| COT016 |
COT.002.016
|
RECORD-ID |
The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). |
COT016 Values
|
| COT017 |
COT.002.017
|
SUBMITTING-STATE |
A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. |
COT017 Values
|
| COT018 |
COT.002.018
|
RECORD-NUMBER |
A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file. |
N/A
|
| COT019 |
COT.002.019
|
ICN-ORIG |
A unique number assigned by the state's payment system that identifies an original or adjustment claim. |
N/A
|
| COT020 |
COT.002.020
|
ICN-ADJ |
A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. |
N/A
|
| COT021 |
COT.002.021
|
SUBMITTER-ID |
The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. |
N/A
|
| COT022 |
COT.002.022
|
MSIS-IDENTIFICATION-NUM |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual. Value may be an SSN, temporary SSN or State-assigned eligible individual identifier. MSIS Identification Numbers are a unique "key" value used to maintain referential integrity of data distributed over multiples files, segments and reporting periods. See T-MSIS Guidance Document, "CMS Guidance: Reporting Shared MSIS Identification Numbers" for information on reporting the MSIS Identification Numbers ID for pregnant women, unborn children, mothers, and their deemed newborns younger than 1 year of age who share the same MSIS Identification Number.
https://www.medicaid.gov/tmsis/dataguide/t-msis-coding-blog/reporting-shared-msis-identification-numbers-eligibility/ |
N/A
|
| COT023 |
COT.002.023
|
CROSSOVER-INDICATOR |
An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare. |
COT023 Values
|
| COT024 |
COT.002.024
|
1115A-DEMONSTRATION-IND |
In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration. |
COT024 Values
|
| COT025 |
COT.002.025
|
ADJUSTMENT-IND |
Indicates the type of adjustment record. |
COT025 Values
|
| COT026 |
COT.002.026
|
ADJUSTMENT-REASON-CODE |
Claim adjustment reason codes communicate why a claim was paid differently than it was billed. |
COT026 Values
|
| COT033 |
COT.002.033
|
BEGINNING-DATE-OF-SERVICE |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. |
N/A
|
| COT034 |
COT.002.034
|
ENDING-DATE-OF-SERVICE |
For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. |
N/A
|
| COT035 |
COT.002.035
|
ADJUDICATION-DATE |
The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. |
N/A
|
| COT036 |
COT.002.036
|
MEDICAID-PAID-DATE |
The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment. |
N/A
|
| COT037 |
COT.002.037
|
TYPE-OF-CLAIM |
A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C' or an S-CHIP sub-capitated encounter record |
COT037 Values
|
| COT038 |
COT.002.038
|
TYPE-OF-BILL |
A data element corresponding with UB-04 form locator FL4 that classifies the claim as to the type of facility (2nd digit), type of care (3rd digit) and the billing record's sequence in the episode of care (4th digit). (Note that the 1st digit is always zero.) |
COT038 Values
|
| COT039 |
COT.002.039
|
CLAIM-STATUS |
The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim. |
COT039 Values
|
| COT040 |
COT.002.040
|
CLAIM-STATUS-CATEGORY |
The general category of the claim status (accepted, rejected, pended, finalized, additional information requested, etc.) from the 277 transaction set which is then further detailed in the companion data element claim status. |
COT040 Values
|
| COT041 |
COT.002.041
|
SOURCE-LOCATION |
The field denotes the claims payment system from which the claim was extracted.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.
For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.
