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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 Segment Number

CLT00003

File Segment Name

CLAIM-LINE-RECORD-LT

Last updated

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
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