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Data Element
CLT282
CLT.003.282
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)). |
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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 not equal to $0 |
Valid Value Code Set | Valid Value Code | Valid Value Name | Valid Value Description | Effective Start Date | Effective End Date |
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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 |