| 02/27/2025 |
3.34.0 |
ELG.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Sex List (VVL)2. Value must be 1 character3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal "1"4. Mandatory |
1. Value must be in Sex List (VVL)2. Value must be 1 character4. Mandatory |
| 02/27/2025 |
3.34.0 |
CRX.002.162 |
UPDATE |
Coding requirement |
1. Value must be one digit2. Value must be 1:43. Conditional |
1. Value must be one digit2. Value must be in Prescription Origin Code List (VVL)3. Conditional |
| 12/10/2024 |
3.33.0 |
CRX.002.162 |
UPDATE |
Medicaid valid value info |
See https://www.ncpdp.org/ |
For background and context, see https://www.ncpdp.org/ |
| 02/27/2025 |
3.34.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is "1" or "7" then Eligibility Group (EGL.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 is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in [72,73,74,75] and State Plan Option Type (ELG.DE.163) must equal "06"11. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06]12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 02/27/2025 |
3.34.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 02/27/2025 |
3.34.0 |
ELG.003.044 |
UPDATE |
Definition |
The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified alien." |
The date the five-year bar for an individual ends. Section 403 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) provides that certain immigrants who enter the United States on or after August 22, 1996 are not eligible to receive federally-funded benefits, including Medicaid and the State Children's Health Insurance Program (Separate CHIP), for five years from the date they enter the country with a status as a "qualified noncitizen." |
| 02/27/2025 |
3.34.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 02/27/2025 |
3.34.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 02/20/2025 |
3.34.0 |
ELG.002.023 |
UPDATE |
Definition |
Either individual's biological sex or their self-identified sex. |
The individual's biological sex assigned at birth. |
| 02/27/2025 |
3.34.0 |
CRX.003.150 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/30/2024 |
3.30.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 02/27/2025 |
3.34.0 |
CRX.002.058 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
CRX.002.032 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
CRX.002.029 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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†for an S-CHIP sub-capitated encounter record. |
| 02/27/2025 |
3.34.0 |
COT.003.211 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01",then a valid value is mandatory and must be reported5. If value is in [14,35,42,44],then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01",then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated then must not be populated |
| 02/27/2025 |
3.34.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122],Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020,021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066,067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085,086,087,088,089,115,119,120,121,122,127,131,134,135,136,137,138,139,140,141,142,143,144,145,147]5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated9. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated10. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated11. When value is not in [025,085], Sex (ELG.002.023) equals "M"12. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122],Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020,021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066,067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085,086,087,088,089,115,119,120,121,122,127,131,134,135,136,137,138,139,140,141,142,143,144,145,147]5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated9. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated10. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated11. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 09/30/2024 |
3.30.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 02/27/2025 |
3.34.0 |
COT.002.068 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.037 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “F”. |
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†for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “Fâ€. |
| 02/27/2025 |
3.34.0 |
CLT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated, then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated, then must not be populated |
| 09/30/2024 |
3.30.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 02/27/2025 |
3.34.0 |
CLT.002.082 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.056 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.052 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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†for an S-CHIP sub-capitated encounter record. |
| 02/27/2025 |
3.34.0 |
CIP.003.270 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If XXI MBESCBES Category of Service is populated then must not be populated |
| 02/27/2025 |
3.34.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal "086" if Sex (ELG.002.023) equals "M"4. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
1. Value must be 3 characters2. Mandatory3. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
| 09/30/2024 |
3.30.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 02/27/2025 |
3.34.0 |
CIP.002.132 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.104 |
UPDATE |
Definition |
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. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.100 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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†for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
TPL.006.082 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational3. Value must be in ZIP Code List (VVL) |
| 09/12/2024 |
3.29.0 |
PRV.003.052 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory3. Value must be in ZIP Code List (VVL) |
| 09/12/2024 |
3.29.0 |
MCR.003.047 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)3. Value must be in ZIP Code List (VVL)2. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.004.071 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Mandatory3. Value must be in ZIP Code List (VVL) |
| 09/12/2024 |
3.29.0 |
COT.003.208 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Conditional |
3. Value must be in ZIP Code List (VVL)1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.203 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Conditional |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)3. Value must be in ZIP Code List (VVL)2. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.291 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.290 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.030 |
UPDATE |
Coding requirement |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. When populated, value cannot equal Diagnosis Code 1 (COT.002.027)11. When Diagnosis Code 1 (COT.002.027) is not populated, value should not be populated |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is "1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. When populated, value cannot equal Diagnosis Code 1 (COT.002.027)11. When Diagnosis Code 1 (COT.002.027) is not populated, value should not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.027 |
UPDATE |
Coding requirement |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (COT.002.037) is in ("1", "3", "A", "C", "U", "W") then Diagnosis Code 1 (COT.002.027) must be populated. |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is "1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (COT.002.037) is in [1,3,A,C,U,W] then Diagnosis Code 1 (COT.002.027) must be populated |
| 09/12/2024 |
3.29.0 |
CLT.002.029 |
UPDATE |
Coding requirement |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CLT.002.052) in ("1", "3", "A", "C", "U", "W") then value must be populated. |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CLT.002.052) in [1,3,A,C,U,W] then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.056 |
UPDATE |
Coding requirement |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. Value must not be populated when Diagnosis Code 8 (CIP.002.053) is not populated |
1. When populated, a Diagnosis Code Flag is required10. Value must not be populated when Diagnosis Code 8 (CIP.002.053) is not populated2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.032 |
UPDATE |
Coding requirement |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CIP.002.100) in ("1", "3", "A", "C", "U", "W") then value must be populated. |
1. When populated, a Diagnosis Code Flag is required2. If associated Diagnosis Code Flag value is "1" (ICD-9), then value must be in ICD-9 Diagnosis Code List (VVL)3. If associated Diagnosis Code Flag value is "2" (ICD-10), then value must be in ICD-10 Diagnosis Code List (VVL)4. Value must be a minimum of 3 characters5. Value must not contain a decimal point6. If associated Diagnosis Code Flag value is '"1" (ICD-9), value must not exceed 5 characters7. If associated Diagnosis Code Flag value is "2" (ICD-10), value must not exceed 7 characters8. When there is more than one diagnosis code on a claim, each value must be unique9. Conditional10. If Type of Claim (CIP.002.100) in [1,3,A,C,U,W] then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.099 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
| 09/12/2024 |
3.29.0 |
COT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in[1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
| 09/12/2024 |
3.29.0 |
CLT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
| 09/12/2024 |
3.29.0 |
CIP.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Mandatory6. If value is in [0,5,6], then associated Adjustment ICN must not be populated7. If value is in [4,1] then Adjustment ICN must be populated8. Value must equal "1", when associated Claim Status equals "686" |
| 09/12/2024 |
3.29.0 |
TPL.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.189 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ["1","3","A","C"] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in "01", "02", "03", "04", "05", "06"] (active) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X], then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X], then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in [1,3,A,C] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in [01,02,03,04,05,06] (active) |
| 09/12/2024 |
3.29.0 |
ELG.005.091 |
UPDATE |
Coding requirement |
1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1"5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" |
1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI) If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1"5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" |
| 09/12/2024 |
3.29.0 |
CLT.003.212 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.002.019) Submitting State Provider ID |
| 09/12/2024 |
3.29.0 |
CLT.002.150 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Split Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.260 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in (Z,3,C,W,2,B,V,4,D,X) then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in (Z,3,C,W,2,B,V,4,D,X) then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in [1,3,A,C] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in [01,02,03,04,05,06] (active) |
| 09/12/2024 |
3.29.0 |
CIP.002.203 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Split Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.190 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim (COT.002.037) not in [3,C,W]. then value must match Provider Identifier (PRV.005.081)6. When Type of Claim is in [1,3,A,C], then value must be populated7.When Type of Claim is in [1,3,A,C] and value is not populated, Servicing Provider Number (COT.003.189) must be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.213 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to "2"3. Conditional4. When Type of Claim (CLT.002.052) not in [3,C,W] then value must match Provider Identifier (PRV.005.081) |
| 09/12/2024 |
3.29.0 |
CIP.003.261 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file5. When Type of Claim is in ['1','3','A','C'], then value must be populated |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim is in [1,3,A,C], then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.075 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Mandatory4. Value must exist in the NPPES NPI data file5. NPPES Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Mandatory5. NPPES Entity Type Code associate with this NPI must equal '1' (Individual) |
| 09/12/2024 |
3.29.0 |
CIP.003.265 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim is in [1,3,A,C], then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.169 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an CPT-4 encoding '01', then value must be a valid CPT-4 procedure code3. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code4. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding '06', then value must be a valid HCPCS code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an CPT-4 encoding "01", then value must be a valid CPT-4 procedure code3. If associated Procedure Code Flag List (VVL) value indicates "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list,and value must be a valid State-specific procedure code4. If associated Procedure Code Flag List (VVL) value indicates an HCPCS encoding "06", then value must be a valid HCPCS code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.101 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 09/12/2024 |
3.29.0 |
TPL.006.085 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.006.084 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
TPL.005.069 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.005.068 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20']6. Value must occur on or before individual's Date of Death (ELG.002.025) when populated |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20]6. Value must occur on or before individual's Date of Death (ELG.002.025) when populated |
| 09/12/2024 |
3.29.0 |
TPL.005.066 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
TPL.004.060 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.004.059 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
TPL.004.058 |
UPDATE |
Coding requirement |
1. Value must be in Coverage Type List (VVL).2. Value must be 2 characters3. Mandatory |
1. Value must be in Coverage Type List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.003.049 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99']6. When associated Date of Death (ELG.002.025) is populated, data element value must be less than or equal to Date of Death |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99]6. When associated Date of Death (ELG.002.025) is populated, data element value must be less than or equal to Date of Death |
| 09/12/2024 |
3.29.0 |
TPL.003.048 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
TPL.003.038 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
TPL.003.089 |
UPDATE |
Coding requirement |
1. Value must be in Coverage Type List (VVL).2. Value must be 2 characters3. Mandatory |
1. Value must be in Coverage Type List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.003.032 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
TPL.002.026 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
TPL.002.025 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20']6. Value must be equal to or less than the individual's Date of Death (ELG.002.025) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20]6. Value must be equal to or less than the individual's Date of Death (ELG.002.025) |
| 09/12/2024 |
3.29.0 |
TPL.002.020 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals "1", there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
| 09/12/2024 |
3.29.0 |
TPL.002.019 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
TPL.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.001.007 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory4. Value must be the same for all records |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
TPL.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'TPL-FILE'2. Mandatory |
1. Value must equal "TPL-FILE"2. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.010.131 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in[18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.010.130 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.009.122 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.009.121 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.008.112 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.008.111 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.007.099 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.007.098 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.006.091 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.006.090 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.006.089 |
UPDATE |
Coding requirement |
1. If associated Provider Classification Type equals 1, value must be in Provider Taxonomy List (VVL)2. If associated Provider Classification Type equals 2, value must be in Provider Specialty List (VVL)3. If associated Provider Classification Type equals 3, value must be in Provider Type Code List (VVL)4. If associated Provider Classification Type equals 4, value must be in Provider Authorized Category of Service Code List (VVL)5. Value must be 20 characters or less6. Mandatory |
1. If associated Provider Classification Type equals "1", value must be in Provider Taxonomy List (VVL)2. If associated Provider Classification Type equals 2, value must be in Provider Specialty List (VVL)3. If associated Provider Classification Type equals "3", value must be in Provider Type Code List (VVL)4. If associated Provider Classification Type equals "4", value must be in Provider Authorized Category of Service Code List (VVL)5. Value must be 20 characters or less6. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.006.088 |
UPDATE |
Definition |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, 'CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File' https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
| 09/12/2024 |
3.29.0 |
PRV.005.080 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.005.079 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.005.078 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbol2. (State-specific Medicaid Provider) if associated Provider Identifier Type (PRV.005.077) value is equal to 1, then value must equal (PRV.005.073) Submitting State3. (NPI) if associated Provider Identifier Type (PRV.005.077) value is equal to 2, then value must equal 'NPI'4. (Medicare) if associated Provider Identifier Type (PRV.005.077) value is equal to 3, then value must equal 'CMS'5. (NCPDP) if associated Provider Identifier Type (PRV.005.077) value is equal to 4, then value must equal 'NCPDP'6. (Federal Tax ID) if associated Provider Identifier Type (PRV.005.077) value is equal to 5, then value must equal 'IRS'7. (SSN) if associated Provider Identifier Type (PRV.005.077) value is equal to 7, then value must be equal to 'SSA'8. Value must be 18 characters or less9. Mandatory |
1. Value must not contain a pipe or asterisk symbol2. (State-specific Medicaid Provider) if associated Provider Identifier Type (PRV.005.077) value is equal to 1, then value must equal (PRV.005.073) Submitting State3. (NPI) if associated Provider Identifier Type (PRV.005.077) value is equal to "2", then value must equal "NPI"4. (Medicare) if associated Provider Identifier Type (PRV.005.077) value is equal to "3", then value must equal "CMS"5. (NCPDP) if associated Provider Identifier Type (PRV.005.077) value is equal to "4", then value must equal "NCPDP"6. (Federal Tax ID) if associated Provider Identifier Type (PRV.005.077) value is equal to "5", then value must equal "IRS"7. (SSN) if associated Provider Identifier Type (PRV.005.077) value is equal to "7", then value must be equal to "SSA"8. Value must be 18 characters or less9. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.005.077 |
UPDATE |
Coding requirement |
1. Value must be in Provider Identifier Type List (VVL)2. Mandatory3. Value must be 1 character4. When value equals '2', the associated Provider Identifier (PRV.005.081) must be a valid NPI |
1. Value must be in Provider Identifier Type List (VVL)2. Mandatory3. Value must be 1 character4. When value equals "2", the associated Provider Identifier (PRV.005.081) must be a valid NPI |
| 09/12/2024 |
3.29.0 |
PRV.004.068 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbol2. Value must be 60 characters or less3. (required) if associated License or Accreditation Number (PRV.004.069) value is populated, then value is mandatory and must be provided4. Mandatory5. Value must equal 'DEA' when associated License Type equals '2' |
1. Value must not contain a pipe or asterisk symbol2. Value must be 60 characters or less3. (required) if associated License or Accreditation Number (PRV.004.069) value is populated, then value is mandatory and must be provided4. Mandatory5. Value must equal "DEA" when associated License Type equals "2" |
| 09/12/2024 |
3.29.0 |
PRV.004.066 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.004.065 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.003.054 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
1. Must contain the "@" symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot "." that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 09/12/2024 |
3.29.0 |
PRV.003.045 |
UPDATE |
Data element name text |
Provider Location & Contact Info End Date |
Provider Location Contact Info End Date |
| 09/12/2024 |
3.29.0 |
PRV.003.045 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.003.044 |
UPDATE |
Data element name text |
Provider Location & Contact Info Effective Date |
Provider Location Contact Info Effective Date |
| 09/12/2024 |
3.29.0 |
PRV.003.044 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.002.032 |
UPDATE |
Coding requirement |
1. Value must be in Ownership Code List (VVL)2. Value must be 2 characters3. Conditional4. Value is mandatory when associated Facility Group Individual Code (PRV.002.026) is in ['01, '02'] (organization) |
1. Value must be in Ownership Code List (VVL)2. Value must be 2 characters3. Conditional4. Value is mandatory when associated Facility Group Individual Code (PRV.002.026) is in [01,02] (organization) |
| 02/20/2025 |
3.34.0 |
PRV.002.031 |
UPDATE |
Definition |
Either individual's biological sex or their self-identified sex. |
The individual's biological sex assigned at birth. |
| 09/12/2024 |
3.29.0 |
PRV.002.027 |
UPDATE |
Coding requirement |
1. Value must be in Teaching Indicator List (VVL)2. Value must be 1 character3. Value must be '0' when Facility Group Individual Code (PRV.002.026) equals '02' or '03'4. Conditional |
1. Value must be in Teaching Indicator List (VVL)2. Value must be 1 character3. Value must be "0" when Facility Group Individual Code (PRV.002.026) in [02,03]4. Conditional |
| 09/12/2024 |
3.29.0 |
PRV.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals '03', then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to ‘2’ (NPI) |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals "03", then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal "03", then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals "03", then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals "03", then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals "03", then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value is in [01,02], then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals "03", then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to "2" (NPI) |
| 09/12/2024 |
3.29.0 |
PRV.002.021 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
PRV.002.020 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
PRV.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.001.007 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory4. Value must be the same for all records |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
PRV.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'PROVIDER'2. Mandatory |
1. Value must equal "PROVIDER"2. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.007.088 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.007.087 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.006.079 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19, 20, 99] |
| 09/12/2024 |
3.29.0 |
MCR.006.078 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19, 20] |
| 09/12/2024 |
3.29.0 |
MCR.005.070 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.005.069 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.005.067 |
UPDATE |
Coding requirement |
1. Value must be in Operating Authority List (VVL)2. Value must be 2 characters or less3. Mandatory |
1. Value must be in Operating Authority List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.004.060 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.004.059 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.004.058 |
UPDATE |
Coding requirement |
1. Value must be in Managed Care Service Area Name List (VVL)2. If associated Managed Care Service Area (MCR.002.029) is in [ 2, 3, 4, 5, 6 ], then value is mandatory and must be provided3. Value must not contain a pipe or asterisk symbol4. Value must be 30 characters or less5. Conditional6. If associated Managed Care Service Area (MCR.002.029) equals '5' (zipcode), then value must be a 5-digit zipcode7. If associated Managed Care Service Area (MCR.002.029) equals '2' (county code), then value must be a 3-digit number |
1. Value must be in Managed Care Service Area Name List (VVL)2. If associated Managed Care Service Area (MCR.002.029) is in [2,3,4,5,6], then value is mandatory and must be provided3. Value must not contain a pipe or asterisk symbol4. Value must be 30 characters or less5. Conditional6. If associated Managed Care Service Area (MCR.002.029) equals "5" (zipcode), then value must be a 5-digit zipcode7. If associated Managed Care Service Area (MCR.002.029) equals "2" (county code), then value must be a 3-digit number |
| 09/12/2024 |
3.29.0 |
MCR.003.050 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot "." that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 09/12/2024 |
3.29.0 |
MCR.003.044 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 09/12/2024 |
3.29.0 |
MCR.003.040 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.003.039 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.003.038 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe symbol2. Each managed care entity's locations must have a unique identifier3. Value must be populated if associated Managed Care Address Type (MCR.003.041) equals 3 (Managed care entity's service location address)4. Value must be 15 characters or less5. Mandatory |
1. Value must not contain a pipe symbol2. Each managed care entity's locations must have a unique identifier3. Value must be populated if associated Managed Care Address Type (MCR.003.041) equals "3" (Managed care entity's service location address)4. Value must be 15 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.002.031 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
MCR.002.030 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
MCR.002.029 |
UPDATE |
Coding requirement |
1. Value must be in Managed Care Service Area List (VVL)2. Value must be 1 character3. Mandatory4. When value equals '2', the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
1. Value must be in Managed Care Service Area List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "2", the associated Managed Care Service Area Name (MCR.004.058) value must be a valid US County Code |
| 09/12/2024 |
3.29.0 |
MCR.002.020 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20']6. Mandatory7. Value must occur before Managed Care Contract End Date (MCR.002.021) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20]6. Mandatory7. Value must occur before Managed Care Contract End Date (MCR.002.021) |
