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TMSIS Dataguide Medicaid.gov

Version:

RESTRICTED-BENEFITS-CODE

Data Element

DE Number

ELG097

System DE Number

ELG.005.097

File Name

ELG - ELIGIBLE

File Segment Number

ELG00005

File Segment Name

ELIGIBILITY-DETERMINANTS

Last updated

Definition A flag that indicates the scope of Medicaid or CHIP benefits to which an individual is entitled to.
Size X(1)
FLF Start Position 79
FLF Stop Position 79
Segment Key Field Identifier Not Applicable
Coding Requirements 1. Value must be 1 character
2. Value must be in Restricted Benefits Code List (VVL)
3. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "05", then Eligibility Group (ELG.005.087) must be "24"
4. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "06", then Eligibility Group (ELG.005.087) must be "26"
5. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "02", then Eligibility Group (ELG.005.087) must be "23"
6. (Restricted Benefits) if value equals "1" and Dual Eligible Code (ELG.005.085) value equals "04", then Eligibility Group (ELG.005.087) must be "25"
7. (Restricted Benefits) if value equals "3", then Dual Eligible Code (ELG.005.085) cannot be "00"
8. Mandatory
9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]
10. If value is in [1,7] then Eligibility Group (ELG.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"
11. (Restricted Pregnancy-Related) if value equals "4", then associated Sex (ELG.002.023) value must be "F"
12. (Non-Citizen) if value equals "2", then associated Citizenship Indicator (ELG.003.040) value must not be equal to "1"
13. If value is "D", there must be a corresponding MFP enrollment segment (ELG00010) with Effective and End dates that are within the timespan of this segment
14. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "01", then Eligibility Group (ELG.005.087) must be "23"
15. (Restricted Benefits) if value equals "3" and Dual Eligible Code (ELG.005.085) value equals "03", then Eligibility Group (ELG.005.087) must be "25"
16. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]
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