COT.002.136

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TMSIS Dataguide

Medicaid.gov

Version:

CLAIM-DENIED-INDICATOR

Data Element

DE Number

COT136

System DE Number

COT.002.136

File Name

COT - CLAIM OTHER

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	An indicator to identify a claim that the state refused pay in its entirety.
Size	X(1)
FLF Start Position	875
FLF Stop Position	875
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 1 character 2. Value must be in Claim Denied Indicator List (VVL) 3. If value equals "0", then Claim Status Category must equal "F2" 4. Mandatory

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-1575	If the claim denied indicator is populated on a non-denied claim from an OT file, then the claim denied indicator reported must be found in the list of valid values.
RULE-1576	If the claim status category or the type of claim is for denied claims on a claim from an OT file, the claim denied indicator value reported must also indicate the claim is denied.
RULE-6163	If a claim is a non-denied claim from an OT file, then the claim denied indicator value reported must be compatible with specified T-MSIS picture format: X(1).
RULE-7424	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7552	If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an OT file, and the beginning date of service is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
RULE-7635	All non-denied, paid OT claim header records must have a corresponding non-denied claim line record.
RULE-7741	If a claim in a non-denied, original or adjustment Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7772	If a claim is a non-denied claim from an OT file, and the waiver type is populated, and the claim beginning date of service is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
RULE-7978	All denied, OT claim line records must have a corresponding claim header record with a claim denied indicator equal to '0' (Denied).
RULE-7983	If a claim in a non-denied, original or adjustment FFS crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'

Measure ID	Measure Name

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP212	CIP.002.212	CLAIM-DENIED-INDICATOR	CIP00002	CLAIM-HEADER-RECORD-IP
CLT159	CLT.002.159	CLAIM-DENIED-INDICATOR	CLT00002	CLAIM-HEADER-RECORD-LT
CRX094	CRX.002.094	CLAIM-DENIED-INDICATOR	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	COT.002.136	UPDATE	File segment	None	35
09/16/2024	4.0.0	COT.002.136	ADD	N/A		Created