| 09/12/2024 |
3.29.0 |
MCR.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.001.007 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory4. Value must be the same for all records |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
MCR.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'MNGDCARE'2. Mandatory |
1. Value must equal "MNGDCARE"2. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.022.266 |
UPDATE |
Definition |
A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligibile Identifier Type = '2-Old MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID'
or 'Unmerge'. |
A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligibile Identifier Type = "2-Old MSIS Identification Number". For example, If MSIS Identification Number of a beneficiary is being changed due to "Merge with other MSIS ID"
or "Unmerge". |
| 09/12/2024 |
3.29.0 |
ELG.022.266 |
UPDATE |
Coding requirement |
1. Value must be in Reason for Change List (VVL)2. Value must be 10 characters or less3. Conditional4. (Old MSIS Identification Number) value must be populated when Eligible Identifier Type (ELG.022.261) equals '2' |
1. Value must be in Reason for Change List (VVL)2. Value must be 10 characters or less3. Conditional4. (Old MSIS Identification Number) value must be populated when Eligible Identifier Type (ELG.022.261) equals "2" |
| 09/12/2024 |
3.29.0 |
ELG.022.265 |
UPDATE |
Definition |
A data element to capture the various identifiers assigned to Medicaid and CHIP beneficiary by various entities. The specific type of identifier is shown in the corresponding value in the Eligible Identifier Type data element. States should provide all Old MSIS Identification Number with Eligible Identifier Type = 2 to T-MSIS in case the state changes the MSIS Identification Number of a beneficiary. The state should submit updates to T-MSIS whenever an identifier is retired or issued. States should provide Old MSIS Identification Number with Reason for Change = 'MERGE' to T-MSIS if the state was reporting multiple MSIS Identification Numbers for a single beneficiary and merges them under a single MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = 'UNMERGE' to T-MSIS if the state unmerges a beneficiary from another beneficiary. For example, if a newborn child is originally reported with the mother's MSIS Identification Number and is then assigned a different MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = 'LSE' to T-MSIS if the state assigns a new MSIS Identification Number to any beneficiaries during large system enhancement in state MMIS. States should provide Old MSIS Identification Number with Reason for Change = 'TCAM' to T-MSIS if the Medicaid and Separate CHIP programs use different MSIS Identifier Number schemas and beneficiaries are transferred from CHIP to Medicaid or from Medicaid to CHIP and a new MSIS Identification Number is issued. |
A data element to capture the various identifiers assigned to Medicaid and CHIP beneficiary by various entities. The specific type of identifier is shown in the corresponding value in the Eligible Identifier Type data element. States should provide all Old MSIS Identification Number with Eligible Identifier Type = "2" to T-MSIS in case the state changes the MSIS Identification Number of a beneficiary. The state should submit updates to T-MSIS whenever an identifier is retired or issued. States should provide Old MSIS Identification Number with Reason for Change = "MERGE" to T-MSIS if the state was reporting multiple MSIS Identification Numbers for a single beneficiary and merges them under a single MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = "UNMERGE" to T-MSIS if the state unmerges a beneficiary from another beneficiary. For example, if a newborn child is originally reported with the mother's MSIS Identification Number and is then assigned a different MSIS Identification Number. States should provide Old MSIS Identification Number with Reason for Change = "LSE" to T-MSIS if the state assigns a new MSIS Identification Number to any beneficiaries during large system enhancement in state MMIS. States should provide Old MSIS Identification Number with Reason for Change = "TCAM" to T-MSIS if the Medicaid and Separate CHIP programs use different MSIS Identifier Number schemas and beneficiaries are transferred from CHIP to Medicaid or from Medicaid to CHIP and a new MSIS Identification Number is issued. |
| 09/12/2024 |
3.29.0 |
ELG.022.264 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.022.263 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.022.262 |
UPDATE |
Coding requirement |
Value must be 18 characters or less |
1. Value must be 18 characters or less |
| 09/12/2024 |
3.29.0 |
ELG.022.260 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
ELG.021.254 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.021.253 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.021.252 |
UPDATE |
Coding requirement |
1. Value must be in Enrollment Type List (VVL)2. Value must be 1 character3. If value equals 1, then associated CHIP Code (ELG.003.054) value must be in [1, 2]4. If value equals 2, then associated CHIP Code (ELG.003.054) value must be "3"5. A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.)6. Mandatory |
1. Value must be in Enrollment Type List (VVL)2. Value must be 1 character3. If value equals "1", then associated CHIP Code (ELG.003.054) value must be in [1,2]4. If value equals "2", then associated CHIP Code (ELG.003.054) value must be "3"5. A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day).6. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.020.244 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.020.243 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.018.235 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.018.234 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.018.233 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.017.226 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.017.225 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.016.217 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.016.216 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.016.215 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.016.214 |
UPDATE |
Coding requirement |
1. If associated Race (ELG.016.213) value is in [ "010", "015" ], then value must be populated.2. Value must not contain a pipe or asterisk symbol3. Value must be 25 characters or less4. Conditional |
1. If associated Race (ELG.016.213) value is in [010,015,018], then value must be populated.2. Value must not contain a pipe or asterisk symbol3. Value must be 25 characters or less4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.015.271 |
UPDATE |
Coding requirement |
1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated. 3. Conditional |
1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated.3. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.015.206 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.015.205 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.015.204 |
UPDATE |
Definition |
A code indicating that the individual's ethnicity is Hispanic, Latino/a, or Spanish ethnicity of a Medicaid/CHIP enrolled individual..
Ethnicity Code clarifications:
If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified."
NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. |
A code indicating that the individual's ethnicity is Hispanic, Latino/a, or Spanish ethnicity of a Medicaid/CHIP enrolled individual.
Ethnicity Code clarifications:
If state has beneficiaries coded in their database as "Hispanic" or "Latino," then code them in T-MSIS as "Hispanic or Latino Unknown" (valid value "5"). DO NOT USE "Another Hispanic, Latino, or Spanish Origin," "Ethnicity Unknown" or "Ethnicity Unspecified."
NOTE 1: The "Ethnicity Unspecified" category in T-MSIS (valid value "6") should be used with an individual who explicitly did not provide information or refused to answer a question. |
| 09/12/2024 |
3.29.0 |
ELG.014.197 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.014.196 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.013.185 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.013.184 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.012.175 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.012.174 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30]4. (1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.011.165 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.011.164 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.011.163 |
UPDATE |
Coding requirement |
1. Value must be in State Plan Option Type List (VVL)2. If associated Eligibility Group (ELG.005.087) value is in [ "72", "73", "74", "75" ], and Restricted Benefits Code (ELG.DE.097) is "1" or "7", then value must be "06"3. Value must be 2 characters4. Mandatory5. Value must equal '02' when Program Type (CIP.002.129) equals '13'6. Value must equal '02' when Program Type (COT.002.065) equals '13' |
1. Value must be in State Plan Option Type List (VVL)2. If associated Eligibility Group (ELG.005.087) value is in [ "72", "73", "74", "75" ], and Restricted Benefits Code (ELG.DE.097) is "1" or "7", then value must be "06"3. Value must be 2 characters4. Mandatory5. Value must equal "02" when Program Type (CIP.002.129) equals "13"6. Value must equal "02" when Program Type (COT.002.065) equals "13" |
| 09/12/2024 |
3.29.0 |
ELG.011.159 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 8 characters3. Value must be in Record ID List (VVL)4. Value must equal "ELG00011" |
1. Mandatory3. Value must be in Record ID List (VVL)3. Value must be in Record ID List (VVL)4. Value must equal "ELG00011" |
| 09/12/2024 |
3.29.0 |
ELG.010.156 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.010.155 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.010.153 |
UPDATE |
Coding requirement |
1. Value must be in MFP Reason Participation Ended List (VVL)2. Value must be 2 characters3. Conditional4. Value must not be populated when Enrollment End Date equals '9999-12-31'5. Value must be populated when Enrollment End Date does not equal '9999-12-31' |
1. Value must be in MFP Reason Participation Ended List (VVL)2. Value must be 2 characters3. Conditional4. Value must not be populated when Enrollment End Date equals "9999-12-31"5. Value must be populated when Enrollment End Date does not equal "9999-12-31" |
| 09/12/2024 |
3.29.0 |
ELG.009.270 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service (VVL) |
1. Value must be 3 characters2. Conditional3. Value must be in Type of Service List (VVL) |
| 09/12/2024 |
3.29.0 |
ELG.009.143 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.009.142 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.008.133 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.008.132 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.007.122 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.007.121 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in[18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.006.110 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.006.109 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.005.100 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.005.099 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated9. If value is "6" then Eligibility Group(ELG.DE.087) must be in [35,70]10. If value is "1" or "7" then Eligibility Group (EGL.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 is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in [01,03,06] |
| 09/12/2024 |
3.29.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value "21" (Other) or "22" (Unknown), then the state should not report the co-occurring value "21" and/or "22" to T-MSIS. If there are multiple co-occurring distinct values between "01" and "19", then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of "01" through "19", CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
| 09/12/2024 |
3.29.0 |
ELG.005.094 |
UPDATE |
Coding requirement |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = "14" (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.005.092 |
UPDATE |
Coding requirement |
1. Value must be in SSI Status List (VVL)2. Value must be 3 characters3. Conditional4. When value is '001' or '002', then SSI Indicator must be '1'5. When value is '000' or '003' or not populate, then SSI Indicator must be '0' |
1. Value must be in SSI Status List (VVL)2. Value must be 3 characters3. Conditional4. When value is "001" or "002", then SSI Indicator must be "1"5. When value is "000" or "003" or not populate, then SSI Indicator must be "0" |
| 09/12/2024 |
3.29.0 |
ELG.005.090 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSI Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must equal '0' when SSI status (ELG.005.092) equals '000' or '003' or is not populated7. Value must equal '1' when SSI status (ELG.005.092) equals '001' or '002' |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSI Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must equal "0" when SSI status (ELG.005.092) equals "000" or "003" or is not populated7. Value must equal "1" when SSI status (ELG.005.092) equals "001" or "002" |
| 09/12/2024 |
3.29.0 |
ELG.005.087 |
UPDATE |
Coding requirement |
Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [72,73,74,75], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [07,31,61]7. If associated CHIP Code value is 3,then value must be in [61,62,63,64,65,66,67,68]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in [01,02]10. If value is "25", then Dual Eligible Code value must be in [03,04]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
| 09/12/2024 |
3.29.0 |
ELG.005.086 |
UPDATE |
Definition |
A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0. |
A flag indicating the eligibility record is the primary eligibility in cases where there are multiple eligibility records submitted with overlapping or concurrent eligibility determinant effective and end dates. It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to "1"(YES). Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = "1"; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = "0". |
| 09/12/2024 |
3.29.0 |
ELG.005.086 |
UPDATE |
Coding requirement |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1]4. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.005.085 |
UPDATE |
Coding requirement |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is in [01,02,03,04,05,06,08,09,10], then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values 01,03,05,06) must have a Restricted Benefits Code (ELG.005.097) equal to "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 09/12/2024 |
3.29.0 |
ELG.004.076 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.004.075 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.004.073 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) = ''01', then value is mandatory and must be provided |
1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) equals "01", then value is mandatory and must be provided |
| 09/12/2024 |
3.29.0 |
ELG.004.065 |
UPDATE |
Coding requirement |
1. Value must be in Eligible Address Type List (VVL)2. Value must be 2 characters3. Mandatory |
1. Value must be in Eligible Address Type List (VVL)2. Value must be 2 characters3. Mandatory4. When Address Type equals "01" (Primary), Eligible State (ELG.004.070) must equal Submitting State (ELG.001.007) |
| 09/12/2024 |
3.29.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 09/12/2024 |
3.29.0 |
ELG.003.058 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.003.057 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.003.054 |
UPDATE |
Coding requirement |
1. Value must be in CHIP Code List (VVL)2. If value is in [ 2, 3 ], then associated Eligibility Group (ELG.005.087) value must be in [ "07", "31", "61", 62", "63", "64", "65", "66", "67", or "68" ]3. If value is "1", then associated Eligibility Group (ELG.005.087) value must not be in [ "61", 62", "63", "64", "65", "66", "67", or "68" ]4. Value must be 1 character5. Mandatory |
1. Value must be in CHIP Code List (VVL)2. If value is in [ 2, 3 ], then associated Eligibility Group (ELG.005.087) value must be in [07,31,61,62,63,64,65,66,67,68 ]3. If value is 1, then associated Eligibility Group (ELG.005.087) value must not be in [61,62,63,64,65,66,67,68]4. Value must be 1 character5. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.003.051 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols15. When Dual Eligible Code (ELG.005.085) equals '00' and End of Time Period (ELG.001.010) greater than or equal to '2015-11-01', value should not be populated16. (Medicare Enrolled) if associated Dual Eligible Code value (ELG.005.085) is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then the value for either HICN or MBI is mandatory and must be provided |
1. Conditional2. Value must be an 11 character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols15. When Dual Eligible Code (ELG.005.085) equals "00" and End of Time Period (ELG.001.010) greater than or equal to "2015-11-01", value should not be populated16. (Medicare Enrolled) if associated Dual Eligible Code value (ELG.005.085) is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then the value for either HICN or MBI is mandatory and must be provided |
| 09/12/2024 |
3.29.0 |
ELG.003.050 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [ "01", "02", "03", "04", "05", "06", "08", "09", or "10" ], then value for either HICN or MBI is mandatory and must be provided |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06, 08,09,10], then value for either HICN or MBI is mandatory and must be provided |
| 09/12/2024 |
3.29.0 |
ELG.003.044 |
UPDATE |
Coding requirement |
1. Conditional2. (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' |
1. Conditional2. (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals "8" |
| 09/12/2024 |
3.29.0 |
ELG.003.042 |
UPDATE |
Coding requirement |
1. Value must be in Immigration Status List (VVL)2. If associated Citizenship Indicator (ELG.003.040) value is coded as '0', then value must be in [ 1, 2, 3 ]3. If associated Citizenship Indicator (ELG.003.040) value is coded as '1', then value must equal '8'4. Value must be 1 character5. Mandatory |
1. Value must be in Immigration Status List (VVL)2. If associated Citizenship Indicator (ELG.003.040) value is coded as "0", then value must be in [ 1, 2, 3 ]3. If associated Citizenship Indicator (ELG.003.040) value is coded as "1", then value must equal "8"4. Value must be 1 character5. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.003.041 |
UPDATE |
Coding requirement |
1. Value must be in Citizenship Verification Flag List (VVL)2. Value must be 1 character3. Value must be populated when Citizenship Indicator (ELG.003.040) equals '1' (Yes)4. Conditional |
1. Value must be in Citizenship Verification Flag List (VVL)2. Value must be 1 character3. Value must be populated when Citizenship Indicator (ELG.003.040) equals "1" (Yes)4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.003.040 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'5. Mandatory |
1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as "0", then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as "1", then associated Immigration Status (ELG.003.042) value must equal "8"5. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.003.039 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in [1,2,3] |
| 09/12/2024 |
3.29.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the federal poverty level range in which the family income falls.If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 09/12/2024 |
3.29.0 |
ELG.003.035 |
UPDATE |
Coding requirement |
1. If associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided2. Value must be 50 characters or less3. Value must not contain a pipe or asterisk symbol4. Conditional |
1. If associated Marital Status (ELG.003.035) equals "14" (Other), then value is mandatory and must be provided2. Value must be 50 characters or less3. Value must not contain a pipe or asterisk symbol4. Conditional |
| 09/12/2024 |
3.29.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 09/12/2024 |
3.29.0 |
ELG.002.027 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20', '99'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be greater than or equal to associated Segment Effective Date value4. Mandatory5. Value of the CC component must be in [18,19,20,99] |
| 09/12/2024 |
3.29.0 |
ELG.002.026 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in ['18', '19', '20'] |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be before or the same as the associated Segment End Date value4. Mandatory5. Value of the CC component must be in [18,19,20] |
| 09/12/2024 |
3.29.0 |
ELG.002.024 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mothers date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal "1" and Eligibility Group (ELG.005.087) does not equal "64" value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal "1" and Eligibility Group (ELG.005.087) does not equal "64" value minus Start of Time Period (ELG.001.10) must be less than 125 years |
| 09/12/2024 |
3.29.0 |
ELG.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Sex List (VVL)2. Value must be 1 character3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal '1'4. Mandatory |
1. Value must be in Sex List (VVL)2. Value must be 1 character3. (Pregnancy) if value equals "M", then associated Pregnancy Indicator (ELG.003.049) value must not equal "1"4. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
ELG.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'ELIGIBLE'2. Mandatory |
1. Value must equal "ELIGIBLE"2. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.003.172 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.003.171 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.170 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.169 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.168 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.167 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.152 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.151 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02", then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
CRX.003.150 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.149 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals "02", then the eligibles CHIP Code (ELG.003.054) must be in [2, 3]4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
| 09/12/2024 |
3.29.0 |
CRX.003.147 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
CRX.003.144 |
UPDATE |
Coding requirement |
1. Value must be numeric2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.8903. Value must be populated when Compound Drug Indicator (CRX.002.086) equals 14. Conditional |
1. Value must be numeric2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.8903. Value must be populated when Compound Drug Indicator (CRX.002.086) equals "1"4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.143 |
UPDATE |
Definition |
A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes. |
A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Reasons of Service Code" (bytes 1 & 2 of the T-MSIS DRUG-UTILIZATION-CODE) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist"s professional service. Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use "spaces" as placeholders for not applicable codes. |
| 09/12/2024 |
3.29.0 |
CRX.003.141 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value may include up to 6 digits to the left of the decimal point, and 2 digits to the right e.g. 123456.784. Mandatory |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value may include up to 6 digits to the left of the decimal point, and 2 digits to the right e.g. 123456.784. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.003.136 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Taxonomy Code List (VVL).2. Value must be 5 characters or less3. Conditional |
1. Value must be in HCBS Taxonomy Code List (VVL)2. Value must be 5 characters or less3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.135 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Service Code List (VVL).2. Value must be 1 character3. If value is 1-7, then HCBS Taxonomy must be populated.4. Conditional |
1. Value must be in HCBS Service Code List (VVL)2. Value must be 1 character3. If value is in [1-7], then HCBS Taxonomy must be populated.4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.134 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] |
1. Value must be 3 characters2. Mandatory3. Value must be in [011,018,033,034,036,085,089,127,131,136,137,145] |
| 09/12/2024 |
3.29.0 |
CRX.003.133 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.132 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported.4. When populated, corresponding Unit of Measure must be populated |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1,3,A,C,U,W], then this value must be reported.4. When populated, corresponding Unit of Measure must be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.129 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
CRX.003.128 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated (or must be 99998)4. Value must not be populated if Medicare Deductible Amount is not populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated (or must be 99998)4. Value must not be populated if Medicare Deductible Amount is not populated5. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.127 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP on this claim at the claim line 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 and Medicare Coinsurance Payment is not required. |
The amount paid by Medicaid/CHIP on this claim at the claim line 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 and Medicare Coinsurance Payment is not required. |
| 09/12/2024 |
3.29.0 |
CRX.003.127 |
UPDATE |
Coding requirement |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. If associated Crossover Indicator value is '0' (not a crossover claim), value should not be populated5. If value is greater than '0,' then Crossover Indicator must be '1' |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated5. If value is greater than "0", then Crossover Indicator must be "1" |
| 09/12/2024 |
3.29.0 |
CRX.003.126 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value in [3,C,W], then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.125 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
The amount paid to the provider by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CRX.003.125 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.124 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.122 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state"s MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CRX.003.122 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.121 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CRX.003.121 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.119 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 03/14/2025 |
3.35.0 |
CRX.003.118 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 03/14/2025 |
3.35.0 |
CRX.003.118 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Mandatory |
1. Value must be 12 characters or less2. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.003.116 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.115 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is "1", then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
| 09/12/2024 |
3.29.0 |
CRX.003.113 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.003.111 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM is in [4,D,X] (lump sum payment), value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CRX.002.166 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.165 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.164 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.163 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 12/10/2024 |