For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee. |
COT041 Values
|
| COT042 |
COT.002.042
|
CHECK-NUM |
The check or electronic funds transfer number. |
N/A
|
| COT043 |
COT.002.043
|
CHECK-EFF-DATE |
The date a check is issued to the payee. In the case of electronic funds transfer, it is the date the transfer is made. |
N/A
|
| COT044 |
COT.002.044
|
CLAIM-PYMT-REM-CODE-1 |
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
COT044 Values
|
| COT045 |
COT.002.045
|
CLAIM-PYMT-REM-CODE-2 |
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
COT045 Values
|
| COT046 |
COT.002.046
|
CLAIM-PYMT-REM-CODE-3 |
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
COT046 Values
|
| COT047 |
COT.002.047
|
CLAIM-PYMT-REM-CODE-4 |
Remittance Advice Remark Codes are used to convey information about remittance processing or to provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason Code. Each Remittance Advice Remark Code identifies a specific message as shown in the Remittance Advice Remark Code List. It is a code set used by the health care industry to convey non-financial information critical to understanding the adjudication of a health care claim for payment. It is an external code set whose use is as mandated by the Administrative Simplification provisions of the Health Insurance Portability and Accountably Act of 1996 (P.L.104-191, commonly referred to as HIPAA). |
COT047 Values
|
| COT048 |
COT.002.048
|
TOT-BILLED-AMT |
The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is in [3, C, W], then value must equal amount the provider billed to the managed care plan. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| COT049 |
COT.002.049
|
TOT-ALLOWED-AMT |
The claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. On managed care encounters the Allowed Amount is determined by the managed care organization. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity allowed for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| COT050 |
COT.002.050
|
TOT-MEDICAID-PAID-AMT |
The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| COT052 |
COT.002.052
|
TOT-MEDICARE-DEDUCTIBLE-AMT |
The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a '1' and leave Total Medicare Coinsurance Amount unpopulated. |
N/A
|
| COT053 |
COT.002.053
|
TOT-MEDICARE-COINS-AMT |
The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance. |
N/A
|
| COT054 |
COT.002.054
|
TOT-TPL-AMT |
Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim header level paid by the third party. |
N/A
|
| COT056 |
COT.002.056
|
TOT-OTHER-INSURANCE-AMT |
The amount paid by insurance other than Medicare or Medicaid on this claim. |
N/A
|
| COT057 |
COT.002.057
|
OTHER-INSURANCE-IND |
The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid. |
COT057 Values
|
| COT058 |
COT.002.058
|
OTHER-TPL-COLLECTION |
This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. |
COT058 Values
|
| COT061 |
COT.002.061
|
FIXED-PAYMENT-IND |
This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined 'medical record' associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review. |
COT061 Values
|
| COT062 |
COT.002.062
|
FUNDING-CODE |
A code to indicate the source of non-federal share funds. |
COT062 Values
|
| COT063 |
COT.002.063
|
FUNDING-SOURCE-NONFEDERAL-SHARE |
A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government. |
COT063 Values
|
| COT064 |
COT.002.064
|
MEDICARE-COMB-DED-IND |
Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated. |
COT064 Values
|
| COT065 |
COT.002.065
|
PROGRAM-TYPE |
A code to indicate special Medicaid program under which the service was provided. |
COT065 Values
|
| COT066 |
COT.002.066
|
PLAN-ID-NUMBER |
A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.
For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report the PLAN-ID-NUMBER for the MCP (MCO, PIHP, or PAHP that has a contract with a state) that is making the payment to the sub-capitated entity or sub-capitated network provider.
For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field. |
N/A
|
| COT068 |
COT.002.068
|
PAYMENT-LEVEL-IND |
The field denotes whether the payment amount was determined at the claim header or line/detail level. For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines' associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only. For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.
For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.
