PRV.007.100

PROV-MEDICAID-ENROLLMENT-STATUS-CODE

Data Element

DE Number

PRV100

System DE Number

PRV.007.100

File Name

PRV - PROVIDER

File Segment Number

PRV00007

File Segment Name

PROV-MEDICAID-ENROLLMENT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A code representing the provider's Medicaid and/or CHIP enrollment status for the time span specified by the Provider Medicaid Effective Date and Provider Medicaid End Date data elements. Note: The State Plan Enrollment data element identifies whether the provider is enrolled in Medicaid, CHIP, or both.
Size	X(2)
FLF Start Position	68
FLF Stop Position	69
Segment Key Field Identifier	3
Coding Requirements	1. Value must be 2 characters 2. Value must be in Provider Medicaid Enrollment Status Code List (VVL) 3. 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-7924	If the billing provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the prescription fill date.
RULE-7936	If the dispensing prescription drug provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the claim dispensing prescription drug provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the prescription fill date is within effective and end dates of the provider medicaid enrollment segment on the pharmacy claim.
RULE-7935	If the servicing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
RULE-7934	If the servicing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
RULE-7933	If the servicing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
RULE-7932	If the billing provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the prescription fill date.
RULE-7931	If the billing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7930	If the billing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7929	If the billing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the admission date.
RULE-7928	If the dispensing prescription drug provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the claim dispensing prescription drug provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the prescription fill date is within effective and end dates of the provider medicaid enrollment segment on the pharmacy claim.
RULE-7927	If the servicing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
RULE-7926	If the servicing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
RULE-7925	If the servicing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status where the effective and end dates of the provider medicaid enrollment segment overlap with the beginning date of service and (if populated) ending date of service on the claim line.
RULE-2956	If the provider medicaid enrollment status code is populated on a provider medicaid enrollment file, then the provider medicaid enrollment status code reported must be found in the list of valid values.
RULE-7923	If the billing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7922	If the billing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7921	If the billing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the admission date.
RULE-7446	If the dispensing prescription drug provider number is populated on a non-denied claim from an RX file and the claim is an Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the claim dispensing prescription drug provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the prescription fill date.
RULE-7445	If the servicing provider number is populated on a non-denied claim from an OT file and the claim is an Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7444	If the servicing provider number is populated on a non-denied claim from an LT file and the claim is an Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7443	If the servicing provider number is populated on a non-denied claim from an IP file and the claim is an Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the claim line servicing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7442	If the billing provider number is populated on a non-denied claim from an RX file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the prescription fill date.
RULE-7441	If the billing provider number is populated on a non-denied claim from an OT file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7440	If the billing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7439	If the billing provider number is populated on a non-denied claim from an IP file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the admission date.
RULE-6557	If a segment is a provider medicaid enrollment segment, then the provider medicaid enrollment status code value reported must be compatible with the specified T-MSIS picture format: X(2).

Measure ID	Measure Name
RULE-7441	% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
RULE-7936	% of claim headers with a Dispensing Prescription Drug Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Prescription Fill Date
RULE-7935	% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service
RULE-7934	% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service
RULE-7933	% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service
RULE-7928	% of claim headers with a Dispensing Prescription Drug Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Prescription Fill Date
RULE-7927	% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service
RULE-7926	% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service
RULE-7925	% of claim lines with a Servicing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Ending Date of Service
RULE-7446	% of claim headers that have a DISPENSING-PRESCRIPTION-DRUG-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Prescription Fill Date
RULE-7445	% of claim lines that have a SERVICING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
RULE-7444	% of claim lines that have a SERVICING-PROV-NUM does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
RULE-7443	% of claim lines with a of SERVICING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
RULE-7442	% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Prescription Fill Date
PRV-3-005-1	% of Submitting State Provider IDs with PROV-MEDICAID-ENROLLMENT-STATUS-CODE of 20-24 (denied)
RULE-7440	% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
RULE-7439	% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Admission Date
ALL-21-008-8	% of DISPENSING-PRESCRIPTION-DRUG-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Prescription Fill Date
ALL-21-007-7	% of SERVICING-PROV-NUM on claim lines that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
ALL-21-006-6	% of SERVICING-PROV-NUM on claim lines that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
ALL-21-005-5	% of SERVICING-PROV-NUM on claim lines that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
ALL-21-004-4	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Prescription Fill Date
ALL-21-003-3	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
ALL-21-002-2	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
ALL-21-001-1	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Admission Date
MIS-11-045-45	% distinct SUBMITTING-STATE-PROV-IDs with only missing values in any active segment: PROV-MEDICAID-ENROLLMENT-STATUS-CODE (PRV00007)
PRV-3-006-2	% of Submitting State Provider IDs with PROV-MEDICAID-ENROLLMENT-STATUS-CODE of 60-83 (termed)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	PRV.007.100	UPDATE	File segment	None	93
09/16/2024	4.0.0	PRV.007.100	ADD	N/A		Created