3.33.0 |
CRX.002.162 |
UPDATE |
Medicaid valid value info |
|
See https://www.ncpdp.org/ |
| 09/12/2024 |
3.29.0 |
CRX.002.160 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equals "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.156 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Submitting State Provider ID (PRV.002.019) or3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) = '1'4. Mandatory |
1. Value must be 30 characters or less2. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match Submitting State Provider ID (PRV.002.019) or3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match Provider Identifier (PRV.005.081) where the Provider Identifier Type (PRV.005.077) equals "1"4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.105 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
CRX.002.104 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Conditional4. Value must exist in the NPPES NPI data file |
| 09/12/2024 |
3.29.0 |
CRX.002.102 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. Nppes Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. When Type of Claim not in [3,C,W] then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. Nppes Entity Type Code associate with this NPI must equal "1" (Individual) |
| 09/12/2024 |
3.29.0 |
CRX.002.100 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CRX.002.098 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CRX.002.094 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.093 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Beneficiary Deductible Amount4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Beneficiary Deductible Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.092 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.088 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Beneficiary Coinsurance Amount4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Beneficiary Coinsurance Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.090 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Beneficiary Copayment Amount4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Beneficiary Copayment Amount4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.089 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.087 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.086 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Compound Drug Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Compound Drug Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.085 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be on or before associated End of Time Period (CRX.001.010)4. Value must be on or after associated Start of Time Period (CRX.001.009)5. Value must be on or after associated Date Prescribed (CRX.002.084)6. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)7. Value must be on or before associated eligible party's Date of Death (ELG.002.025)8. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal '1' and Type of Claim (CRX.002.029) does not equal 'Z'9. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be on or before associated End of Time Period (CRX.001.010)4. Value must be on or after associated Start of Time Period (CRX.001.009)5. Value must be on or after associated Date Prescribed (CRX.002.084)6. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)7. Value must be on or before associated eligible party's Date of Death (ELG.002.025)8. Value must be populated when Adjustment Indicator (CRX.002.025) does not equal "1" and Type of Claim (CRX.002.029) does not equal "Z"9. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.084 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)4. Value must be on or before associated Prescription Fill Date (CRX.002.085)5. Value must be on or before associated Adjudication Date (CRX.002.027)6. Value must be on or before associated eligible party's Date of Death (ELG.002.025)7. Mandatory8. Value should be on or before End of Time Period (CRX.001.010) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be on or after associated eligible party's Date of Birth (ELG.002.024)4. Value must be on or before associated Prescription Fill Date (CRX.002.085)5. Value must be on or before associated Adjudication Date (CRX.002.027)6. Value must be on or before associated eligible party's Date of Death (ELG.002.025)7. Mandatory8. Value should be on or before End of Time Period (CRX.001.010) |
| 09/12/2024 |
3.29.0 |
CRX.002.082 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.079 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (CRX.002.023) equals '1' and Medicare Beneficiary Identifier (CRX.002.105) must not be populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.De085) value = "00", then value must not be populated5. Value must be populated when Crossover Indicator (CRX.002.023) equals "1" and Medicare Beneficiary Identifier (CRX.002.105) must not be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.073 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.071 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01"6. When Type of Claim is in [1,3,A,C], then value must be populated7. When Type of Claim not in [3,C,W] then value must match Provider Identifier (PRV.002.081)8. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 09/12/2024 |
3.29.0 |
CRX.002.070 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to "1"5. When Type of Claim is in [1,3,A,C], then value must be populated6. When Type of Claim in [1,3,A,C] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in [01,02,03,04,05,06] (active)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/12/2024 |
3.29.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.068 |
UPDATE |
Coding requirement |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. Value must have a corresponding value in Waive ID (CRX.002.069)5. Conditional6. Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. Value must have a corresponding value in Waive ID (CRX.002.069)5. Conditional6. Value must be in [06,07,08,09,10,11,12,13,14,15,16,17,18,19,20,33] when associated Program Type equals "07" |
| 09/12/2024 |
3.29.0 |
CRX.002.067 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.066 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.060 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (eg. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.059 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.058 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CRX.002.056 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should be populated when Type of Claim (CRX.002.029) is in [3, C, W, 2, B, V]7. When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in (3, C, W, 2, B, V) value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should be populated when Type of Claim (CRX.002.029) is in [3,C,W,2,B,V]7. When Type of Claim in [3,C,W,2,B,V] value must have a Managed Care Enrollment (ELG.014) for the beneficiary where the Prescription Fill Date (CRX.002.085) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in [3,C,W,2,B,V] value must have a Managed Care Main Record (MCR.002) for the plan where the Prescription Fill Date (CRX.002.085) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
CRX.002.055 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 09/12/2024 |
3.29.0 |
CRX.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if Type of Claim in not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if Type of Claim in not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.052 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.051 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. If associated Type of Claim value is in [4,D,X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.050 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.048 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.047 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.045 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.044 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CRX.002.043 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CRX.002.041 |
UPDATE |
Definition |
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 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. |
The total amount paid to the provider 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 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.
|
| 09/12/2024 |
3.29.0 |
CRX.002.041 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D] |
| 09/12/2024 |
3.29.0 |
CRX.002.040 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CRX.002.040 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. When populated and Payment Level Indicator = "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.039 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
| 09/12/2024 |
3.29.0 |
CRX.002.039 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (eg. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.002.034 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Check Number4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Check Number4. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.032 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CRX.002.031 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.030 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be "0" and Claim Status Category must be 'F2' |
| 09/12/2024 |
3.29.0 |
CRX.002.029 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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” for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
CRX.002.029 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "Z", claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
CRX.002.028 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Total Medicaid Paid Amount4. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Total Medicaid Paid Amount4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.027 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value should be on or before End of Time Period value found in associated T-MSIS File Header Record4. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value should be on or before End of Time Period value found in associated T-MSIS File Header Record4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
CRX.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 03/14/2025 |
3.35.0 |
CRX.002.021 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 03/14/2025 |
3.35.0 |
CRX.002.021 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Mandatory |
1. Value must be 12 characters or less2. Conditional |
| 09/12/2024 |
3.29.0 |
CRX.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
CRX.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CRX.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-RX'2. Mandatory |
1. Value must equal "CLAIM-RX"2. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.234 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.225 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional |
1. Value may include up to 8 digits to the left of the decimal point and 3 digits to the right e.g. 12345678.9992. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.213 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.212 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02",then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
COT.003.211 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01",then a valid value is mandatory and must be reported5. If value is in [14,35,42,44],then Sex (ELG.002.023) must not equals "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/12/2024 |
3.29.0 |
COT.003.210 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals "02", then the eligibles CHIP Code (ELG.003.054) must be in [2,3]4. (Federal Funding under Title XIX) if value equals "01", then the eligibles CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header,then value must be reported7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated,then value must be reported |
| 09/12/2024 |
3.29.0 |
COT.003.198 |
UPDATE |
Coding requirement |
1. Value must be in Tooth Surface Code List (VVL)2. Value must be 1 character3. Conditional4. When populated, associated type of service value must be in [013, 029, 035] |
1. Value must be in Tooth Surface Code List (VVL)2. Value must be 1 character3. Conditional4. When populated,associated type of service value must be in [013,029,035] |
| 09/12/2024 |
3.29.0 |
COT.003.197 |
UPDATE |
Coding requirement |
1. Value must be in Tooth Quad Code List (VVL)2. Value must be 2 characters3. Conditional4. When populated, associated type of service value must be in [013, 029, 035] |
1. Value must be in Tooth Quad Code List (VVL)2. Value must be 2 characters3. Conditional4. When populated,associated type of service value must be in [013,029,035] |
| 09/12/2024 |
3.29.0 |
COT.003.196 |
UPDATE |
Coding requirement |
1. Value must be in Tooth Number List (VVL)2. If Tooth Designation System (COT.003.195) is 'JP' value must be found in [1..32][51-82][A..T]or [AS..KS]3. If Tooth Designation System (COT.003.195) is 'JO' value must have 1 digit before and after the decimal (N.N)4. If Tooth Designation System (COT.003.195) is 'JO' value must be a first digit of 1-4 and the decimal must be between 1-85. Value must be 2 characters or less6. Conditional7. When value is in ['A'-'T'], the difference between Ending Date of Service (COT.002.034) and Date of Birth (COT.002.108) is less than 15 years |
1. Value must be in Tooth Number List (VVL)2. If Tooth Designation System (COT.003.195) is "JP" value must be found in [1-32][51-82][A-T]or [AS-KS]3. If Tooth Designation System (COT.003.195) is "JO" value must have 1 digit before and after the decimal (N.N)4. If Tooth Designation System (COT.003.195) is "JO" value must be a first digit of 1-4 and the decimal must be between 1-85. Value must be 2 characters or less6. Conditional7. When value is in [A-T], the difference between Ending Date of Service (COT.002.034) and Date of Birth (COT.002.108) is less than 15 years |
| 09/12/2024 |
3.29.0 |
COT.003.193 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.192 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.188 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Taxonomy Code List (VVL).2. Value must be 5 characters or less3. Conditional |
1. Value must be in HCBS Taxonomy Code List (VVL)2. Value must be 5 characters or less3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.187 |
UPDATE |
Coding requirement |
1. Value must be in HCBS Service Code List (VVL).2. Value must be 1 character3. If value is 1-7, then HCBS Taxonomy must be populated.4. Conditional |
1. Value must be in HCBS Service Code List (VVL)2. Value must be 1 character3. If value is in [1-7], then HCBS Taxonomy must be populated4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147']5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122],Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in [002,003,004,005,006,007,008,010,011,012,013,014,015,016,017,018,019,020,021,022,023,024,025,026,027,028,029,030,031,032,035,036,037,038,039,040,041,042,043,049,050,051,052,053,054,055,056,057,058,060,061,062,063,064,065,066,067,068,069,070,071,072,073,074,075,076,077,078,079,080,081,082,083,084,085,086,087,088,089,115,119,120,121,122,127,131,134,135,136,137,138,139,140,141,142,143,144,145,147]5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated9. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated10. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated11. When value is not in [025,085], Sex (ELG.002.023) equals "M"12. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 09/12/2024 |
3.29.0 |
COT.003.184 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional |
1. Value may include up to 8 digits to the left of the decimal point and 3 digits to the right e.g. 12345678.9992. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.183 |
UPDATE |
Coding requirement |
1. Value may include up to 8 digits to the left of the decimal point, and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1, 3, A, C, U, W], then this value must be reported.4. When populated, corresponding Unit of Measure must be populated |
1. Value may include up to 8 digits to the left of the decimal point and 3 digits to the right e.g. 12345678.9992. Conditional3. If Type of Claim is in [1,3,A,C,U,W], then this value must be reported4. When populated,corresponding Unit of Measure must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.182 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
COT.003.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value equals [3,C,W],then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.178 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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.
|
| 09/12/2024 |
3.29.0 |
COT.003.178 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. Value should not be populated or equal to zero,when associated Claim Line Status is in [26,026,87,087,542,585,654] |
| 09/12/2024 |
3.29.0 |
COT.003.177 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.176 |
UPDATE |
Coding requirement |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50)4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
| 09/12/2024 |
3.29.0 |
COT.003.175 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
COT.003.175 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. When Type of Claim is in [1,A], Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
| 09/12/2024 |
3.29.0 |
COT.003.174 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
COT.003.174 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.173 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
COT.003.171 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional |
1. When populated,there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.003.168 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional |
1. Value must be in Revenue Code List (VVL)2. When Source Location does not equal “23”, value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional5. When populated, Type of Bill must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.167 |
UPDATE |
Definition |
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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.003.167 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.166 |
UPDATE |
Definition |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.003.166 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligibles Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.003.165 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654],then Claim Denied Indicator must be 0 and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
COT.003.162 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.161 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is "0", then value must not be populated3. If associated Line Adjustment Indicator value is "1", then value is mandatory and must be provided4. Conditional5. When populated,value must be one or greater |
| 09/12/2024 |
3.29.0 |
COT.003.160 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory4. When populated, value must be one or greater |
1. Value must be 3 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory4. When populated,value must be one or greater |
| 09/12/2024 |
3.29.0 |
COT.003.159 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.003.157 |
UPDATE |
Definition |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
A state-assigned unique identification number used to identify a Medicaid/CHIP enrolled individual (except on service tracking payments). 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/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47572 |
| 09/12/2024 |
3.29.0 |
COT.003.157 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) is in [4,D,X] (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
COT.002.233 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.232 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.231 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.230 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.229 |
UPDATE |
Definition |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.
[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 09/12/2024 |
3.29.0 |
COT.002.229 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Conditional4. Value must exist in the NPPES NPI data file |
| 09/12/2024 |
3.29.0 |
COT.002.150 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
COT.002.147 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
COT.002.146 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Conditional4. When Type of Service (COT.003.186) equals "121", value must not be populated5. Value must exist in the NPPES NPI data file |
| 09/12/2024 |
3.29.0 |
COT.002.142 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
COT.002.140 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
COT.002.138 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals ‘138’ (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals ‘45’ (health homes for substance use services) |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals "138" (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals "45" (health homes for substance use services) |
| 09/12/2024 |
3.29.0 |
COT.002.137 |
UPDATE |
Coding requirement |
1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Situational |
1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1]4. Situational |
| 09/12/2024 |
3.29.0 |
COT.002.136 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.134 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.132 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.130 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.128 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.123 |
UPDATE |
Coding requirement |
1. Value must be in Place of Service Code List (VVL)2. Value must be 2 characters3. Conditional4. If value is populated on a non-denied claim, then Procedure Code (COT.003.169) must be populated.5. When Type of Service (COT.003.186) is in [119-122], Place of Service (COT.002.123) should not be populated |
1. Value must be in Place of Service Code List (VVL)2. Value must be 2 characters3. Conditional4. If value is populated on a non-denied claim, then Procedure Code (COT.003.169) must be populated5. When Type of Service (COT.003.186) is in [119-122], value should not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.122 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (COT.002.023) equals '1' and Medicare Beneficiary Identifier (COT.002.147) is not populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated5. Value must be populated when Crossover Indicator (COT.002.023) equals "1" and Medicare Beneficiary Identifier (COT.002.147) is not populated |
| 09/12/2024 |
3.29.0 |
COT.002.118 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must be in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must be in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.116 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.115 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.114 |
UPDATE |
Coding requirement |
1. Value must be in Provider Taxonomy List (VVL)2. Value must be 12 characters or less3. Conditional4. Value is in [119, 120, 121, 122 ], then value should not be populated |
1. Value must be in Provider Taxonomy List (VVL)2. Value must be 12 characters or less3. Conditional4. If Type of Service (COT.003.186) is in [119,120,121,122], then value should not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.113 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
COT.002.113 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When Type of Claim (COT.002.037) not in [3,C,W] then value must match Provider Identifier (PRV.002.081)6. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 09/12/2024 |
3.29.0 |
COT.002.112 |
UPDATE |
Definition |
A unique identification number assigned by the state to a provider or capitation 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.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
A unique identification number assigned by the state to a provider or capitation 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.
For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
| 09/12/2024 |
3.29.0 |
COT.002.112 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to "1"5. When Type of Claim is in [1,3,A,C], then value must be populated6. When Type of Claim is in [1,3,A,C] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in [01,02,03,04,05,06] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in [119,120,122], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to "1" |
| 09/12/2024 |
3.29.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.110 |
UPDATE |
Coding requirement |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. When populated, Waiver ID (COT.002.111) must be populated5. Conditional6. Value must be in [ '06', '07', '08', '09', '10', '11', '12', '13', '14', '15', '16', '17', '18', '19', '20', '33'] when associated Program Type equals "07" |
1. Value must be in Waiver Type List (VVL)2. Value must be 2 characters3. Value must match Eligible Waiver Type (ELG.012.173) for the enrollee for the same time period (by date of service)4. When populated, Waiver ID (COT.002.111) must be populated5. Conditional6. Value must be in [06,07,08,09,10,11,12,13,14,15,16,17,18,19,20, 33] when associated Program Type equals "07" |
| 09/12/2024 |
3.29.0 |
COT.002.109 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.104 |
UPDATE |
Coding requirement |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbol3. Conditional |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional |
| 02/27/2025 |
3.34.0 |
COT.002.083 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.082 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.081 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.080 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.079 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.078 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.077 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.076 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.075 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
COT.002.074 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 09/12/2024 |
3.29.0 |
COT.002.073 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.072 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.069 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.068 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
COT.002.066 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
COT.002.066 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (COT.002.037) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.033) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (COT.002.037) in [3,C,W,2,B,V] value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (COT.002.033) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (COT.002.037) in (3,C,W,2,B,V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (COT.002.033) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
COT.002.065 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 09/12/2024 |
3.29.0 |
COT.002.064 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equal "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.063 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if Type of Claim is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if Type of Claim is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.060 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [4,D,X]], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
COT.002.059 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.057 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.056 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.054 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.053 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
COT.002.052 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
COT.002.050 |
UPDATE |
Definition |
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.For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
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.