For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts. |
COT068 Values
|
| COT069 |
COT.002.069
|
MEDICARE-REIM-TYPE |
A code to indicate the type of Medicare reimbursement. |
COT069 Values
|
| COT070 |
COT.002.070
|
CLAIM-LINE-COUNT |
The total number of lines on the claim. |
N/A
|
| COT072 |
COT.002.072
|
FORCED-CLAIM-IND |
Indicates if the claim was processed by forcing it through a manual override process. |
COT072 Values
|
| COT073 |
COT.002.073
|
HEALTH-CARE-ACQUIRED-CONDITION-IND |
This code indicates whether the claim has a Health Care Acquired Condition. For additional coding information refer to the following site:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/index.html?redirect=/hospitalacqcond/05_Coding.asp#TopOfPage |
COT073 Values
|
| COT074 |
COT.002.074
|
OCCURRENCE-CODE-01 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT074 Values
|
| COT075 |
COT.002.075
|
OCCURRENCE-CODE-02 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT075 Values
|
| COT076 |
COT.002.076
|
OCCURRENCE-CODE-03 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT076 Values
|
| COT077 |
COT.002.077
|
OCCURRENCE-CODE-04 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT077 Values
|
| COT078 |
COT.002.078
|
OCCURRENCE-CODE-05 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT078 Values
|
| COT079 |
COT.002.079
|
OCCURRENCE-CODE-06 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT079 Values
|
| COT080 |
COT.002.080
|
OCCURRENCE-CODE-07 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT080 Values
|
| COT081 |
COT.002.081
|
OCCURRENCE-CODE-08 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT081 Values
|
| COT082 |
COT.002.082
|
OCCURRENCE-CODE-09 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT082 Values
|
| COT083 |
COT.002.083
|
OCCURRENCE-CODE-10 |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are Form Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
COT083 Values
|
| COT084 |
COT.002.084
|
OCCURRENCE-CODE-EFF-DATE-01 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT085 |
COT.002.085
|
OCCURRENCE-CODE-EFF-DATE-02 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT086 |
COT.002.086
|
OCCURRENCE-CODE-EFF-DATE-03 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT087 |
COT.002.087
|
OCCURRENCE-CODE-EFF-DATE-04 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT088 |
COT.002.088
|
OCCURRENCE-CODE-EFF-DATE-05 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT089 |
COT.002.089
|
OCCURRENCE-CODE-EFF-DATE-06 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT090 |
COT.002.090
|
OCCURRENCE-CODE-EFF-DATE-07 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT091 |
COT.002.091
|
OCCURRENCE-CODE-EFF-DATE-08 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT092 |
COT.002.092
|
OCCURRENCE-CODE-EFF-DATE-09 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT093 |
COT.002.093
|
OCCURRENCE-CODE-EFF-DATE-10 |
The start date of the corresponding occurrence code or occurrence span codes. |
N/A
|
| COT094 |
COT.002.094
|
OCCURRENCE-CODE-END-DATE-01 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT095 |
COT.002.095
|
OCCURRENCE-CODE-END-DATE-02 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT096 |
COT.002.096
|
OCCURRENCE-CODE-END-DATE-03 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT097 |
COT.002.097
|
OCCURRENCE-CODE-END-DATE-04 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT098 |
COT.002.098
|
OCCURRENCE-CODE-END-DATE-05 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT099 |
COT.002.099
|
OCCURRENCE-CODE-END-DATE-06 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT100 |
COT.002.100
|
OCCURRENCE-CODE-END-DATE-07 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT101 |
COT.002.101
|
OCCURRENCE-CODE-END-DATE-08 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT102 |
COT.002.102
|
OCCURRENCE-CODE-END-DATE-09 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT103 |
COT.002.103
|
OCCURRENCE-CODE-END-DATE-10 |
The last date that the corresponding occurrence code or occurrence span code was applicable. If occurrence date span is a single day, value must be equal to the value of the associated Occurrence Code Effective Date. |
N/A
|
| COT104 |
COT.002.104
|
PATIENT-CONTROL-NUM |
A patient's unique number assigned by the provider agency during claim submission, which identifies the client or the client's episode of service within the provider's system to facilitate retrieval of individual financial and clinical records and posting of payment |
