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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

PROVIDER-CLAIM-FORM-CODE

Data Element

DE Number

COT247

System DE Number

COT.002.247

File Name

COT - CLAIM OTHER

File Segment Number

COT00002

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances
Definition A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other".
Size X(2)
FLF Start Position 1389
FLF Stop Position 1390
Segment Key Field Identifier Not Applicable
Coding Requirements 1. Value must not be more than 2 characters
2. Value must be in Provider Claim Form Code List (VVL)
3. Mandatory
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
CIP309 CIP.002.309 PROVIDER-CLAIM-FORM-CODE CIP00002 CLAIM-HEADER-RECORD-IP
CLT255 CLT.002.255 PROVIDER-CLAIM-FORM-CODE CLT00002 CLAIM-HEADER-RECORD-LT
CRX174 CRX.002.174 PROVIDER-CLAIM-FORM-CODE CRX00002 CLAIM-HEADER-RECORD-RX