For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
| 09/12/2024 |
3.29.0 |
COT.002.050 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D]10. Value must not be greater than Total Allowed Amount (COT.002.049)11. Value must be populated, when Type of Claim (COT.002.037) is in [2,5,B,E] |
| 09/12/2024 |
3.29.0 |
COT.002.049 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
COT.002.049 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.048 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
| 09/12/2024 |
3.29.0 |
COT.002.048 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated |
| 09/12/2024 |
3.29.0 |
COT.002.041 |
UPDATE |
Definition |
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-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
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-capitation payments, report a SOURCE-LOCATION of "20", indicating the managed care plan is the source of payment. |
| 09/12/2024 |
3.29.0 |
COT.002.040 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.039 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [542,585,654], Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
COT.002.038 |
UPDATE |
Coding requirement |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a '0'4. Conditional |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a "0"4. Conditional5. When populated, Revenue Code must be populated |
| 09/12/2024 |
3.29.0 |
COT.002.037 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
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” for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = "6" or “F”. |
| 09/12/2024 |
3.29.0 |
COT.002.037 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "Z", claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
COT.002.034 |
UPDATE |
Definition |
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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.002.034 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.033 |
UPDATE |
Definition |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 09/12/2024 |
3.29.0 |
COT.002.033 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
COT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 09/12/2024 |
3.29.0 |
COT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) in [4,D,X] (lump sum payment), value must begin with an "'&"4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 09/12/2024 |
3.29.0 |
COT.002.020 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
COT.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
COT.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-OT'2. Mandatory |
1. Value must equal "CLAIM-OT"2. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.243 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.229 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.225 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02", then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
CLT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated, then must not be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.219 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in [2,3]4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported |
| 09/12/2024 |
3.29.0 |
CLT.003.216 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.215 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.211 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] |
1. Value must be 3 characters2. Mandatory3. Value must be in [009,044,045,046,047,048,050,059,133,136,137,146,147] |
| 09/12/2024 |
3.29.0 |
CLT.003.210 |
UPDATE |
Coding requirement |
1. Value must be in Billing Unit List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Billing Unit List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.209 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [3,C,W], then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.208 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CLT.003.208 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in [26,026,87,087,542,585,654] |
| 09/12/2024 |
3.29.0 |
CLT.003.207 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.206 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.205 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state"s MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CLT.003.205 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.204 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CLT.003.204 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than or equal to associated Total Billed Amount value4. When populated and the Source Location does not equal “23”, the associated claim line Revenue Code must be populated5. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.003.203 |
UPDATE |
Definition |
On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field |
On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field. |
| 09/12/2024 |
3.29.0 |
CLT.003.202 |
UPDATE |
Definition |
On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field |
On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field. |
| 09/12/2024 |
3.29.0 |
CLT.003.201 |
UPDATE |
Coding requirement |
Not Applicable |
|
| 09/12/2024 |
3.29.0 |
CLT.003.198 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. When Source Location does not equal “23”, value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.197 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.196 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.003.195 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654], then Claim Denied Indicator must be "1" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CLT.003.192 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.191 |
UPDATE |
Coding requirement |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is 0, then value must not be populated3. If associated Line Adjustment Indicator value is 1, then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
1. Value must be 3 characters or less2. If associated Line Adjustment Indicator value is "0", then value must not be populated3. If associated Line Adjustment Indicator value is "1", then value is mandatory and must be provided4. Conditional5. When populated, value must be one or greater |
| 09/12/2024 |
3.29.0 |
CLT.003.189 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
CLT.003.187 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) is in [4,D,X] (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CLT.002.242 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.241 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.240 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.239 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
CLT.002.178 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.176 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.174 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Conditional4. Value must exist in the NPPES data file |
| 09/12/2024 |
3.29.0 |
CLT.002.168 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
CLT.002.167 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.165 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CLT.002.163 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CLT.002.159 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.157 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.155 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.153 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.151 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.149 |
UPDATE |
Coding requirement |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. When populated, value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. (nursing facility) value is required when the Type of Service in [009, 045, 047, 059]6. When populated, if value is greater than zero, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '003' (Nursing Facility) for the same month as the begin and end date of service |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. When populated, value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. (nursing facility) value is required when the Type of Service in [009,045,047,059]6. When populated, if value is greater than zero, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal "003" (Nursing Facility) for the same month as the begin and end date of service |
| 09/12/2024 |
3.29.0 |
CLT.002.148 |
UPDATE |
Coding requirement |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009, 045, 046, 047, 059] |
1. Value must be numeric2. Value must be 5 digits or less3. Conditional4. (Intermediate Care Facility for Individuals with Intellectual Disabilities) value is required when Type of Service (CLT.003.211) in [009,045,046,047,059] |
| 09/12/2024 |
3.29.0 |
CLT.002.147 |
UPDATE |
Coding requirement |
1. Value must be 5 digits or less2. Conditional3. Value is mandatory when associated Type of Service (CLT.003.211) = '046'4. Value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. When populated, if value is greater than 0 and less than 99998, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '004' (ICF/IID) for the same month as the begin and end date of service |
1. Value must be 5 digits or less2. Conditional3. Value is mandatory when associated Type of Service (CLT.003.211) equals "046"4. Value must be less than or equal to the number of days between (ending date of service minus beginning date of service) plus one day5. When populated, if value is greater than 0 and less than 99998, then Level of Care Status (ELG.005.088) for the associated MSIS Identification Number (CLT.002.022) must equal '004' (ICF/IID) for the same month as the begin and end date of service |
| 09/12/2024 |
3.29.0 |
CLT.002.145 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.141 |
UPDATE |
Coding requirement |
1. Value must be in Patient Status List (VVL).2. Value must be 2 characters3. Mandatory |
1. Value must be in Patient Status List (VVL)2. Value must be 2 characters3. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.140 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (CLT.002.023) equals '1' and Medicare Beneficiary Identifier (CLT.002.168) is not populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated5. Value must be populated when Crossover Indicator (CLT.002.023) equals "1" and Medicare Beneficiary Identifier (CLT.002.168) is not populated |
| 09/12/2024 |
3.29.0 |
CLT.002.136 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.134 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.133 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.131 |
UPDATE |
Coding requirement |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W'), then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01"6. When Type of Claim is in [1,3,A,C], then value must be populated7. When Type of Claim not in [3,C,W], then value must match Provider Identifier (PRV.002.081)8. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 09/12/2024 |
3.29.0 |
CLT.002.130 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X] then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.007) equal to "2"5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/12/2024 |
3.29.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be "01" or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.122 |
UPDATE |
Coding requirement |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbol3. Conditional |
1. Value must be 20 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional |
| 02/27/2025 |
3.34.0 |
CLT.002.101 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.100 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.099 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.098 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.097 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.096 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.095 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.094 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.093 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CLT.002.092 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.091 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.090 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.085 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.083 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.082 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.080 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should not be populated when Type of Claim is not equal to '3', 'C' or 'W'7. When Type of Claim in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (CLT.002.048) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (CLT.002.048) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. Value should not be populated when Type of Claim is in [3,C,W]7. When Type of Claim in [3,C,W,2,B,V] value must have a managed care enrollment (ELG.014) for the beneficiary where the Beginning DOS (CLT.002.048) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)8. When Type of Claim in [3,C,W,2,B,V] value must have a managed care main record (MCR.002) for the plan where the Beginning DOS (CLT.002.048) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
CLT.002.079 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
| 09/12/2024 |
3.29.0 |
CLT.002.078 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equals "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.077 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM is not in [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.075 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.074 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [4,D,X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
CLT.002.073 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.071 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.070 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.069 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.068 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CLT.002.067 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.067 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CLT.002.065 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.065 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount11. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [1,A]9. Value must not be populated or equal to "0.00" when associated Claim Status is in [26,026,87,087,542,585,654]10. Value should not be populated, when associated Type of Claim value is in [4,D]11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [5,E] |
| 09/12/2024 |
3.29.0 |
CLT.002.064 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.064 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.063 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.063 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated 6. Value should not be populated when associated Type of Claim (CLT.002.052) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated6. Value should not be populated when associated Type of Claim (CLT.002.052) is in [4,D,X]7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
| 09/12/2024 |
3.29.0 |
CLT.002.056 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CLT.002.055 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [542,585,654], Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CLT.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a '0'4. Mandatory |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a "0"4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.052 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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” for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
CLT.002.052 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
CLT.002.049 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.048 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.002.046 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value4. Value must be greater than or equal to associated Admission Date value5. Value must be greater than or equal to associated eligible Date of Birth value6. Value must be less than or equal to associated eligible Date of Death value7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
| 09/12/2024 |
3.29.0 |
CLT.002.044 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header4. Value must be greater than or equal to associated eligible Date of Birth value5. Value must be less than or equal to associated eligible Date of Death value6. Mandatory7. When associated Type of Claim (CLT.002.052) is not in [2,B,V] (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not [2,B,V] (capitated payment) and Type of Service (CLT.003.211) is not [119,120,121,122] value must be before Adjudication Date (CLT.003.233) |
| 09/12/2024 |
3.29.0 |
CLT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
CLT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 09/12/2024 |
3.29.0 |
CLT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM is in [4,D,X] (lump sum payment), value must begin with an "&"4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 09/12/2024 |
3.29.0 |
CLT.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1], then value must be populated |
| 09/12/2024 |
3.29.0 |
CLT.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CLT.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-LT'2. Mandatory |
1. Value must equal "CLAIM-LT"2. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.296 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
1. Value must be 1 character2. Value must be in [0,1]3. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.285 |
UPDATE |
Coding requirement |
1. Value must be in NDC Unit of Measure List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in NDC Unit of Measure List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.272 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.271 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is "02", then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 09/12/2024 |
3.29.0 |
CIP.003.270 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is "01", then a valid value is mandatory and must be reported5. If value is in [14,35,42,44], then Sex (ELG.002.023) must not equal "M"6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’,‘A’], value must be populated |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals "02", then the eligible's CHIP Code (ELG.003.054) must be in [2,3]4. (Federal Funding under Title XIX) if value equals "01" then the eligible's CHIP Code (ELG.003.054) must be "1"5. Conditional6. If Type of Claim is in [1,2,5,A,B,E,U,V,Y] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in [4,D] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [1,A], value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.264 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.263 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] |
1. Value must be 3 characters2. Mandatory3. Value must not equal "086" if Sex (ELG.002.023) equals "M"4. Value must be in [001,058,060,084,086,090,091,092,093,123,132,135,136,137] |
| 09/12/2024 |
3.29.0 |
CIP.003.256 |
UPDATE |
Coding requirement |
1. Value must be in Billing Unit List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Billing Unit List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.255 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [3,C,W], then value is mandatory and must be provided4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.254 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CIP.003.254 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in [26,026,87,087,542,585,654] |
| 09/12/2024 |
3.29.0 |
CIP.003.252 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state"s MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CIP.003.252 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.251 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/12/2024 |
3.29.0 |
CIP.003.251 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than or equal to associated Total Billed Amount value4. When populated and the Source Location does not equal “23”, the associated claim line Revenue Code must be populated5. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.003.245 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. When Source Location does not equal “23”, value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.244 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be greater than or equal to associated Beginning Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be equal to or greater than associated Date of Birth (ELG.002.024) value8. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.243 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated End of Time Period value4. Value must be less than or equal to associated Ending Date of Service value5. When Type of Claim is not in [2,4,B,D,V] value must be less than or equal to associated Adjudication Date value6. Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated7. Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values8. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.003.242 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545, 585, 654], then Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [545,585,654], then Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CIP.003.239 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [1,3,5,A,C,E,U,W,Y], then value must be in [0,1,4]3. If associated Type of Claim value is in [4,D,X], then value must be in [5,6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.236 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.003.234 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) is in [4,D,X] (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CIP.002.295 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.294 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.293 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.292 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.228 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0", then the value must not be populated4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 09/12/2024 |
3.29.0 |
CIP.002.222 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S, L, O, I, B, Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)11. Character 9 must be alphabetic values A thru Z (minus S, L, O, I, B, Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
1. Conditional2. Value must be an 11-character string3. Character 1 must be numeric values 1 thru 94. Character 2 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)5. Character 3 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)6. Character 4 must be numeric values 0 thru 97. Character 5 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)8. Character 6 must be alphanumeric values 0 thru 9 or A thru Z (minus S,L,O,I,B,Z)9. Character 7 must be numeric values 0 thru 910. Character 8 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)11. Character 9 must be alphabetic values A thru Z (minus S,L,O,I,B,Z)12. Character 10 must be numeric values 0 thru 913. Character 11 must be numeric values 0 thru 914. Value must not contain a pipe or asterisk symbols |
| 09/12/2024 |
3.29.0 |
CIP.002.221 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.220 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['4', 'D', 'X'], value must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional4. When Type of Claim is in [4,D,X], value must not be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.218 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CIP.002.216 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Situational |
| 09/12/2024 |
3.29.0 |
CIP.002.214 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CIP.002.213 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Situational |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 09/12/2024 |
3.29.0 |
CIP.002.212 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is "0", then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.210 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.208 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.206 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.204 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.199 |
UPDATE |
Coding requirement |
1. Value must be in Patient Status List (VVL).2. Value must be 2 characters3. Mandatory4. When value in ["20", "40", "41", "42"], then associated Discharge Date (CIP.002.096) must be less than or equal to Date of Death (ELG.002.025) |
1. Value must be in Patient Status List (VVL)2. Value must be 2 characters3. Mandatory4. When value in [20,40,41,42], then associated Discharge Date (CIP.002.096) must be less than or equal to Date of Death (ELG.002.025) |
| 09/12/2024 |
3.29.0 |
CIP.002.198 |
UPDATE |
Coding requirement |
1. Value must be numeric2. The value may be up to 5 digits in length3. Value must be populated, if Outlier Code (CIP.002.197) equals '01.'4. Conditional |
1. Value must be numeric2. The value may be up to 5 digits in length3. Value must be populated, if Outlier Code (CIP.002.197) equals "01"4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.196 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value = "00", then value must not be populated.5. Value must be populated when Crossover Indicator (CIP.002.023) equals '1' and Medicare Beneficiary Identifier (CIP.002.222) is not populated. |
1. Conditional2. Value must be 12 characters or less3. Value must not contain a pipe or asterisk symbols4. (Not Dual Eligible) if Dual Eligible Code (ELG.DE.085) value equals "00", then value must not be populated5. Value must be populated when Crossover Indicator (CIP.002.023) equals "1" and Medicare Beneficiary Identifier (CIP.002.222) is not populated |
| 09/12/2024 |
3.29.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be populated when Outlier Code (CIP.002.197) is in [01,02,10]4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.190 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.188 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.186 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.184 |
UPDATE |
Coding requirement |
1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to '2'4. Value must exist in the NPPES NPI File |
1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to "2"4. Value must exist in the NPPES NPI File |
| 09/12/2024 |
3.29.0 |
CIP.002.183 |
UPDATE |
Coding requirement |
1. Value must be in Provider Specialty List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Specialty List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.182 |
UPDATE |
Coding requirement |
1. Value must be in Provider Type Code List (VVL).2. Value must be 2 characters3. Conditional |
1. Value must be in Provider Type Code List (VVL)2. Value must be 2 characters3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.180 |
UPDATE |
Coding requirement |
1.Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to "2"3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal "01"6. When Type of Claim is in [1,3,A,C], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal "2" (Organization) |
| 09/12/2024 |
3.29.0 |
CIP.002.179 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in [Z,3,C,W,2,B,V,4,D,X) then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in (Z,3,C,W,2,B,V,4,D,X) then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to "1"5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/12/2024 |
3.29.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30](1115 demonstration) If value begins with"11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by the last digit of the CMS Region [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20,32,33]6. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.176 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.167 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 02/27/2025 |
3.34.0 |
CIP.002.149 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.148 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.147 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.146 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.145 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.144 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.143 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.142 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.141 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 02/27/2025 |
3.34.0 |
CIP.002.140 |
UPDATE |
Definition |
A code to describe specific event(s) relating to this billing period covered by the claim. (These are From Locators 31, 32, 33, 34, 35, and 36 - Occurrence Codes on the UB04.) These fields can be used for either occurrences or occurrence spans. |
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. |
| 09/12/2024 |
3.29.0 |
CIP.002.139 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.138 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.136 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:99999999999 (inclusive)3. Conditional4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day5. Value must be 7 digits or less6. Value is required if the associated Type of Service (CIP.002.257) is in [001, 058, 060, 084, 086, 090, 091, 092, 093, 123, 132]7. Value is required if at least one associated Revenue Code (CIP.003.245) is in [100-219] |
1. Value must be a positive integer2. Value must be between 0:99999999999 (inclusive)3. Conditional4. Value must be less than or equal to double the number of days between Admission Date Discharge Date (CIP.002.094) and Discharge Date Discharge Date (CIP.002.096) plus one day5. Value must be 7 digits or less6. Value is required if the associated Type of Service (CIP.002.257) is in [001,058,060,084,086,090,091,092,093,123,132]7. Value is required if at least one associated Revenue Code (CIP.003.245) is in [100-219] |
| 09/12/2024 |
3.29.0 |
CIP.002.135 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.133 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to '1' (Crossover Claim)3. Value must be 2 characters4. Conditional |
1. Value must be in Medicare Reimbursement Type List (VVL)2. Value is mandatory and must be provided, when Crossover Indicator is equal to "1" (Crossover Claim)3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.132 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CIP.002.130 |
UPDATE |
Coding requirement |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (CIP.002.100) in (3, C, W, 2, B, V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Admission Date (CIP.002.094) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (CIP.002.100) in (3, C, W, 2, B, V) value must have a managed care main record (MCR.002) for the plan where the Admission Date (CIP.002.094) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
1. Value must be 12 characters or less2. Value must not contain a pipe or asterisk symbols3. Conditional4. Value must match Managed Care Plan ID (ELG.014.192)5. Value must match State Plan ID Number (MCR.002.019)6. When Type of Claim (CIP.002.100) in (3,C,W,2,B,V) value must have a managed care enrollment (ELG.014) for the beneficiary where the Admission Date (CIP.002.094) occurs between the managed care plan enrollment eff/end dates (ELG.014.197/198)7. When Type of Claim (CIP.002.100) in (3,C,W,2,B,V) value must have a managed care main record (MCR.002) for the plan where the Admission Date (CIP.002.094) occurs between the managed care contract eff/end dates (MCR.002.020/021) |
| 09/12/2024 |
3.29.0 |
CIP.002.129 |
UPDATE |
Coding requirement |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals '11', then State Plan Option Type (ELG.011.163) must equal '01' for the same time period5. If value equals '13', then State Plan Option Type (ELG.011.163) must equal '02' for the same time period |
1. Value must be in Program Type List (VVL)2. Value must be 2 characters3. Mandatory4. (Community First Choice) If value equals "11", then State Plan Option Type (ELG.011.163) must equal "01" for the same time period5. If value equals "13", then State Plan Option Type (ELG.011.163) must equal "02" for the same time period |
| 09/12/2024 |
3.29.0 |
CIP.002.128 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If value equals "1", then Total Medicare Coinsurance amount must not be populated5. If value equals "0", then Crossover Indicator must equals "0"6. If value equals "1", then Crossover Indicator must equals "1"7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if Type of Claim is not equal to [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if Type of Claim is not equal to [3,C,W,6]4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.125 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.124 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value is in [4, D, or X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Type of Claim value is in [4,D,X], then value is mandatory and must be provided4. Conditional5. When populated, Service Tracking Type must be populated6. When populated, Total Medicaid Amount must not be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.123 |
UPDATE |
Coding requirement |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in ['4','D', 'X'] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
1. Value must be in Service Tracking Type List (VVL)2. (Service Tracking Claim) if associated Type of Claim is in [4,D,X] then value is mandatory and must be reported3. Value must be 2 characters4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.121 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.119 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.118 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.117 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. If associated Medicare Combined Deductible Indicator is '1', then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. Conditional5. If associated Medicare Combined Deductible Indicator is "1", then value must not be populated6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CIP.002.116 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. If associated Crossover Indicator value is "0" (not a crossover claim), then value should not be populated4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in [01,02,03,04,05,06,08,09,10], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
| 09/12/2024 |
3.29.0 |
CIP.002.114 |
UPDATE |
Definition |
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. |
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.