N/A
|
| COT105 |
COT.002.105
|
ELIGIBLE-LAST-NAME |
The last name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) |
N/A
|
| COT106 |
COT.002.106
|
ELIGIBLE-FIRST-NAME |
The first name of the individual to whom the services were provided. (The patients name should be captured as it appears on the claim record, it does not need to be the same as it appears on the eligibility file. The MSIS Identification Number will be used to associate a claim record with the appropriate eligibility data.) |
N/A
|
| COT107 |
COT.002.107
|
ELIGIBLE-MIDDLE-INIT |
Individual's middle initial; middle initial component of full name (e.g. First Name, Middle Initial, Last Name). |
N/A
|
| COT108 |
COT.002.108
|
DATE-OF-BIRTH |
An individual's date of birth. |
N/A
|
| COT109 |
COT.002.109
|
HEALTH-HOME-PROV-IND |
Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model. |
COT109 Values
|
| COT110 |
COT.002.110
|
WAIVER-TYPE |
A code for specifying waiver type under which the eligible individual is covered during the month and receiving services/under which claim is submitted. |
COT110 Values
|
| COT111 |
COT.002.111
|
WAIVER-ID |
Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments. |
N/A
|
| COT112 |
COT.002.112
|
BILLING-PROV-NUM |
A unique identification number assigned by the state to a provider or managed care plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan. |
N/A
|
| COT113 |
COT.002.113
|
BILLING-PROV-NPI-NUM |
The National Provider ID (NPI) of the billing entity responsible for billing a patient for healthcare services. The billing provider can also be servicing, referring, or prescribing provider. Can be admitting provider except for Long Term Care. For sub-capitation payments, report the national provider identifier (NPI) for the sub-capitated entity if the provider has one. |
N/A
|
| COT114 |
COT.002.114
|
BILLING-PROV-TAXONOMY |
The taxonomy code for the provider billing for the service. |
COT114 Values
|
| COT115 |
COT.002.115
|
BILLING-PROV-TYPE |
A code to describe the type of provider being reported. |
COT115 Values
|
| COT116 |
COT.002.116
|
BILLING-PROV-SPECIALTY |
This code describes the area of specialty for the provider being reported. |
COT116 Values
|
| COT117 |
COT.002.117
|
REFERRING-PROV-NUM |
A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. |
N/A
|
| COT118 |
COT.002.118
|
REFERRING-PROV-NPI-NUM |
The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. |
N/A
|
| COT122 |
COT.002.122
|
MEDICARE-HIC-NUM |
The Medicare HIC Number (HICN) is an identifier formerly used by SSA and CMS to identify all Medicare beneficiaries. For many beneficiaries, their SSN was a major component of their HICN. To prevent identify theft, among other reasons, HICN gradually were retired and replaced by the Medicare Beneficiary Identifier (MBI) over the course of 2018 and 2019. HICN continue to be used by Medicare for limited administrative purposes after 2019 but starting in 2020 the MBI became the primary identifier for Medicare beneficiaries. HICN consists of two components: SSN & alpha-suffix or (for Railroad IDs) prefix and ID (not always SSN based) |
N/A
|
| COT123 |
COT.002.123
|
PLACE-OF-SERVICE |
A pass-through data element meaning that the state should report the field in T-MSIS as reported by the provider on the claim form (i.e., 837P or 837D - Place of Service is only captured at the line level of the CMS-1500). If the claim is submitted on the 837p electronic claims form and the Facility Code Qualifier is reported with any value other than 'B', then the PLACE-OF-SERVICE value should be blank or space-filled. If the claim is submitted on the CMS-1450 (UB-04) institutional claims form, the PLACE-OF-SERVICE field should be blank or space-filled. Otherwise, if the claim is submitted with the place of service populated with any value other than the valid values listed in T-MSIS Data Guide for PLACE-OF-SERVICE values, that value should still be reported in the PLACE-OF-SERVICE data element. If the claim is submitted by a provider with the place of service fields blank, then the PLACE-OF-SERVICE on the T-MSIS OT claims file should be blank or space-filled. |
COT123 Values
|
| COT126 |
COT.002.126
|
REMITTANCE-NUM |
The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount. |
N/A
|
| COT127 |
COT.002.127
|
DAILY-RATE |
The amount a policy will pay per day for a covered service. In some cases for OT claims this is referred to as a flat rate. |
N/A
|
| COT128 |
