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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

PROVIDER-CLAIM-FORM-OTHER-TEXT

Data Element

DE Number

CRX175

System DE Number

CRX.002.175

File Name

CRX - CLAIM PHARMACY

File Segment Number

CRX00002

File Segment Name

CLAIM-HEADER-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances
Definition A free-form text field where a state can identify the "other" claim form used by the provider to submit their claim. Required when "Other" is reported to Provider Claim Form Code.
Size X(50)
FLF Start Position 909
FLF Stop Position 958
Segment Key Field Identifier Not Applicable
Coding Requirements 1. Value must not be more than 50 characters long
2. Conditional
3. Value must be provided when corresponding Provider Claim Form Code is "Other"
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
CIP310 CIP.002.310 PROVIDER-CLAIM-FORM-OTHER-TEXT CIP00002 CLAIM-HEADER-RECORD-IP
CLT256 CLT.002.256 PROVIDER-CLAIM-FORM-OTHER-TEXT CLT00002 CLAIM-HEADER-RECORD-LT
COT248 COT.002.248 PROVIDER-CLAIM-FORM-OTHER-TEXT COT00002 CLAIM-HEADER-RECORD-OT