|
| 09/12/2024 |
3.29.0 |
CIP.002.114 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [‘5’, ‘E’]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [1,A]8. Value must not be populated or equal to "0.00" when associated Claim Status is in [26,026,87,087,542,585,654]9. Value should not be populated, when associated Type of Claim value is in [4,D]10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [5,E]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 09/12/2024 |
3.29.0 |
CIP.002.113 |
UPDATE |
Definition |
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. |
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.
|
| 09/12/2024 |
3.29.0 |
CIP.002.113 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. When populated and Payment Level Indicator = '2' then value must equal the sum of all claim line Allowed Amount values4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. When populated and Payment Level Indicator equals "2" then value must equal the sum of all claim line Allowed Amount values4. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.112 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
| 09/12/2024 |
3.29.0 |
CIP.002.112 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [1,3,A,C] and Source Location does not equal "23", value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals "2" value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
| 09/12/2024 |
3.29.0 |
CIP.002.104 |
UPDATE |
Definition |
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. |
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. |
| 09/12/2024 |
3.29.0 |
CIP.002.103 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [ 542, 585, 654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
1. Value must be in Claim Status Category List (VVL)2. (Denied Claim) if associated Claim Denied Indicator indicates the claim was denied, then value must be "F2"3. (Denied Claim) if associated Claim Status is in [542,585,654 ], then value must be "F2"4. Value must be 3 characters or less5. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.102 |
UPDATE |
Coding requirement |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2' |
1. Value must be in Claim Status List (VVL)2. Value must be 3 characters or less3. Conditional4. If value in [542,585,654], Claim Denied Indicator must be "0" and Claim Status Category must be "F2" |
| 09/12/2024 |
3.29.0 |
CIP.002.101 |
UPDATE |
Coding requirement |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a '0'4. Mandatory |
1. Value must be in Type of Bill List (VVL)2. Value must be 4 characters3. First character must be a "0"4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.002.100 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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” for an S-CHIP sub-capitated encounter record. |
| 09/12/2024 |
3.29.0 |
CIP.002.100 |
UPDATE |
Coding requirement |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals 'Z', claim denied indicator must equal '0' |
1. Value must be in Type of Claim List (VVL)2. Value must be 1 character3. Mandatory4. When value equals "Z", claim denied indicator must equal "0" |
| 09/12/2024 |
3.29.0 |
CIP.002.096 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value4. Value must be greater than or equal to associated Admission Date value5. Value must be greater than or equal to associated eligible Date of Birth value6. Value must be less than or equal to associated eligible Date of Death value7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated9. When populated, Discharge Hour (CIP.002.097) must be populated |
| 09/12/2024 |
3.29.0 |
CIP.002.094 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value5. Value must be less than or equal to associated eligible Date of Death value6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not in [2,B,V] and Type of Service (CIP.002.257) is not in [119,120,121,122] value must be before Adjudication Date (CIP.003.286) |
| 09/12/2024 |
3.29.0 |
CIP.002.090 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.086 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.082 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.078 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.074 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.072 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional5. If Procedure Code 1 (CIP.002.070) is populated, Procedure Code Flag 1 (CIP.002.072) must be '02' (ICD-9 CM) or '07' (ICD-10 - CM PCS). |
1. When populated, there must be a corresponding Procedure Code2. Value must be in Procedure Code Flag List (VVL)3. Value must be 2 characters4. Conditional5. If Procedure Code 1 (CIP.002.070) is populated, Procedure Code Flag 1 (CIP.002.072) must be "02" (ICD-9 CM) or "07" (ICD-10-CM PCS). |
| 09/12/2024 |
3.29.0 |
CIP.002.070 |
UPDATE |
Coding requirement |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding '02', then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding '07', then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding '10-87', then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
1. When populated, there must be a corresponding Procedure Code Flag2. If associated Procedure Code Flag List (VVL) value indicates an ICD-9-CM encoding "02", then value must be a valid ICD-9-CM procedure code3. If associated Procedure Code Flag List (VVL) value indicates an ICD-10-CM encoding "07", then value must be a valid ICD-10-CM procedure code4. If associated Procedure Code Flag List (VVL) value indicates an "Other" encoding "10-87", then State must provide T-MSIS system with State-specific procedure code list, and value must be a valid State-specific procedure code5. Value must be 8 characters or less6. Value must be in Procedure Code List (VVL)7. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.069 |
UPDATE |
Coding requirement |
1. Value must be 4 characters or less2. The right-most 2 positions must be found in 01-993. Conditional4. Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated |
1. Value must be 4 characters or less2. The right-most 2 positions must be in [01-99]3. Conditional4. Value must be populated, when associated Diagnosis Related Group (CIP.002.068) is populated |
| 09/12/2024 |
3.29.0 |
CIP.002.025 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0,1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals "0", is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal "0", is invalid or not populated |
| 09/12/2024 |
3.29.0 |
CIP.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported6. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in [01,02,04,08,09,10] for the same time period (by date of service)5. If the Type of Claim value is in [1,3,A,C], then value is mandatory and must be reported6. Conditional |
| 09/12/2024 |
3.29.0 |
CIP.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in [4,D,X,Z,U,V,Y,W], value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an "&" |
| 09/12/2024 |
3.29.0 |
CIP.002.020 |
UPDATE |
Coding requirement |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is "0", then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [4,1] then value must be populated |
| 09/12/2024 |
3.29.0 |
CIP.001.011 |
UPDATE |
Coding requirement |
1. For production files, value must be equal to 'P'2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
1. For production files, value must be equal to "P"2. Value must be in File Status Indicator List (VVL)3. Value must be 1 character4. Mandatory |
| 09/12/2024 |
3.29.0 |
CIP.001.006 |
UPDATE |
Coding requirement |
1. Value must equal 'CLAIM-IP'2. Mandatory |
1. Value must equal "CLAIM-IP"2. Mandatory |
| 09/07/2023 |
3.12.0 |
COT.003.184 |
UPDATE |
Definition |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
| 09/21/2023 |
3.13.0 |
CRX.002.101 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 09/21/2023 |
3.13.0 |
COT.002.143 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 09/21/2023 |
3.13.0 |
CLT.002.166 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 09/21/2023 |
3.13.0 |
CIP.002.219 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.065 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount11. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
| 08/28/2023 |
3.12.0 |
COT.002.050 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049)8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
| 09/21/2023 |
3.13.0 |
ELG.012.172 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Value must have a corresponding value in Waiver Type (ELG.012.173)7. Mandatory |
| 08/28/2023 |
3.12.0 |
MCR.003.050 |
UPDATE |
Coding requirement |
Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 09/21/2023 |
3.13.0 |
ELG.009.140 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
ELG.013.183 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
TPL.006.082 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 09/21/2023 |
3.13.0 |
CRX.003.113 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CRX.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
COT.003.159 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
COT.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CLT.003.189 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CLT.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CIP.003.236 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
CIP.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
COT.002.146 |
UPDATE |
Coding requirement |
Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
| 09/21/2023 |
3.13.0 |
ELG.022.265 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/06/2023 |
3.12.0 |
TPL.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
PRV.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
MCR.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
ELG.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
CRX.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
COT.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 09/06/2023 |
3.12.0 |
CLT.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 08/28/2023 |
3.12.0 |
CLT.001.002 |
UPDATE |
Coding requirement |
Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 09/21/2023 |
3.13.0 |
CIP.001.002 |
UPDATE |
Definition |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. Use the version number specified on the Cover Sheet of the data dictionary". |
A data element to capture the version of the T-MSIS data dictionary that was used to build the file. |
| 08/28/2023 |
3.12.0 |
COT.002.137 |
UPDATE |
Definition |
Not Applicable |
An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
| 08/29/2023 |
3.12.0 |
CRX.002.101 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CRX.002.101 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount4. Situational |
| 08/29/2023 |
3.12.0 |
COT.002.143 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CLT.002.166 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CIP.002.219 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/23/2023 |
3.12.0 |
CLT.002.166 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 08/23/2023 |
3.12.0 |
CIP.002.219 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 08/29/2023 |
3.12.0 |
CRX.002.100 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
COT.002.142 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CLT.002.165 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CIP.002.218 |
UPDATE |
Necessity |
Optional |
Situational |
| 09/21/2023 |
3.13.0 |
CRX.002.099 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 09/21/2023 |
3.13.0 |
COT.002.141 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 09/21/2023 |
3.13.0 |
CLT.002.164 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 09/21/2023 |
3.13.0 |
CIP.002.217 |
UPDATE |
Coding requirement |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount4. Conditional |
| 08/29/2023 |
3.12.0 |
CRX.002.098 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
COT.002.140 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CLT.002.163 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
CIP.002.216 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.006.086 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/21/2023 |
3.12.0 |
TPL.006.086 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/29/2023 |
3.12.0 |
TPL.005.070 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.004.061 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.003.050 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.002.027 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
TPL.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.010.136 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.009.123 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.008.113 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.007.104 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.006.092 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.005.082 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.004.070 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.003.058 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.002.037 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
PRV.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.007.089 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.006.080 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.005.071 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.004.061 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/29/2023 |
3.12.0 |
MCR.003.052 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.002.032 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.022.267 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.021.255 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.020.245 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.018.236 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.017.227 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.016.218 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.015.207 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.014.198 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.013.186 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.012.176 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.011.166 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.010.157 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.009.144 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.008.134 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.007.124 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.006.112 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.005.101 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.004.077 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.003.059 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.002.028 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
ELG.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.003.153 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.106 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
COT.003.214 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
COT.002.152 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
COT.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.003.226 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.173 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.003.273 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.229 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.001.014 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/16/2023 |
3.12.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’,‘A’], value must be populated |
| 08/16/2023 |
3.12.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported.8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
| 08/16/2023 |
3.12.0 |
COT.002.112 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
| 08/16/2023 |
3.12.0 |
CRX.002.071 |
UPDATE |
Coding requirement |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
CIP.002.180 |
UPDATE |
Coding requirement |
Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file 4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
1.Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
COT.003.176 |
UPDATE |
Coding requirement |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )4. Value must be 11 digits or less left of the decimal i.e. 9999999999 99 |
| 09/21/2023 |
3.13.0 |
CRX.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CRX.002.025 |
UPDATE |
Coding requirement |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 09/21/2023 |
3.13.0 |
COT.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
COT.002.025 |
UPDATE |
Coding requirement |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 09/21/2023 |
3.13.0 |
CLT.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CLT.002.025 |
UPDATE |
Coding requirement |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 09/21/2023 |
3.13.0 |
CIP.002.026 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CIP.002.026 |
UPDATE |
Coding requirement |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 08/28/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
1. Value must have a corresponding value in Waiver Type (ELG.012.173)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
| 08/28/2023 |
3.12.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 08/28/2023 |
3.12.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 08/28/2023 |
3.12.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", then the value must include slash “/” in the 11th position followed by a version number [0-9] in the 12th position 5. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]6. Conditional |
| 09/06/2023 |
3.12.0 |
COT.003.205 |
UPDATE |
Definition |
The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. |
The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional. |
| 08/14/2023 |
3.12.0 |
CIP.002.094 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date (CE) value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth (CE) value.5. Value must be less than or equal to associated eligible Date of Death (CE) value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. Value must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)8. (capitated payment) when associated Type of Claim (CIP.002.100) is not '2','B' or 'V' and Type of Service (CIP.002.257) is not '119, '120', '121', 122' value must be before Adjudication Date (CIP.003.286) |
| 08/15/2023 |
3.12.0 |
CRX.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 08/28/2023 |
3.12.0 |
CRX.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 09/21/2023 |
3.13.0 |
CRX.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.005.099 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/15/2023 |
3.12.0 |
CIP.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 08/28/2023 |
3.12.0 |
CIP.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported6. Conditional |
| 08/15/2023 |
3.12.0 |
CLT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 08/28/2023 |
3.12.0 |
CLT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 09/21/2023 |
3.13.0 |
ELG.005.086 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
CLT.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.005.082 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
CIP.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.004.071 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/15/2023 |
3.12.0 |
COT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory6. If value is in [‘0’, ‘5’, ‘6’ ], then associated Adjustment ICN must not be populated7. If value is in [‘4’, ‘1’] then Adjustment ICN must be populated8. Value must equal ‘1’, when associated Claim Status equals ‘686’ |
| 08/28/2023 |
3.12.0 |
COT.002.023 |
UPDATE |
Coding requirement |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. Value must be 1 character6. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.7. Conditional |
1. Value must be in Crossover Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If Crossover Indicator value is "1", the associated Dual Eligible Code (ELG.005.085) value must be in "01", "02", "04", "08", "09", or "10" for the same time period (by date of service)5. If the Type of Claim value is in ["1", "3", "A", "C"], then value is mandatory and must be reported.6. Conditional |
| 09/21/2023 |
3.13.0 |
COT.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/15/2023 |
3.12.0 |
COT.003.175 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['1', 'A'}, Medicaid Paid Amount (COT.003.177) is less than or equal to the value submitted |
| 08/11/2023 |
3.11.0 |
COT.002.037 |
UPDATE |
Definition |
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” for an S-CHIP sub-capitated encounter record. |
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” for an S-CHIP sub-capitated encounter record.For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
| 08/28/2023 |
3.12.0 |
CRX.002.041 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] |
| 08/28/2023 |
3.12.0 |
COT.002.050 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (COT.002.049)8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must not be greater than Total Allowed Amount (COT.002.049) 11. Value must be populated, when Type of Claim (COT.002.037) is in [‘2’, '5', ‘B’, 'E'] |
| 08/28/2023 |
3.12.0 |
CLT.002.065 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount8. Value must be populated, when Type of Claim is in [‘1’, ‘A’]9. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']10. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 11. Value must be less than Total Allowed Amount12. Value must be populated when the associated Type of Claim (CLT.002.052) is in [‘5’, ‘E’] |
| 08/28/2023 |
3.12.0 |
CIP.002.114 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be greater than Total Allowed Amount (CIP.002.113) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals '2', value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must be populated, when Type of Claim is in [‘1’, ‘A’]8. Value must not be populated or equal to ‘0.00’ when associated Claim Status is in ['26', '026', '87', '087', '542', '585', '654']9. Value should not be populated, when associated Type of Claim value is in [‘4’, ‘D’] 10. Value must be populated when the associated Type of Claim (CIP.002.100) is in [‘5’, ‘E’]11. Value must not be greater than Total Allowed Amount (CIP.002.113) |
| 08/28/2023 |
3.12.0 |
CRX.002.039 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
| 08/28/2023 |
3.12.0 |
COT.002.048 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X] |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated |
| 08/28/2023 |
3.12.0 |
CLT.002.063 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X]6. Value should not be populated when associated Type of Claim (CIP.002.100) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated 6. Value should not be populated when associated Type of Claim (CLT.002.052) is equal to '4', 'D' or 'X'7. (individual line item payments) when populated and Payment Level Indicator (CLT.002.082) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CLT.003.204) |
| 08/28/2023 |
3.12.0 |
CIP.002.112 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. Value should not be populated when associated Type of Claim is in [2, 4, 5, B, D E or X]6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must equal the sum of all Billed Amount instances for the associated claim4. Conditional5. When associated Type of Claim in [‘1’, ’3’, ’A’, ’C’], value must be populated6. (individual line item payments) when populated and Payment Level Indicator (CIP.002.132) equals = '2' value must be greater than or equal to the sum of all claim line Revenue Charges (CIP.003.251) |
| 08/09/2023 |
3.11.0 |
CIP.002.112 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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 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. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
| 08/15/2023 |
3.12.0 |
CLT.003.204 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount (CE) value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
| 08/15/2023 |
3.12.0 |
CIP.003.251 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount (CE) value.4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than or equal to associated Total Billed Amount value4. When populated, associated claim line Revenue Charge must be populated5. Conditional |
| 09/01/2023 |
3.12.0 |
COT.003.178 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 09/01/2023 |
3.12.0 |
CLT.003.208 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 09/01/2023 |
3.12.0 |
CIP.003.254 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated or equal to zero, when associated Claim Line Status is in ['26', '026', '87', '087', '542', '585', '654'] |
| 08/16/2023 |
3.12.0 |
COT.002.112 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. When Type of Service (COT.003.186) is not in ['119', '120', '122'], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Must have an enrollment where the Ending Date of Service (COT.003.167) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) 9. When Type of Service (COT.003.186) is not in ['119', ‘120’, ‘122’], value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1' |
| 08/09/2023 |
3.11.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid. |
| 09/21/2023 |
3.13.0 |
CRX.003.116 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
COT.003.162 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
CLT.003.192 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
CIP.003.239 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 08/22/2023 |
3.12.0 |
ELG.016.215 |
UPDATE |
Definition |
"American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the `Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
"American Indian or Alaska Native" means any individual defined at 25 USC 1603(13), 1603(28), or 1679(a), or who has been determined eligible as an Indian, pursuant to 42 CFR 136.12. This means the individual: a. Is a member of a Federally-recognized Indian tribe; b. Resides in an urban center and meets one or more of the following four criteria: i. Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member; ii. Is an Eskimo or Aleut or other Alaska Native; iii. Is considered by the Secretary of the Interior to be an Indian for any purpose; or iv. Is determined to be an Indian under regulations promulgated by the Secretary of Health and Human Services; c. Is considered by the Secretary of the Interior to be an Indian for any purpose; or d. Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. NOTE Applicants who complete Appendix B of the Marketplace/Medicaid application and respond affirmatively to the two questions shown below are considered to meet the definition of an American Indian/Alaskan Native. Are you a member of a federally recognized tribe? Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? |
| 09/21/2023 |
3.13.0 |
ELG.018.233 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/07/2023 |
3.11.0 |
COT.002.136 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/28/2023 |
3.12.0 |
CLT.003.225 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/28/2023 |
3.12.0 |
CLT.003.224 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/07/2023 |
3.11.0 |
CRX.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 08/09/2023 |
3.11.0 |
COT.002.112 |
UPDATE |
Definition |
A unique identification number assigned by the state to a provider or capitation 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. |
A unique identification number assigned by the state to a provider or capitation 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.For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
| 08/15/2023 |
3.12.0 |
COT.002.111 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/07/2023 |
3.11.0 |
CIP.002.212 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/28/2023 |
3.12.0 |
CRX.003.150 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/28/2023 |
3.12.0 |
CRX.003.151 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/16/2023 |
3.12.0 |
CIP.002.179 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Discharge Date (CIP.002.096) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Discharge Date (CIP.002.096) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 08/28/2023 |