COT.002.128
|
BORDER-STATE-IND |
A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.) |
COT128 Values
|
| COT130 |
COT.002.130
|
TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/s on behalf of the beneficiary. |
N/A
|
| COT131 |
COT.002.131
|
BENEFICIARY-COINSURANCE-DATE-PAID |
The date the beneficiary paid the coinsurance amount. |
N/A
|
| COT132 |
COT.002.132
|
TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/s on behalf of the beneficiary. |
N/A
|
| COT133 |
COT.002.133
|
BENEFICIARY-COPAYMENT-DATE-PAID |
The date the beneficiary paid the copayment amount. |
N/A
|
| COT134 |
COT.002.134
|
TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/s on behalf of the beneficiary. |
N/A
|
| COT135 |
COT.002.135
|
BENEFICIARY-DEDUCTIBLE-DATE-PAID |
The date the beneficiary paid the deductible amount. |
N/A
|
| COT136 |
COT.002.136
|
CLAIM-DENIED-INDICATOR |
An indicator to identify a claim that the state refused pay in its entirety. |
COT136 Values
|
| COT137 |
COT.002.137
|
COPAY-WAIVED-IND |
An indicator signifying that the copay was waived by the provider |
COT137 Values
|
| COT138 |
COT.002.138
|
HEALTH-HOME-ENTITY-NAME |
A free-form text field to indicate the health home program that authorized payment for the service on the claim or to identify the health home SPA in which an individual is enrolled. The name entered should be the name that the state uses to uniquely identify the team. A "Health Home Entity" can be a designated provider (e.g., physician, clinic, behavioral health organization), a health team which links to a designated provider, or a health team (physicians, nurses, behavioral health professionals). Because an identification numbering schema has not been established, the entities' names are being used instead. |
N/A
|
| COT140 |
COT.002.140
|
THIRD-PARTY-COINSURANCE-AMOUNT-PAID |
The amount of money paid by a third party on behalf of the beneficiary towards coinsurance. |
N/A
|
| COT141 |
COT.002.141
|
THIRD-PARTY-COINSURANCE-DATE-PAID |
The date the third party paid the coinsurance amount |
N/A
|
| COT142 |
COT.002.142
|
THIRD-PARTY-COPAYMENT-AMOUNT-PAID |
The amount of money paid by a third party on behalf of the beneficiary towards copayment. |
N/A
|
| COT143 |
COT.002.143
|
THIRD-PARTY-COPAYMENT-DATE-PAID |
The date the third party paid the copayment amount. |
N/A
|
| COT146 |
COT.002.146
|
HEALTH-HOME-PROVIDER-NPI |
The National Provider ID (NPI) of the health home provider. |
N/A
|
| COT147 |
COT.002.147
|
MEDICARE-BENEFICIARY-IDENTIFIER |
The Medicare Beneficiary Identifier (MBI) is a randomly generated identifier used to identify all Medicare beneficiaries. It replaced the previously-used SSN-based Medicare HIC Number (HICN). To prevent identity theft, among other reasons, HICN gradually were retired and replaced by the MBI over the course of 2018 and 2019. Starting in 2020, the MBI became the primary identifier for Medicare beneficiaries. |
N/A
|
| COT226 |
COT.002.226
|
PROV-LOCATION-ID |
A code to uniquely identify the geographic location where the provider's services were performed. The Provider Location Identifier values reported on Inpatient, Long-Term Care, Other, and Pharmacy Claim Header Segments must correspond to an active Provider Location Identifier value on a Provider Location and Contact Info (PRV.003) segment. If a particular license (e.g., a physician's medical license) or provider identifier (e.g., an individual provider's NPI or SSN) is applicable to all of their servicing locations, value "000" (a string of exactly three zeros) can be used in the PRV.004 or PRV.005, respectively, to represent all locations, however that location identifier must not be attributed to claims or provider bed type info. |
N/A
|
| COT230 |
COT.002.230
|
TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT |
The total copayment amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary copayment liability for covered service on the claim. Do not subtract out any payments made toward the copayment. |
N/A
|
| COT231 |
COT.002.231
|
TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT |
The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance. |
N/A
|
| COT232 |
COT.002.232
|
TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT |
The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible. |
N/A
|
| COT233 |
COT.002.233
|
COMBINED-BENE-COST-SHARING-PAID-AMOUNT |
