CLT.003.282

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TMSIS Dataguide

Medicaid.gov

Version:

MBESCBES-FORM-GROUP

Data Element

DE Number

CLT282

System DE Number

CLT.003.282

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	Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). States should populate these data elements for claims when Medicaid Paid Amount is 0 or less than 0. For example, these data elements are still expected to be populated on voided or replacement claims. The data elements should align with quarterly MBES/CBES reporting.
Size	X(1)
FLF Start Position	484
FLF Stop Position	484
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 1 character 2. Value must be in MBESCBES Form Group List (VVL) 3. Conditional 4. 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

RULE ID	RULE Definition
RULE-8906	if a claim is a non-denied claim from a LT file, then the MBESCBES form group value reported must be compatible with the specified T-MSIS picture format: X(1).
RULE-9093	If the MBESCBES form group is populated on a non-denied claim line from a LT file, then the MBESCBES form group reported must be found in the list of valid values for 'MBESCBES-FORM-GROUP'.
RULE-9180	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 group must be populated.

Measure ID	Measure Name
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
CIP340	CIP.003.340	MBESCBES-FORM-GROUP	CIP00003	CLAIM-LINE-RECORD-IP
COT290	COT.003.290	MBESCBES-FORM-GROUP	COT00003	CLAIM-LINE-RECORD-OT
CRX209	CRX.003.209	MBESCBES-FORM-GROUP	CRX00003	CLAIM-LINE-RECORD-RX
FTX048	FTX.002.048	MBESCBES-FORM-GROUP	FTX00002	INDIVIDUAL-CAPITATION-PMPM
FTX093	FTX.003.093	MBESCBES-FORM-GROUP	FTX00003	INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX137	FTX.004.137	MBESCBES-FORM-GROUP	FTX00004	GROUP-INSURANCE-PREMIUM-PAYMENT
FTX179	FTX.005.179	MBESCBES-FORM-GROUP	FTX00005	COST-SHARING-OFFSET
FTX221	FTX.006.221	MBESCBES-FORM-GROUP	FTX00006	VALUE-BASED-PAYMENT
FTX266	FTX.007.266	MBESCBES-FORM-GROUP	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX306	FTX.008.306	MBESCBES-FORM-GROUP	FTX00008	COST-SETTLEMENT-PAYMENT
FTX345	FTX.009.345	MBESCBES-FORM-GROUP	FTX00009	FQHC-WRAP-PAYMENT
FTX393	FTX.095.393	MBESCBES-FORM-GROUP	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
08/29/2025	4.0.17	CLT.003.282	UPDATE	Definition	Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)).	Indicates group of MBES/CBES forms that this payment applies to (e.g., the CMS-64.9 Base form is for Title XIX-funded Medicaid, the CMS-64.21 form is for Title XXI-funded Medicaid-expansion CHIP (M-CHIP), and the CMS-21 Base form is for Title XXI-funded separate CHIP (S-CHIP)). States should populate these data elements for claims when Medicaid Paid Amount is 0 or less than 0. For example, these data elements are still expected to be populated on voided or replacement claims. The data elements should align with quarterly MBES/CBES reporting.
08/29/2025	4.0.17	CLT.003.282	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Conditional4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount not equal to $0	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Conditional4. 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
12/19/2024	4.0.1	CLT.003.282	UPDATE	Coding requirement	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Conditional4. 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	1. Value must be 1 character2. Value must be in MBESCBES Form Group List (VVL)3. Conditional4. If Type of Claim in [1,A,U], then value must be populated on all claim lines with a Medicaid Paid Amount not equal to $0
09/16/2024	4.0.0	CLT.003.282	UPDATE	File segment	None	31
09/16/2024	4.0.0	CLT.003.282	ADD	N/A		Created