3.12.0 |
COT.003.212 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/28/2023 |
3.12.0 |
COT.003.211 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/07/2023 |
3.11.0 |
CLT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 08/07/2023 |
3.11.0 |
CIP.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 08/07/2023 |
3.11.0 |
CLT.002.159 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/07/2023 |
3.11.0 |
CRX.002.094 |
UPDATE |
Coding requirement |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category (CE) must equal "F2"3. Value must be 1 character4. Mandatory |
1. Value must be in Claim Denied Indicator List (VVL)2. If value is '0', then Claim Status Category must equal "F2"3. Value must be 1 character4. Mandatory |
| 08/16/2023 |
3.12.0 |
CLT.002.130 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080)7. Ending Date of Service (CLT.002.049) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or8. Ending Date of Service (CLT.002.049) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 08/28/2023 |
3.12.0 |
CIP.003.271 |
UPDATE |
Coding requirement |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '2', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
1. Value must be in XXI MBESCBES Category of Service List (VVL)2. Conditional3. (CHIP Claim) if the associated CMS-64 Category for Federal Reimbursement value is '02', then a valid value is mandatory and must be reported4. If XIX MBESCBES Category of Service is populated then value must not be populated5. Value must be 3 characters or less |
| 08/28/2023 |
3.12.0 |
CIP.003.270 |
UPDATE |
Coding requirement |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '1', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
1. Value must be in XIX MBESCBES Category of Service List (VVL)2. Value must be 5 characters or less3. Conditional4. (Medicaid Claim) if the associated CMS-64 Category for Federal Reimbursement value is '01', then a valid value is mandatory and must be reported5. If value is in ['14', '35', '42' or '44'], then Sex (ELG.002.023) must not equals 'M'6. If XXI MBESCBES Category of Service is populated then must not be populated |
| 08/07/2023 |
3.11.0 |
COT.002.025 |
UPDATE |
Coding requirement |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
1. Value must be in Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is '4, D, X', then value must be in [ 5, 6 ]4. Value must be 1 character5. Mandatory |
| 08/16/2023 |
3.12.0 |
CRX.002.070 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier5. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or6. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type (PRV.005.081) equal to '1' 5. When Type of Claim is in ['1','3','A','C'], then value must be populated 6. When Type of Claim in ('1','3','A','C’) then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active)7. Prescription Fill Date (CRX.002.085) may be between Provider Attributes Effective Date (PRV.002.020) and Provider Attributes End Date (PRV.002.021) or 8. Prescription Fill Date (CRX.002.085) may be between Provider Identifier Effective Date (PRV.005.079) and Provider Identifier End Date (PRV.005.080) |
| 09/21/2023 |
3.13.0 |
PRV.007.100 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
PRV.007.098 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.009.139 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.005.066 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.003.032 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.022.260 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.021.251 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.020.241 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.018.232 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.017.223 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.016.212 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.015.203 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.014.191 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.013.181 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.012.171 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.011.162 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.010.149 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.008.129 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.007.117 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.006.106 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.004.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.003.033 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
ELG.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/12/2023 |
3.10.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
| 07/12/2023 |
3.10.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'4. Conditional |
| 07/12/2023 |
3.10.0 |
CRX.002.081 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 07/12/2023 |
3.10.0 |
COT.002.126 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 07/12/2023 |
3.10.0 |
CLT.002.144 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 07/12/2023 |
3.10.0 |
CIP.002.202 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))3. Value must not contain a pipe or asterisk symbols4. Mandatory |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Mandatory |
| 08/16/2023 |
3.12.0 |
ELG.003.040 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1, 2] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
1. Value must be 1 character2. Value must be in Citizenship Indicator List (VVL)3. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]4. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'5. Mandatory |
| 08/15/2023 |
3.12.0 |
ELG.009.270 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service valid value list |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service (VVL) |
| 07/12/2023 |
3.10.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 09/21/2023 |
3.13.0 |
PRV.009.120 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/09/2023 |
3.11.0 |
COT.002.113 |
UPDATE |
Definition |
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. |
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. |
| 08/16/2023 |
3.12.0 |
CLT.002.131 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W'), then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
CRX.002.071 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) |
1. Value must be 10 digits 2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file 4. Conditional 5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' 6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.002.081) 8. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 08/16/2023 |
3.12.0 |
CIP.002.180 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01' |
Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file 4. Conditional5. When populated, value must match Provider Identifier (PRV.005.081) and Facility Group Individual Code (PRV.002.028) must equal '01'6. When Type of Claim is in ['1','3','A','C'], then value must be populated 7. NPPES Entity Type Code associated with this NPI must equal ‘2’ (Organization) |
| 09/07/2023 |
3.12.0 |
COT.003.186 |
UPDATE |
Definition |
A code to categorize the services provided to a Medicaid or CHIP enrollee. |
A code to categorize the services provided to a Medicaid or CHIP enrollee. For sub-capitation payments, report a TYPE-OF-SERVICE value 119, 120, or 122. |
| 06/02/2023 |
3.8.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] |
| 06/02/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 08/15/2023 |
3.12.0 |
COT.002.229 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 06/01/2023 |
3.8.0 |
COT.002.229 |
UPDATE |
Definition |
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm).The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 06/02/2023 |
3.8.0 |
CRX.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
COT.002.063 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CLT.002.077 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CIP.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/02/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/02/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Value must be populated if TYPE-OF-CLAIM <> ‘3', ‘C’, ‘W’, or '6’4. Conditional |
| 06/02/2023 |
3.8.0 |
CRX.003.134 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] when associated Claim Type is CRX (RX Claim) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] |
| 06/02/2023 |
3.8.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147'] when associated Claim Type is COT (Other Claim)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147']5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 06/02/2023 |
3.8.0 |
CLT.003.211 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] when associated Claim Type is CLT (Long Term Claim) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] |
| 06/02/2023 |
3.8.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
| 06/01/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/01/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 06/01/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 06/01/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 09/01/2023 |
3.12.0 |
CRX.003.129 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 08/28/2023 |
3.12.0 |
CRX.002.043 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/01/2023 |
3.12.0 |
COT.003.182 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 08/28/2023 |
3.12.0 |
COT.002.052 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/01/2023 |
3.12.0 |
CLT.002.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 08/28/2023 |
3.12.0 |
CLT.002.067 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. (Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided5. Conditional6. When populated, value must be less than or equal to Total Billed Amount |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated.4. Conditional5. When populated, value must be less than or equal to Total Billed Amount |
| 09/01/2023 |
3.12.0 |
CIP.002.228 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the Medicare Paid Amount must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Crossover Indicator value is "0", then the value must not be populated.4. Conditional5. If value is populated, Crossover Indicator must be equal to "1" |
| 05/31/2023 |
3.8.0 |
CLT.003.211 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must satisfy the requirements of Type of Service (Long Term Claim) List (VVL) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['009', '044', '045', '046', '047', '048', '050', '059', '133', '136', '137', '146', '147'] when associated Claim Type is CLT (Long Term Claim) |
| 07/13/2023 |
3.10.0 |
CRX.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
1. Mandatory2. Value must be 20 characters or less3. The Prescription Fill Date (CRX.002.085) on the claim must fall between Enrollment Timespan Effective Date (ELG.021.253) and Enrollment Timespan End Date (ELG.021.253) |
| 09/21/2023 |
3.13.0 |
ELG.004.062 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 05/31/2023 |
3.8.0 |
COT.003.186 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must satisfy the requirements of Type of Service (Other Claim) List (VVL)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
1. Value must be 3 characters2. Mandatory3. When value is in [119-122], Servicing Provider NPI Num (COT.002.190) should not be populated4. Value must be in ['002', '003', '004', '005', '006', '007', '008', '010', '011', '012', '013', '014', '015', '016', '017', '018', '019', '020', '021', '022', '023', '024', '025', '026', '027', '028', '029', '030', '031', '032', '035', '036', '037', '038', '039', '040', '041', '042', '043', '049', '050', '051', '052', '053', '054', '055', '056', '057', '058', '060', '061', '062', '063', '064', '065', '066', '067', '068', '069', '070', '071', '072', '073', '074', '075', '076', '077', '078', '079', '080', '081', '082', '083', '084', '085', '086', '087', '088', '089', '115', '119', '120', '121', '122', '127', '131', '134', '135', '136', '137', '138', '139', '140', '141', '142', '143', '144', '145', '147'] when associated Claim Type is COT (Other Claim)5. When value is in [119-122], Servicing Provider Taxonomy (COT.003.191) should not be populated6. When value is in [119-122], Referring Provider NPI Num (COT.002.118) should not be populated7. Value must be 3 characters8. Mandatory9. When value is in [119-122], Billing Provider NPI Num (COT.002.113) should not be populated10. When value is in [119-122], Billing Provider Taxonomy (COT.002.114) should not be populated11. When value is in [119-122], Referring Provider Taxonomy (COT.002.119) should not be populated12. When value is not in ['025','085'], Sex (ELG.002.023) equals 'M'13. When value is in [119-122], Servicing Provider Num (COT.002.189) should not be populated |
| 07/13/2023 |
3.10.0 |
CLT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)6. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when TYPE-OF-CLAIM = 4, D or X (lump sum payment)4. The Beginning Date of Service on the claim must fall between (ELG.021.253) enrollment effective and (ELG.021.253) end date |
| 07/13/2023 |
3.10.0 |
CIP.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)6. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim not in (4, D, X, Z, U, V, Y, W), value must match MSIS Identification Number (ELG.021.251) and the Admission Date (CIP.002.094) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254)4. When Type of Claim (CIP.002.100) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 07/13/2023 |
3.10.0 |
COT.002.022 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)6. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
1. Mandatory2. Value must be 20 characters or less3. Populated value must begin with an '&', when Type of Claim (COT.002.037) = 4, D or X (lump sum payment)4. Value must match MSIS Identification Number (ELG.021.251) and the Beginning Date of Service (COT.002.033) must be between Enrollment Effective Date (ELG.021.253) and Enrollment End Date (ELG.021.254) |
| 05/31/2023 |
3.8.0 |
CIP.003.257 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must satisfy the requirements of Type of Service (Inpatient Claim) List (VVL) |
Value must be 3 characters2. Mandatory3. Value must not equal '086' if Sex (ELG.002.023) equals 'M'4. Value must be in ['001', '058', '060', '084', '086', '090', '091', '092', '093', '123', '132', '135', '136', '137'] when associated Claim Type is CIP (Inpatient Claim) |
| 06/01/2023 |
3.8.0 |
CRX.003.134 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Mandatory3. Value must satisfy the requirements of Type of Service (RX Claim) List (VVL) |
1. Value must be 3 characters2. Mandatory3. Value must be in ['011', '018', '033', '034', '036', '085', '089', '127', '131', '136', '137', '145'] when associated Claim Type is CRX (RX Claim) |
| 07/14/2023 |
3.10.0 |
ELG.003.038 |
UPDATE |
Definition |
A code indicating the family income level. |
A code indicating the federal poverty level range in which the family income falls.If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 08/09/2023 |
3.11.0 |
MCR.002.020 |
UPDATE |
Definition |
The first calendar day on which all of the other data elements in the same segment were effective. |
The start date of the managed care contract period with the state. |
| 09/21/2023 |
3.13.0 |
ELG.014.196 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/07/2023 |
3.11.0 |
CIP.003.239 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 08/07/2023 |
3.11.0 |
CRX.003.116 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 08/07/2023 |
3.11.0 |
CLT.003.192 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 08/07/2023 |
3.11.0 |
COT.003.162 |
UPDATE |
Coding requirement |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim (CE) value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim (CE) value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
1. Value must be in Line Adjustment Indicator List (VVL)2. If associated Type of Claim value is in [ 1, 3, 5, A, C, E, U, W, Y ], then value must be in [ 0, 1, 4 ]3. If associated Type of Claim value is in [ 4, D, X ], then value must be in [5, 6]4. Value must be 1 character5. Conditional6. If associated Line Adjustment Number is populated, then value must be populated |
| 09/21/2023 |
3.13.0 |
MCR.003.037 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.006.087 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.006.085 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.003.035 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.005.075 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.005.073 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.004.063 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.004.061 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
TPL.005.066 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
TPL.005.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
TPL.004.055 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
TPL.004.053 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.003.042 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.003.040 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.007.085 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
MCR.007.083 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.010.128 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.010.126 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.006.076 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
MCR.006.074 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.009.118 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.009.116 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.008.109 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.008.107 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.004.057 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
MCR.004.055 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.007.097 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 09/21/2023 |
3.13.0 |
PRV.007.095 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.003.031 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.012.169 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.011.162 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.011.160 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.010.149 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.010.147 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/14/2023 |
3.10.0 |
ELG.009.139 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
CLT.003.213 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (CLT.002.052) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file |
| 09/21/2023 |
3.13.0 |
ELG.009.137 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.008.129 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.008.127 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.007.117 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.007.115 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.021.251 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.021.249 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.006.106 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.006.104 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.020.241 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.020.239 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
TPL.002.019 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
TPL.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.018.232 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.018.230 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.017.223 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 07/13/2023 |
3.10.0 |
ELG.005.082 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.017.221 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.005.080 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
COT.003.189 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ("Z","3","C",'W',"2","B","V","4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ["1","3","A","C"] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in "01", "02", "03", "04", "05", "06"] (active) |
| 07/13/2023 |
3.10.0 |
ELG.016.212 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 07/13/2023 |
3.10.0 |
ELG.012.171 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
COT.003.190 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081) |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Claim (COT.002.037) not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)5. Value must exist in the NPPES NPI data file |
| 09/21/2023 |
3.13.0 |
ELG.016.210 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/28/2023 |
3.12.0 |
CRX.002.102 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. When Type of Claim not in ('3','C','W') then value must match Provider Identifier (PRV.005.081)4. Mandatory5. Value must exist in the NPPES NPI data file6. Nppes Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 07/13/2023 |
3.10.0 |
ELG.004.064 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 07/13/2023 |
3.10.0 |
ELG.015.203 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.015.201 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/15/2023 |
3.12.0 |
COT.003.168 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Conditional |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Conditional |
| 07/13/2023 |
3.10.0 |
ELG.014.191 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 03/24/2023 |
3.5.0 |
COT.003.169 |
UPDATE |
Medicaid valid value info |
HCPCS Code ListDental Codes ListProcedure Codes |
HCPCS Code ListDental Code ListCPT Code List |
| 09/21/2023 |
3.13.0 |
ELG.014.189 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CIP.003.261 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file5. When Type of Claim is in ['1','3','A','C'], then value must be populated |
| 07/13/2023 |
3.10.0 |
ELG.013.181 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 09/21/2023 |
3.13.0 |
ELG.013.179 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 07/13/2023 |
3.10.0 |
ELG.003.033 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN3. Value must be 20 characters or less |
| 02/23/2023 |
3.4.0 |
CIP.002.099 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
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. |
| 08/28/2023 |
3.12.0 |
CRX.003.172 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 08/28/2023 |
3.12.0 |
COT.003.234 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 08/28/2023 |
3.12.0 |
CLT.003.243 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 08/28/2023 |
3.12.0 |
CIP.003.296 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] |
1. Value must be 1 character2. Value must be in [0, 1]3. Mandatory |
| 02/16/2023 |
3.3.0 |
CRX.003.172 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/16/2023 |
3.3.0 |
COT.003.234 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/16/2023 |
3.3.0 |
CLT.003.243 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 02/16/2023 |
3.3.0 |
CIP.003.296 |
UPDATE |
Definition |
This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
| 09/21/2023 |
3.13.0 |
ELG.010.155 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
CIP.002.096 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date (CE) value.4. Value must be greater than or equal to associated Admission Date (CE) value.5. Value must be greater than or equal to associated eligible Date of Birth (CE) value.6. Value must be less than or equal to associated eligible Date of Death (CE) value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. If associated Adjustment Indicator (CIP.002.026) does not equal "1" (Non-denied claims) and Patient Status (CIP.002.199) is not equal to "30" value must be populated.9. When populated, Discharge Hour (CIP.002.097) must be populated |
| 08/09/2023 |
3.11.0 |
CRX.002.041 |
UPDATE |
Definition |
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. |
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 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. |
| 08/14/2023 |
3.12.0 |
ELG.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/09/2023 |
3.11.0 |
CRX.002.039 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
| 08/09/2023 |
3.11.0 |
CLT.002.065 |
UPDATE |
Definition |
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. |
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. |
| 08/09/2023 |
3.11.0 |
CLT.002.064 |
UPDATE |
Definition |
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. |
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. |
| 08/09/2023 |
3.11.0 |
CLT.002.063 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
| 07/12/2023 |
3.10.0 |
ELG.005.097 |
UPDATE |
Coding requirement |
1. Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25" |
Value must be in Restricted Benefits Code List (VVL)2. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "05", then Eligibility Group (ELG.005.087) must be "24"3. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "06", then Eligibility Group (ELG.005.087) must be "26"4. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "02", then Eligibility Group (ELG.005.087) must be "23"5. (Restricted Benefits) if value is "1" and Dual Eligible Code (ELG.005.085) value is "04", then Eligibility Group (ELG.005.087) must be "25"6. (Restricted Benefits) if value is "3", then Dual Eligible Code (ELG.005.085) cannot be "00"7. Mandatory8. If value is populated, then Eligibility Group (ELG.005.087) must be populated.9. If value is "6" then Eligibility Group(ELG.DE.087) must be in ("35", "70")10. If value is "1" or "7" then Eligibility Group (EGL.DE.087) must be in ("72", "73", "74", "75") and State Plan Option Type (ELG.DE.163) must equal to "06"11. (Restricted Pregnancy-Related) if value is "4", then associated Sex (ELG.002.023) value must be "F"12. (Non-Citizen) if value is "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 segment14. Value must be 1 character15. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "01", then Eligibility Group (ELG.005.087) must be "23"16. (Restricted Benefits) if value is "3" and Dual Eligible Code (ELG.005.085) value is "03", then Eligibility Group (ELG.005.087) must be "25"17. (Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
| 08/01/2023 |
3.11.0 |
ELG.005.086 |
UPDATE |
Coding requirement |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. Mandatory |
1. Value must be in Primary Eligibility Group Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Mandatory |
| 08/09/2023 |
3.11.0 |
COT.002.050 |
UPDATE |
Definition |
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. |
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.For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
| 08/09/2023 |
3.11.0 |
COT.002.049 |
UPDATE |
Definition |
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. |
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. |
| 08/09/2023 |
3.11.0 |
COT.002.048 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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. |
| 08/09/2023 |
3.11.0 |
COT.002.034 |
UPDATE |
Definition |
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. For capitation premium payments, the date on
which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. |
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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
COT.002.033 |
UPDATE |
Definition |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
COT.003.167 |
UPDATE |
Definition |
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. For capitation premium payments, the date on
which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. |
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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
COT.003.166 |
UPDATE |
Definition |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
| 08/09/2023 |
3.11.0 |
CIP.002.114 |
UPDATE |
Definition |
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. |
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. |
| 08/09/2023 |
3.11.0 |
CIP.002.113 |
UPDATE |
Definition |
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. |
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. |
| 08/09/2023 |
