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TMSIS Dataguide Medicaid.gov

Version:

MBESCBES-FORM

Data Element

DE Number

CLT262

System DE Number

CLT.003.262

File Segment Number

CLT00003

File Segment Name

CLAIM-LINE-RECORD-LT

Last updated

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
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
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