CLT.003.262

Definition	The MBES or CBES form to which the expenditure will be mapped (e.g., CMS-64 Base, CMS-64.21U, CMS-21, etc.). This should be determined by the state's MBES/CBES reporting process. The MBES or CBES form reported here will determine what the meaning of the corresponding MBES/CBES category of service value is.
Size	X(50)
FLF Start Position	485
FLF Stop Position	534
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 50 characters or less 2. When MBESCBES Form Group equals "1", value must be in MBESCBES Form Group 1 List (VVL) 3. When MBESCBES Form Group equals "2", value must be in MBESCBES Form Group 2 List (VVL) 4. When MBESCBES Form Group equals "3", value must be in MBESCBES Form Group 3 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

RULE ID	RULE Definition
RULE-8907	if a claim is a non-denied claim from a LT file, then the MBESCBES form value reported must be compatible with the specified T-MSIS picture format: X(50).
RULE-9082	If the MBESCBES form is populated and MBESCBES form group is '3' on a non-denied claim line from a LT file, then the MBESCBES form reported must be found in the list of valid values for 'MBESCBES-3'.
RULE-9083	If the MBESCBES form is populated and MBESCBES form group is '2' on a non-denied claim line from a LT file, then the MBESCBES form reported must be found in the list of valid values for 'MBESCBES-FORMGP-2'.
RULE-9084	If the MBESCBES form is populated and MBESCBES form group is '1' on a non-denied claim line from a LT file, then the MBESCBES form reported must be found in the list of valid values for 'MBESCBES-FORMGP-1'.
RULE-9181	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 form must be populated.

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP316	CIP.003.316	MBESCBES-FORM	CIP00003	CLAIM-LINE-RECORD-IP
COT257	COT.003.257	MBESCBES-FORM	COT00003	CLAIM-LINE-RECORD-OT
CRX181	CRX.003.181	MBESCBES-FORM	CRX00003	CLAIM-LINE-RECORD-RX
FTX047	FTX.002.047	MBESCBES-FORM	FTX00002	INDIVIDUAL-CAPITATION-PMPM
FTX092	FTX.003.092	MBESCBES-FORM	FTX00003	INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX136	FTX.004.136	MBESCBES-FORM	FTX00004	GROUP-INSURANCE-PREMIUM-PAYMENT
FTX178	FTX.005.178	MBESCBES-FORM	FTX00005	COST-SHARING-OFFSET
FTX220	FTX.006.220	MBESCBES-FORM	FTX00006	VALUE-BASED-PAYMENT
FTX265	FTX.007.265	MBESCBES-FORM	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX305	FTX.008.305	MBESCBES-FORM	FTX00008	COST-SETTLEMENT-PAYMENT
FTX344	FTX.009.344	MBESCBES-FORM	FTX00009	FQHC-WRAP-PAYMENT
FTX392	FTX.095.392	MBESCBES-FORM	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	CLT.003.262	UPDATE	File segment	None	31
09/16/2024	4.0.0	CLT.003.262	ADD	N/A		Created
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9BASE\|Medical Assistance Expenditures by Type of Service
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9 WAIVER\|Medical Assistance Expenditures by Type of Service
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9P\|Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program, Prior Period Adjustment
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9P Waiver\|Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program, Prior Period Adjustment
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9 200K\|Medical Assistance Expenditures by Type of Service
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9P 200K\|Medical Assistance Expenditures by Type of Service for the Medical Assistance Program Prior Period Adjustments in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9I\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9PI\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9TP\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9TP WAIVER\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9PE\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9PEP\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9PEPWAIV\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9PEWAIV\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9E\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9EP\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9EPWAIV\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9EWAIV\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9VIII\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9VIIIP\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9VIIIP Waiver\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9E\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9EP\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9EPWAIV\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9EWAIV\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-1	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-1\|00010101\|99991231\|CMS 64.9T\|Medical Assistance Expenditures by Type of Service For the Medical Assistance Program Expenditures in This Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21\|Quarterly Medical Assistance Expenditures By Children's Health Insurance Program
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21U\|Child Health Expenditures by Service
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21 WAIVER\|Quarterly Medical Assistance Expenditures By Children's Health Insurance Program
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21U WAIVER\|Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Expenditure Categories
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21P\|Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Prior Period Expenditures
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21P WAIVER\|Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Prior Period Expenditures
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21UP\|Quarterly Medical Assistance Expenditures by Children’s Health Insurance Program expenditure categories
04/25/2025	4.0.7	MBESCBES-FORMGP-2	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-2\|00010101\|99991231\|CMS 64.21UP WAIVER\|Quarterly Medical Assistance Expenditures By Children's Health Insurance Program Prior Period Expenditures
04/25/2025	4.0.7	MBESCBES-FORMGP-3	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-3\|00010101\|99991231\|CMS 21BASE\|Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-3	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-3\|00010101\|99991231\|CMS 21\|Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-3	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-3\|00010101\|99991231\|CMS 21P\|Quarterly Children's Health Insurance Program
04/25/2025	4.0.7	MBESCBES-FORMGP-3	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-3\|00010101\|99991231\|CMS 21 WAIVER\|Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter
04/25/2025	4.0.7	MBESCBES-FORMGP-3	Add	Data Dictionary - Valid Values	N/A	VALUE_SET_ID\|EFFECTIVE_DATE\|END_DATE\|VALUE\|NAME\|DESCRIPTION MBESCBES-FORMGP-3\|00010101\|99991231\|CMS 21PWAIVER\|Children's Health Expenditures by Type of Service For the Title XXI Program Expenditures in this Quarter

MBESCBES-FORM