3.11.0 |
CIP.002.112 |
UPDATE |
Definition |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial
transactions. |
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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.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 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. |
| 09/21/2023 |
3.13.0 |
PRV.006.088 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/09/2023 |
3.11.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual, there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
| 02/23/2023 |
3.4.0 |
CIP.002.099 |
UPDATE |
Definition |
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. |
The date Medicaid paid this claim or adjustment. |
| 09/21/2023 |
3.13.0 |
PRV.006.089 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.003.057 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.006.073 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
TPL.003.030 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
PRV.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.005.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
MCR.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.022.258 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
ELG.002.017 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CRX.003.109 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
COT.003.155 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CLT.003.185 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 09/21/2023 |
3.13.0 |
CIP.003.232 |
UPDATE |
Segment key field identifier |
Not Applicable |
1 |
| 08/15/2023 |
3.12.0 |
CLT.003.198 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 08/15/2023 |
3.12.0 |
CIP.003.245 |
UPDATE |
Coding requirement |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code (CE) value requires an associated Revenue Charge (CE)3. Value must be 4 characters or less4. Mandatory |
1. Value must be in Revenue Code List (VVL)2. A Revenue Code value requires an associated Revenue Charge3. Value must be 4 characters or less4. Mandatory |
| 09/21/2023 |
3.13.0 |
MCR.004.058 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
TPL.006.081 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.081 |
UPDATE |
Coding requirement |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Optional |
1. Value must be in State Code List (VVL)2. Value must be 2 characters3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.007.086 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/28/2023 |
3.12.0 |
TPL.006.091 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.091 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 30 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.090 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.090 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 10 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.006.084 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/28/2023 |
3.12.0 |
TPL.006.083 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.083 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Optional |
1. Value must be 10-digit number2. Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.082 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.082 |
UPDATE |
Coding requirement |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Optional |
1. Value may only be 5 digits (0-9) (Example: 91320) or 9 digits (0-9) (Example: 913200011)2. Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.080 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
TPL.006.080 |
UPDATE |
Coding requirement |
1. Value must be 28 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 28 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
TPL.006.079 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
TPL.006.078 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
TPL.006.077 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Optional5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Optional5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
TPL.006.076 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
TPL.006.075 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/15/2023 |
3.12.0 |
TPL.006.074 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.005.070 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.005.068 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.005.067 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
TPL.005.065 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.004.061 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.004.059 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.004.058 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
TPL.004.056 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
TPL.004.054 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 09/21/2023 |
3.13.0 |
TPL.003.089 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
TPL.003.050 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.003.048 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
TPL.003.036 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
TPL.003.035 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
TPL.003.034 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
TPL.003.033 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 07/13/2023 |
3.10.0 |
TPL.003.032 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 08/15/2023 |
3.12.0 |
TPL.003.031 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.002.027 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.002.025 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/28/2023 |
3.12.0 |
TPL.002.020 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Value must be 1 character5. Mandatory6. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in TPL Health Insurance Coverage Indicator List (VVL)4. Mandatory5. When value equals '1', there must be one corresponding TPL Medicaid Eligible Person Health Insurance Coverage Information (TPL.003) segment with the same MSIS ID. |
| 08/14/2023 |
3.12.0 |
TPL.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
TPL.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
TPL.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 08/14/2023 |
3.12.0 |
TPL.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
TPL.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
TPL.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
TPL.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.010.136 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.010.134 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.010.130 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.010.129 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
PRV.010.127 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.009.123 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.009.121 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 06/14/2023 |
3.9.0 |
PRV.009.120 |
UPDATE |
Definition |
A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.
If Affiliated Program Type = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in which a provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal Waiver ID in which a provider is
allowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the value in Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in Affiliated Program ID is an identifier for something other than a health plan,
waiver, or health home entity. |
A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. |
| 09/21/2023 |
3.13.0 |
PRV.009.119 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/15/2023 |
3.12.0 |
PRV.009.117 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.008.113 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.008.111 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.008.110 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.008.108 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.007.104 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
PRV.007.096 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.006.092 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.006.090 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 01/03/2023 |
3.2.0 |
PRV.006.089 |
UPDATE |
Medicaid valid value info |
*Valid values for PROV-CLASSIFICATION-CODE depend on the value submitted for PROV-CLASSIFICATION-TYPE. All four valid value sets are shown here below.If PROV-CLASSIFICATION-TYPE = 1 then you should submit a valid value from the PROV-CLASSIFICATION-CODE-TYPE-1 valid value set.If PROV-CLASSIFICATION-TYPE = 2 then you should submit a valid value from the PROV-SPECIALTY valid value set.If PROV-CLASSIFICATION-TYPE = 3 then you should submit a valid value from the PROV-TYPE valid value set.If PROV-CLASSIFICATION-TYPE = 4 then you should submit a valid value from the PROV-CLASSIFICATION-CODE-TYPE-4 valid value set. |
*Valid values for PROV-CLASSIFICATION-CODE depend on the value submitted for PROV-CLASSIFICATION-TYPE. All four valid value sets are shown here below.If PROV-CLASSIFICATION-TYPE = 1 then refer to the Provider Taxonomy Code ListIf PROV-CLASSIFICATION-TYPE = 2 then you should submit a valid value from the PROV-SPECIALTY valid value set.If PROV-CLASSIFICATION-TYPE = 3 then you should submit a valid value from the PROV-TYPE valid value set.If PROV-CLASSIFICATION-TYPE = 4 then you should submit a valid value from the PROV-CLASSIFICATION-CODE-TYPE-4 valid value set. |
| 01/26/2023 |
3.2.0 |
PRV.006.088 |
UPDATE |
Definition |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File"
https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/entry/47562
A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
A code to identify the schema used in the Provider Classification Code field to categorize providers. See T-MSIS Guidance Document, "CMS Guidance: Best Practice for Reporting Provider Classification Type and Provider Classification Code in the T-MSIS Provider File" https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/98581 . A provider may be reported with multiple active record segments with the same Provider Classification Type if different Provider Classification Code values apply. |
| 08/14/2023 |
3.12.0 |
PRV.006.086 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.005.082 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.005.081 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
PRV.005.079 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.005.078 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
PRV.005.077 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.005.076 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.005.074 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.004.070 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
PRV.004.069 |
UPDATE |
Segment key field identifier |
Not Applicable |
6 |
| 09/21/2023 |
3.13.0 |
PRV.004.068 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
PRV.004.067 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.004.065 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.004.064 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.004.062 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.003.058 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/15/2023 |
3.12.0 |
PRV.003.054 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Optional |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 08/15/2023 |
3.12.0 |
PRV.003.053 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Optional |
1. Value must be 10-digit number2. Situational |
| 09/21/2023 |
3.13.0 |
PRV.003.052 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
PRV.003.049 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
PRV.003.048 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
PRV.003.047 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
PRV.003.046 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
PRV.003.044 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.003.043 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
PRV.003.041 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.002.037 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
PRV.002.035 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Conditional4. If populated, value must be on or after individual's Date of Birth5. Value must be less than or equal to associated End of Time Period (PRV.001.010)6. There can only be one value on all records when the value is populated7. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Conditional4. When populated, value must be on or after individual's Date of Birth5. Value must be less than or equal to associated End of Time Period (PRV.001.010)6. There can only be one value on all records when the value is populated7. When populated, the difference between value and Date of Birth (PRV.002.034) must be 18 years or greater |
| 08/28/2023 |
3.12.0 |
PRV.002.026 |
UPDATE |
Coding requirement |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated |
1. Value must be in Facility Group Individual Code List (VVL)2. Value must be 2 characters3. Mandatory4. (individual) if value equals '03', then Provider First Name (PRV.002.028) must be populated5. (organization) if value does not equal '03', then Provider Middle Initial (PRV.002.029) must not be populated6. (individual) if value equals '03', then Provider Last Name (PRV.002.030) must be populated7. (individual) if value equals '03', then Provider Sex (PRV.002.031) must be populated8. (individual) if value equals '03', then Provider Date of Birth (PRV.002.034) must be populated9. (organization) if value equals '01' or '02', then Provider Date of Death (PRV.002.035) must not be populated10. (individual) if value equals '03', then there must be one Provider Identifier (PRV.005.081) populated with an associated Provider Identifier Type (PRV.005.077) equal to ‘2’ (NPI) |
| 08/09/2023 |
3.11.0 |
PRV.002.024 |
UPDATE |
Definition |
The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. |
The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. Provider Organization Name should be same as provider last name when provider is an individual. |
| 09/21/2023 |
3.13.0 |
PRV.002.020 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
PRV.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
PRV.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
PRV.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
PRV.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
PRV.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
PRV.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
PRV.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.007.089 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.007.087 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
MCR.007.084 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.006.080 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.006.078 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.006.077 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
MCR.006.075 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.005.071 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.005.069 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.005.068 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
MCR.005.067 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
MCR.005.066 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
MCR.005.065 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.004.061 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.004.059 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
MCR.004.056 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.003.052 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.051 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.051 |
UPDATE |
Coding requirement |
Optional |
1. Value must be a 10-digit number2. Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.050 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.050 |
UPDATE |
Coding requirement |
1. Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Optional |
Must contain the '@' symbol2. May contain uppercase and lowercase Latin letters A to Z and a to z3. May contain digits 0-94. Must contain a dot '.' that is not the first or last character and provided that it does not appear consecutively5. Value must be 60 characters or less6. Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.049 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
MCR.003.049 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Optional |
1. Value must be 10-digit number2. Situational |
| 09/21/2023 |
3.13.0 |
MCR.003.047 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
MCR.003.043 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
MCR.003.042 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
MCR.003.041 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
MCR.003.039 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.003.038 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
MCR.003.036 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.002.032 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
MCR.002.030 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
MCR.002.024 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 09/21/2023 |
3.13.0 |
MCR.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
MCR.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
MCR.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
MCR.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
MCR.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
MCR.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
MCR.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.022.267 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
ELG.022.265 |
UPDATE |
Coding requirement |
1. Value must be 20 characters or less2. Mandatory3. Must not contain a pipe symbol |
1. Value must be 20 characters or less2. Mandatory3. Must not contain a pipe or asterisk symbol |
| 09/21/2023 |
3.13.0 |
ELG.022.263 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.022.261 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 07/13/2023 |
3.10.0 |
ELG.022.260 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 08/14/2023 |
3.12.0 |
ELG.022.259 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.021.255 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.021.253 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.021.252 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.021.250 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.020.245 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.020.243 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.020.242 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.020.240 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.018.236 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.018.234 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/01/2023 |
3.11.0 |
ELG.018.233 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
ELG.018.231 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.017.227 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.017.225 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.017.224 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.017.222 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.016.218 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.016.216 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/01/2023 |
3.11.0 |
ELG.016.215 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in American Indian Alaskan Native Indicator List (VVL)4. Conditional |
| 09/21/2023 |
3.13.0 |
ELG.016.214 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.016.213 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.016.211 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.015.271 |
UPDATE |
Coding requirement |
1. Value must be 25 characters or less2. Value is required when Ethnicity Code (ELG.015.204) equals '4' (Other)3. Conditional |
1. Value must be 25 characters or less2. If associated Ethnicity Code (ELG.015.204) is in ["4"], then value must be populated. 3. Conditional |
| 08/21/2023 |
3.12.0 |
ELG.015.207 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.015.205 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.015.204 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.015.202 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.014.198 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.014.193 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.014.192 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.014.190 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.013.186 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.013.184 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/28/2023 |
3.12.0 |
ELG.013.183 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Mandatory |
1. Value must be 30 characters or less2. Mandatory3. Value must match a corresponding Provider Identifier (PRV.005.081) |
| 09/21/2023 |
3.13.0 |
ELG.013.182 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.013.180 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.012.176 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.012.174 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/15/2023 |
3.12.0 |
ELG.012.172 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Value must have a corresponding value in Waiver Type (ELG.012.173)6. Mandatory |
| 08/14/2023 |
3.12.0 |
ELG.012.170 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.011.166 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.011.164 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.011.163 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.011.161 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.010.157 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
ELG.010.148 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 07/12/2023 |
3.10.0 |
ELG.009.270 |
UPDATE |
Coding requirement |
1. Value must be 3 characters2. Conditional |
1. Value must be 3 characters2. Conditional3. Must be a 3 digit value from the Type-of-Service valid value list |
| 08/21/2023 |
3.12.0 |
ELG.009.144 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.009.142 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.009.141 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
ELG.009.140 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Mandatory |
1. Value must be 30 characters or less2. Mandatory3. Value must match a corresponding Provider Identifier (PRV.005.081) |
| 08/14/2023 |
3.12.0 |
ELG.009.138 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.008.134 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.008.132 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.008.131 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.008.130 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.008.128 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.007.124 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.007.121 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.007.120 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
ELG.007.119 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.007.118 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.007.116 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.006.112 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.006.109 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 09/21/2023 |
3.13.0 |
ELG.006.108 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 09/21/2023 |
3.13.0 |
ELG.006.107 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.006.105 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.005.101 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 01/09/2023 |
3.2.0 |
ELG.005.095 |
UPDATE |
Definition |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. |
The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual, there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
| 08/16/2023 |
3.12.0 |
ELG.005.094 |
UPDATE |
Coding requirement |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Value must be 1 character8. Conditional |
1. Value must be in Conception to Birth Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If the value is equal to "1", then the Eligibility Group (ELG.005.087) must equal "64"5. If the value is equal to "1", then any associated claims must indicate the Program Type = '14' (State Plan CHIP)6. If the value is equal to "1", then CHIP Code (ELG.003.054) must equal "3" (Individual was not Medicaid Expansion CHIP eligible, but was included in a separate title XXI CHIP Program)7. Conditional |
| 09/21/2023 |
3.13.0 |
ELG.005.091 |
UPDATE |
Coding requirement |
1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be '1'5. Value must not be populated or must be '000' when SSI Status (ELG.005.092) is not populated or is '000' |
1. Value must be in SSI State Supplement Status Code List (VVL)2. Value must be 3 characters3. (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"4. (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be "1"5. Value must not be populated or must be "000" when SSI Status (ELG.005.092) is not populated or is "000" |
| 09/21/2023 |
3.13.0 |
ELG.005.089 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSDI Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in SSDI Indicator List (VVL)4. Conditional |
| 08/28/2023 |
3.12.0 |
ELG.005.087 |
UPDATE |
Coding requirement |
1. Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05" |
Value must be in Eligibility Group List (VVL)2. If value is "26", then Dual Eligible Code value must be "06"3. Conditional4. Value is mandatory and must be provided when associated Eligibility Determinant Effective Date value is on or after 1 January, 2014.5. If value is in [ "72", "73", "74", "75" ], then associated Restricted Benefits Code value must equal "1" or "7" and State Plan Option Type must equal "06"6. If associated CHIP Code value is "2", then value must be in [ "07", 31", "61" ]7. If associated CHIP Code value is "3", then value must be in [ "61", "62", "63", "64", "65", "66", "67", "68" ]8. Value must be 2 characters9. If value is "23", then Dual Eligible Code value must be in ["01", "02"]10. If value is "25", then Dual Eligible Code value must be in ["03", "04"]11. If value is "24", then Dual Eligible Code value must be "05"12. If value is "26", then Dual Eligible Code value must be "06" |
| 05/31/2023 |
3.8.0 |
ELG.005.085 |
UPDATE |
Necessity |
Conditional |
Mandatory |
| 05/31/2023 |
3.8.0 |
ELG.005.085 |
UPDATE |
Coding requirement |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Conditional6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
1. Value must be in Dual Eligible Code List (VVL)2. If value is "05", then Eligibility Group (ELG.005.087) must be "24"3. If value is "06", then Eligibility Group (ELG.005.087) must be "26"4. If Dual Eligible Code (ELG.005.085) is "01", "02", "03", 04", 05", "06", "08", "09", or "10", then Primary Eligibility Group Indicator (ELG.005.086) must be "1" (Yes)5. Mandatory6. A partial dual eligible (values="01', "03", "05" or "06") then Restricted Benefits Code (ELG.005.097) must be "3"7. (Not Dual Eligible) if value = "00", then associated Medicare Beneficiary Identifier (ELG.003.051) value must not be populated.8. Value must be 2 characters9. If value is in ["08", "10"] then Restricted Benefits Code (ELG.005.097) must be "1"10. If value is "09", then Eligibility Group (ELG.005.087) and Restricted Benefits Code (ELG.005.097) must not be populated11. If value equals "10", then CHIP Code (ELG.003.054) must be "03" (S-CHIP) and Medicare Beneficiary Identifier (ELG.003.051) must be populated12. If value is "01", then Eligibility Group (ELG.005.087) must be "23"13. If value is "03", then Eligibility Group (ELG.005.087) must be "25" |
| 09/21/2023 |
3.13.0 |
ELG.005.083 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.005.081 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.004.077 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.004.075 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/09/2023 |
3.11.0 |
ELG.004.074 |
UPDATE |
Definition |
A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid value lists. |
A free-form text field to describe the type of living arrangement used for the eligibility determination process. |
