIS-50-001-1	% missing: MBESCBES-CATEGORY-OF-SERVICE (CLT00003)
ALL-16-013-13	% of claim lines in MBESCBES-FORM-GROUP 1 with MBESCBES-CATEGORY-OF-SERVICE = “14”, “35”, “42” or “44” (LT) linked to an MSIS ID where SEX = “M”

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP315	CIP.003.315	MBESCBES-CATEGORY-OF-SERVICE	CIP00003	CLAIM-LINE-RECORD-IP
COT256	COT.003.256	MBESCBES-CATEGORY-OF-SERVICE	COT00003	CLAIM-LINE-RECORD-OT
CRX180	CRX.003.180	MBESCBES-CATEGORY-OF-SERVICE	CRX00003	CLAIM-LINE-RECORD-RX
FTX046	FTX.002.046	MBESCBES-CATEGORY-OF-SERVICE	FTX00002	INDIVIDUAL-CAPITATION-PMPM
FTX091	FTX.003.091	MBESCBES-CATEGORY-OF-SERVICE	FTX00003	INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX135	FTX.004.135	MBESCBES-CATEGORY-OF-SERVICE	FTX00004	GROUP-INSURANCE-PREMIUM-PAYMENT
FTX177	FTX.005.177	MBESCBES-CATEGORY-OF-SERVICE	FTX00005	COST-SHARING-OFFSET
FTX219	FTX.006.219	MBESCBES-CATEGORY-OF-SERVICE	FTX00006	VALUE-BASED-PAYMENT
FTX264	FTX.007.264	MBESCBES-CATEGORY-OF-SERVICE	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX304	FTX.008.304	MBESCBES-CATEGORY-OF-SERVICE	FTX00008	COST-SETTLEMENT-PAYMENT
FTX343	FTX.009.343	MBESCBES-CATEGORY-OF-SERVICE	FTX00009	FQHC-WRAP-PAYMENT
FTX391	FTX.095.391	MBESCBES-CATEGORY-OF-SERVICE	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
06/05/2025	4.0.10	CLT.003.261	UPDATE	Coding requirement	1. Value must be 5 characters or less2. When MBESCBES Form Group equals �1�, value must be in 64.9COS list (VVL)3. When MBESCBES Form Group equals �2�, value must be in 64.21COS list (VVL)4. When MBESCBES Form Group equals �3�, value must be in 21COS list (VVL)5. Conditional6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $07. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated	1. Value must be 5 characters or less2. When MBESCBES Form Group equals "1", value must be in 64.9COS list (VVL)3. When MBESCBES Form Group equals "2", value must be in 64.21COS list (VVL)4. When MBESCBES Form Group equals "3", value must be in 21COS list (VVL)5. Conditional6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $07. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated
05/29/2025	4.0.9	CLT.003.261	UPDATE	Coding requirement	1. Value must be 5 characters or less2. When MBESCBES Form Group equals “1”, value must be in 64.9COS list (VVL)3. When MBESCBES Form Group equals “2”, value must be in 64.21COS list (VVL)4. When MBESCBES Form Group equals “3”, value must be in 21COS list (VVL)5. Conditional6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $07. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated	1. Value must be 5 characters or less2. When MBESCBES Form Group equals �1�, value must be in 64.9COS list (VVL)3. When MBESCBES Form Group equals �2�, value must be in 64.21COS list (VVL)4. When MBESCBES Form Group equals �3�, value must be in 21COS list (VVL)5. Conditional6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $07. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated
04/24/2025	4.0.7	CLT.003.261	UPDATE	Coding requirement	1. Value must be 5 characters or less2. When MBESCBES Form equals "21P", value must be in 21P Form List (VVL)3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL)4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL)5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL)6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL)7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL)8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL)9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL)10. Conditional11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $012. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated	1. Value must be 5 characters or less2. When MBESCBES Form Group equals “1”, value must be in 64.9COS list (VVL)3. When MBESCBES Form Group equals “2”, value must be in 64.21COS list (VVL)4. When MBESCBES Form Group equals “3”, value must be in 21COS list (VVL)5. Conditional6. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $07. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated
12/19/2024	4.0.1	CLT.003.261	UPDATE	Coding requirement	1. Value must be 5 characters or less2. When MBESCBES Form equals "21.P", value must be in 21.P Form List (VVL)3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL)4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL)5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL)6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL)7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL)8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL)9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL)10. Conditional11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $012. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated	1. Value must be 5 characters or less2. When MBESCBES Form equals "21P", value must be in 21P Form List (VVL)3. When MBESCBES Form equals "21BASE", value must be in 21BASE Form List (VVL)4. When MBESCBES Form equals "64.21U", value must be in 64.21U Form List (VVL)5. When MBESCBES Form equals "64.10BASE", value must be in 64.10BASE Form List (VVL)6. When MBESCBES Form equals "64.9P", value must be in 64.9P Form List (VVL)7. When MBESCBES Form equals "64.9A", value must be in 64.9A Form List (VVL)8. When MBESCBES Form equals "64.9BASE", value must be in 64.9BASE Form List (VVL)9. When MBESCBES Form equals "64.21UP", value must be in 64.21UP Form List (VVL)10. Conditional11. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount greater than $012. When populated, an associated MBESCBES Form Group and MBESCBES Form must be populated
09/16/2024	4.0.0	CLT.003.261	UPDATE	File segment	None	31
09/16/2024	4.0.0	CLT.003.261	ADD	N/A		Created