The combined amounts the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment, coinsurance, and/or deductible for the covered services on the claim. Only report this data element when the claim does not differentiate among copayment, coinsurance, and/or deductible payments made by the beneficiary. Do not include beneficiary cost sharing payments made by a third party/ies on behalf of the beneficiary. |
N/A
|
| COT235 |
COT.002.235
|
LTC-RCP-LIAB-AMT |
The total amount paid by the patient for services where they are required to use their personal funds to cover part of their care before Medicaid funds can be utilized. |
N/A
|
| COT236 |
COT.002.236
|
BILLING-PROV-ADDR-LN-1 |
Billing provider address line 1 from X12 837I, 837P, and 837D loop 2010AA. |
N/A
|
| COT237 |
COT.002.237
|
BILLING-PROV-ADDR-LN-2 |
Billing provider address line 2 from X12 837I, 837P, and 837D loop 2010AA. |
N/A
|
| COT238 |
COT.002.238
|
BILLING-PROV-CITY |
Billing provider address city name from X12 837I, 837P, and 837D loop 2010AA. |
N/A
|
| COT239 |
COT.002.239
|
BILLING-PROV-STATE |
Billing provider address state code from X12 837I, 837P, and 837D loop 2010AA. |
COT239 Values
|
| COT240 |
COT.002.240
|
BILLING-PROV-ZIP-CODE |
Billing provider address ZIP code from X12 837I, 837P, and 837D loop 2010AA. |
COT240 Values
|
| COT241 |
COT.002.241
|
SERVICE-FACILITY-LOCATION-ORG-NPI |
Service facility location organization NPI from X12 837I loop 2310E or 837P and 837D loop 2310C. |
N/A
|
| COT242 |
COT.002.242
|
SERVICE-FACILITY-LOCATION-ADDR-LN-1 |
Service facility location address line 1 from X12 837I loop 2310E or 837P and 837D loop 2310C. |
N/A
|
| COT243 |
COT.002.243
|
SERVICE-FACILITY-LOCATION-ADDR-LN-2 |
Service facility location address line 2 from X12 837I loop 2310E or 837P and 837D loop 2310C. |
N/A
|
| COT244 |
COT.002.244
|
SERVICE-FACILITY-LOCATION-CITY |
Service facility location address city name from X12 837I loop 2310E or 837P and 837D loop 2310C. |
N/A
|
| COT245 |
COT.002.245
|
SERVICE-FACILITY-LOCATION-STATE |
Service facility location address state code from X12 837I loop 2310E or 837P and 837D loop 2310C. |
COT245 Values
|
| COT246 |
COT.002.246
|
SERVICE-FACILITY-LOCATION-ZIP-CODE |
Service facility location address ZIP code from X12 837I loop 2310E or 837P and 837D loop 2310C. |
COT246 Values
|
| COT247 |
COT.002.247
|
PROVIDER-CLAIM-FORM-CODE |
A code indicating the format in which the provider submitted their claim. Very few if any claims should be classified as "Other". |
COT247 Values
|
| COT248 |
COT.002.248
|
PROVIDER-CLAIM-FORM-OTHER-TEXT |
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. |
N/A
|
| COT249 |
COT.002.249
|
TOT-GME-AMOUNT-PAID |
The amount included in the Total Medicaid Amount (COT.002.050) that is attributable to a Graduate Medical Education (GME) payment, when the state makes GME payments by claim. |
N/A
|
| COT250 |
COT.002.250
|
REFERRING-PROV-NUM-2 |
A unique identification number assigned to a provider which identifies the physician or other provider who referred the patient. For physicians, this must be the individual's ID number, not a group identification number. If the referring provider number is not available, but the physician's Drug Enforcement Agency (DEA) ID is on the State file, then the State should use the DEA ID for this data element. This is only applicable when a provider reports a second referral at the header of their claim. |
N/A
|
| COT251 |
COT.002.251
|
REFERRING-PROV-NPI-NUM-2 |
The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient. This is only applicable when a provider reports a second referral at the header of their claim. |
N/A
|
| COT252 |
COT.002.252
|
TOT-SDP-ALLOWED-AMT |
The component (in dollar and cents) of the total allowed amount that represents the difference between what would have been the managed care plan's typical contractual allowed amount and the enhanced allowed amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). |
N/A
|
| COT253 |
COT.002.253
|
TOT-SDP-PAID-AMT |
The component (in dollar and cents) of the total paid amount that represents the difference between what would have been the managed care plan's typical contractual paid amount and the enhanced paid amount for this specific claim as defined by the State's SPA, waiver, or demonstration for a State Directed Payment model per 42 CFR 438.6(c)(1)(iii). |
N/A
|
| COT152 |
COT.002.152
|
STATE-NOTATION |
A free text field for the submitting state to enter whatever information it chooses. |
N/A
|
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