| 08/28/2023 |
3.12.0 |
ELG.004.073 |
UPDATE |
Coding requirement |
1. Value must be 10-digit number2. Conditional |
1. Value must be 10-digit number2. Conditional3. If Eligible Address Type (ELG.004.065) = ''01', then value is mandatory and must be provided |
| 08/14/2023 |
3.12.0 |
ELG.004.068 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 2 (CE) value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 2 value(s)3. If Address Line 2 is not populated, then value should not be populated4. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
ELG.004.067 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
ELG.004.066 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Mandatory5. When populated, the associated Address Type is required |
| 09/21/2023 |
3.13.0 |
ELG.004.065 |
UPDATE |
Segment key field identifier |
Not Applicable |
3 |
| 08/14/2023 |
3.12.0 |
ELG.004.063 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 07/14/2023 |
3.10.0 |
ELG.003.269 |
UPDATE |
Definition |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using
multiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group. |
This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
| 08/21/2023 |
3.12.0 |
ELG.003.059 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/01/2023 |
3.11.0 |
ELG.003.049 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Pregnancy Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Pregnancy Indicator List (VVL)4. Conditional |
| 07/12/2023 |
3.10.0 |
ELG.003.040 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
1. Value must be 1 character2. Value must be in [0, 1, 2] or not populated3. Value must be in Citizenship Indicator List (VVL)4. If value is coded as '0', then associated Immigration Status (ELG.003.042) value must be in [ 1, 2, 3 ]5. If value is coded as '1', then associated Immigration Status (ELG.003.042) value must equal '8'6. Value must be 1 character7. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.003.039 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Value must be 1 character5. Conditional6. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Veteran Indicator List (VVL)4. Conditional5. Value must be populated when Immigration Status (ELG.003.042) is in ['1', '2', '3'] |
| 05/10/2023 |
3.7.0 |
ELG.003.038 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/10/2023 |
3.7.0 |
ELG.003.038 |
UPDATE |
Coding requirement |
1. Value must be in Income Code List (VVL)2. Value must be 2 characters3. Mandatory |
1. Value must be in Income Code List (VVL)2. Value must be 2 characters3. Conditional |
| 06/21/2023 |
3.9.0 |
ELG.003.034 |
UPDATE |
Definition |
A code to classify eligible individual's marital/domestic-relationship status. An eligible individual who is younger than 12 years should have a marital status of never married or
unknown. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization). |
A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value. |
| 08/14/2023 |
3.12.0 |
ELG.003.032 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.002.028 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
ELG.002.026 |
UPDATE |
Segment key field identifier |
Not Applicable |
(a) |
| 08/14/2023 |
3.12.0 |
ELG.002.024 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period (CE) value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Children enrolled in the Separate CHIP prenatal program option should have a date of birth missing or a date of birth equal to the pregnant mother's date of birth4. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value must be less than or equal to associated End of Time Period value5. Value must be less than or equal to associated Date File Created (ELG.001.008) value6. Mandatory7. When Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087) does not equal '64' value minus Start of Time Period (ELG.001.10) must be less than 125 years |
| 07/13/2023 |
3.10.0 |
ELG.002.019 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less |
1. Mandatory2. Value must be 20 characters or less |
| 08/14/2023 |
3.12.0 |
ELG.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
ELG.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/14/2023 |
3.12.0 |
ELG.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
ELG.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
ELG.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
CRX.003.172 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
CRX.003.157 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
CRX.003.153 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/01/2023 |
3.12.0 |
CRX.003.127 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. Value should not be populated if associated Crossover Indicator value is '0' (not a crossover claim)5. If value is greater than '0,' then Crossover Indicator must be '1' |
Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. If associated Crossover Indicator value is '0' (not a crossover claim), value should not be populated5. If value is greater than '0,' then Crossover Indicator must be '1' |
| 08/14/2023 |
3.12.0 |
CRX.003.126 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
CRX.003.125 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 08/28/2023 |
3.12.0 |
CRX.003.123 |
UPDATE |
Necessity |
Conditional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.003.123 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 5 digits or less left of the decimal i.e. 99999.99 |
1. Situational2. Value must be 5 digits or less left of the decimal i.e. 99999.99 |
| 08/09/2023 |
3.11.0 |
CRX.003.122 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 08/09/2023 |
3.11.0 |
CRX.003.121 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/01/2023 |
3.12.0 |
CRX.003.120 |
UPDATE |
Coding requirement |
1. Value must be 12 digits or less2. Value must be a valid National Drug Code3. Mandatory4. Value must have an associated Metric Decimal Quantity (CRX.003.144)5. Value must have an associated Unit of Measure (CRX.003.133) |
1. Value must be 12 digits or less2. Value must be a valid National Drug Code3. Mandatory4. Value must have an associated Dtl Metric Decimal Quantity (CRX.003.144)5. Value must have an associated Unit of Measure (CRX.003.133) |
| 09/21/2023 |
3.13.0 |
CRX.003.115 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CRX.003.114 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
CRX.003.113 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CRX.003.112 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
CRX.003.111 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When TYPE-OF-CLAIM = 4, D or X (lump sum payment), value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
CRX.003.110 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
CRX.002.165 |
UPDATE |
Definition |
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 for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
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. |
| 08/10/2023 |
3.11.0 |
CRX.002.164 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
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. |
| 08/01/2023 |
3.11.0 |
CRX.002.160 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 08/21/2023 |
3.12.0 |
CRX.002.106 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.104 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 08/23/2023 |
3.12.0 |
CRX.002.101 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 08/23/2023 |
3.12.0 |
CRX.002.100 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
CRX.002.099 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
CRX.002.098 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.095 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CRX.002.095 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 09/07/2023 |
3.12.0 |
CRX.002.092 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CRX.002.089 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CRX.002.087 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
CRX.002.082 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 07/12/2023 |
3.10.0 |
CRX.002.081 |
UPDATE |
Definition |
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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
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. |
| 09/21/2023 |
3.13.0 |
CRX.002.075 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Mandatory |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Mandatory4. Value must exist in the NPPES NPI data file5. NPPES Entity Type Code associate with this NPI must equal ‘1’ (Individual) |
| 08/15/2023 |
3.12.0 |
CRX.002.069 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/28/2023 |
3.12.0 |
CRX.002.067 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/01/2023 |
3.11.0 |
CRX.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
CRX.002.060 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
CRX.002.058 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
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. |
| 06/01/2023 |
3.8.0 |
CRX.002.054 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
CRX.002.053 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CRX.002.052 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
CRX.002.048 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
CRX.002.045 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
CRX.002.040 |
UPDATE |
Definition |
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. |
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. |
| 08/09/2023 |
3.11.0 |
CRX.002.032 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
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. |
| 08/09/2023 |
3.11.0 |
CRX.002.029 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this 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” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
CRX.002.028 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
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. |
| 09/21/2023 |
3.13.0 |
CRX.002.027 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 08/01/2023 |
3.11.0 |
CRX.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
CRX.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CRX.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
CRX.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
CRX.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CRX.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 08/14/2023 |
3.12.0 |
CRX.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CRX.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CRX.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
CRX.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
COT.003.234 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
COT.003.221 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
COT.003.214 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
COT.003.208 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
COT.003.205 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.003.204 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
| 09/21/2023 |
3.13.0 |
COT.003.203 |
UPDATE |
Medicaid valid value info |
|
Zip Code List |
| 08/14/2023 |
3.12.0 |
COT.003.200 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 (CE) or Address Line 3 (CE) value(s)3. There must be an Address Line 1 (CE) in order to have an Address Line 2 (CE)4. Value must not contain a pipe or asterisk symbols5. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 1 or Address Line 3 value(s)3. There must be an Address Line 1 in order to have an Address Line 24. Value must not contain a pipe or asterisk symbols5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.003.199 |
UPDATE |
Coding requirement |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 (CE) or Address Line 3 (CE) value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
1. Value must be 60 characters or less2. Value must not be equal to associated Address Line 2 or Address Line 3 value(s)3. Value must not contain a pipe or asterisk symbols4. Conditional |
| 09/07/2023 |
3.12.0 |
COT.003.184 |
UPDATE |
Definition |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use theRevenue center -quantity Allowedfield. NOTE: One prescription for 100 250 milligram tablets results inPrescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value inPrescription Quantity allowedmust correspond with the value in Unit of measure. |
The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure. |
| 09/07/2023 |
3.12.0 |
COT.003.183 |
UPDATE |
Definition |
The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. |
The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. This field is only applicable when the service being billed can be quantified in discrete units, e.g. a number of visits or the number of units of a prescription/refill that were filled. |
| 08/14/2023 |
3.12.0 |
COT.003.179 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
COT.003.178 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 08/16/2023 |
3.12.0 |
COT.003.176 |
UPDATE |
Coding requirement |
1. Conditional2. Value must be 11 digits or less left of the decimal i.e. 99999999999.99 |
1. Situational2. Value must be between -99999999999.99 and 99999999999.993. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ) |
| 08/09/2023 |
3.11.0 |
COT.003.175 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 08/09/2023 |
3.11.0 |
COT.003.174 |
UPDATE |
Definition |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. |
The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/21/2023 |
3.13.0 |
COT.003.161 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
COT.003.160 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
COT.003.159 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
COT.003.158 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
COT.003.157 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (COT.002.037) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
COT.003.156 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
COT.002.232 |
UPDATE |
Definition |
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 for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
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. |
| 08/10/2023 |
3.11.0 |
COT.002.231 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
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. |
| 05/31/2023 |
3.8.0 |
COT.002.229 |
UPDATE |
Definition |
The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. |
A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm).The NPI of Ordering Provider represents the individual who requested the service or items being reported on this service line. Example include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies.[Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 05/31/2023 |
3.8.0 |
COT.002.228 |
UPDATE |
Definition |
The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies |
The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies. [Ordering provider information is only captured at the line level in the X12 837P format but in v3.0.0 of the T-MSIS file layout it is only captured at the header level. This discrepancy will be addressed in a future version of the T-MSIS OT file layout. Until Ordering provider information has been moved from the T-MSIS claim header to the line, there is no need to report it at the header.] |
| 08/21/2023 |
3.12.0 |
COT.002.152 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
COT.002.146 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated |
Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. When Type of Service (COT.003.186) equals '121', value must not be populated5. Value must exist in the NPPES NPI data file |
| 08/23/2023 |
3.12.0 |
COT.002.143 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, must have an associated Third Party Copayment Amount 4. Situational |
| 08/23/2023 |
3.12.0 |
COT.002.142 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
COT.002.141 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
COT.002.140 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
COT.002.138 |
UPDATE |
Coding requirement |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional |
1. Value must not contain a pipe or asterisk symbols2. Value must 50 characters or less3. Conditional4. Value must be populated when an associated Type of Service (COT.003.186) equals ‘138’ (payment for health home services)5. Value must be populated when an associated claim line has a XIX MBESCBES Category of Service (COT.003.211) equals ‘45’ (health homes for substance use services) |
| 08/28/2023 |
3.12.0 |
COT.002.137 |
UPDATE |
Necessity |
Not Applicable |
Situational |
| 08/28/2023 |
3.12.0 |
COT.002.137 |
UPDATE |
Coding requirement |
Optional |
1. Value must be in Copayment Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1]4. Situational |
| 09/07/2023 |
3.12.0 |
COT.002.134 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
COT.002.132 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
COT.002.130 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
COT.002.128 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 07/12/2023 |
3.10.0 |
COT.002.126 |
UPDATE |
Definition |
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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
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. |
| 08/28/2023 |
3.12.0 |
COT.002.118 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must be in the NPPES NPI data file4. Conditional |
| 08/28/2023 |
3.12.0 |
COT.002.109 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.103 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.102 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.101 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.100 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.099 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.098 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.096 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.095 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.094 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.073 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.072 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
COT.002.070 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
COT.002.068 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
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. |
| 08/09/2023 |
3.11.0 |
COT.002.066 |
UPDATE |
Definition |
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. |
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. |
| 08/01/2023 |
3.11.0 |
COT.002.064 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 06/01/2023 |
3.8.0 |
COT.002.063 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
COT.002.062 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.061 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
COT.002.057 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
COT.002.054 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount- (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
COT.002.041 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
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-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
| 08/09/2023 |
3.11.0 |
COT.002.037 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this 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” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
COT.002.036 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
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. |
| 09/21/2023 |
3.13.0 |
COT.002.035 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 08/01/2023 |
3.11.0 |
COT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
COT.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
COT.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
COT.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
COT.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
COT.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 08/14/2023 |
3.12.0 |
COT.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
COT.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
COT.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
COT.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
CLT.003.243 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
CLT.003.233 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
CLT.003.226 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CLT.003.212 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) |
| 08/14/2023 |
3.12.0 |
CLT.003.209 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
CLT.003.208 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 08/09/2023 |
3.11.0 |
CLT.003.205 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 08/09/2023 |
3.11.0 |
CLT.003.204 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the
managed care plan. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/21/2023 |
3.13.0 |
CLT.003.191 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CLT.003.190 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
CLT.003.189 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CLT.003.188 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
CLT.003.187 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CLT.002.052) equals 4, D or X (lump sum payment) value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
CLT.003.186 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
CLT.002.241 |
UPDATE |
Definition |
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 for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
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. |
| 08/10/2023 |
3.11.0 |
CLT.002.240 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
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. |
| 08/15/2023 |
3.12.0 |
CLT.002.174 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES data file |
| 08/21/2023 |
3.12.0 |
CLT.002.173 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.167 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 08/23/2023 |
3.12.0 |
CLT.002.166 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational |
| 08/23/2023 |
3.12.0 |
CLT.002.165 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
CLT.002.164 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
CLT.002.163 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.160 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CLT.002.160 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0,1] or not populated4. Situational |
| 09/07/2023 |
3.12.0 |
CLT.002.157 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CLT.002.155 |
UPDATE |
Definition |
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.. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CLT.002.153 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
CLT.002.151 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/21/2023 |
3.13.0 |
CLT.002.150 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional |
| 07/12/2023 |
3.10.0 |
CLT.002.144 |
UPDATE |
Definition |
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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
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. |
| 08/28/2023 |
3.12.0 |
CLT.002.136 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 08/15/2023 |
3.12.0 |
CLT.002.129 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/28/2023 |
3.12.0 |
CLT.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.121 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.120 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.119 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.118 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.117 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.116 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.115 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.114 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.113 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.112 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.091 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.090 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
CLT.002.087 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
CLT.002.082 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
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. |
| 08/01/2023 |
3.11.0 |
CLT.002.078 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 06/01/2023 |
3.8.0 |
CLT.002.077 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
CLT.002.076 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.075 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.071 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
CLT.002.069 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
CLT.002.056 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
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. |
| 08/09/2023 |
3.11.0 |
CLT.002.052 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this 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” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
CLT.002.051 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
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. |
| 09/21/2023 |
3.13.0 |
CLT.002.050 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 08/14/2023 |
3.12.0 |
CLT.002.046 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date (CE) value.4. Value must be greater than or equal to associated Admission Date (CE) value.5. Value must be greater than or equal to associated eligible Date of Birth (CE) value.6. Value must be less than or equal to associated eligible Date of Death (CE) value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Adjudication Date value.4. Value must be greater than or equal to associated Admission Date value.5. Value must be greater than or equal to associated eligible Date of Birth value.6. Value must be less than or equal to associated eligible Date of Death value.7. Conditional8. When populated, Discharge Hour (CLT.002.047) must be populated |
| 08/14/2023 |
3.12.0 |
CLT.002.044 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date (CE) value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth (CE) value.5. Value must be less than or equal to associated eligible Date of Death (CE) value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Value must be less than or equal to associated Discharge Date value in the claim header.4. Value must be greater than or equal to associated eligible Date of Birth value.5. Value must be less than or equal to associated eligible Date of Death value.6. Mandatory7. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) value must be before Adjudication Date (CLT.002.050)8. When associated Type of Claim (CLT.002.052) is not '2','B' or 'V' (capitated payment) and Type of Service (CLT.003.211) is not '119, '120', '121', 122' value must be before Adjudication Date (CLT.003.233) |
| 08/15/2023 |
3.12.0 |
CLT.002.028 |
UPDATE |
Coding requirement |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CLT.002.024 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
CLT.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CLT.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
CLT.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
CLT.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CLT.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 08/14/2023 |
3.12.0 |
CLT.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CLT.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CLT.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
CLT.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 02/16/2023 |
3.3.0 |
CIP.003.296 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated |
1. Value must be 1 character2. Value must be in [0, 1] |
| 09/21/2023 |
3.13.0 |
CIP.003.286 |
UPDATE |
Segment key field identifier |
Not Applicable |
7 |
| 08/21/2023 |
3.12.0 |
CIP.003.273 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/16/2023 |
3.12.0 |
CIP.003.269 |
UPDATE |
Coding requirement |
1. Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported. |
Value must be in CMS 64 Category for Federal Reimbursement List (VVL)2. Value must be 2 characters3. (Federal Funding under Title XXI) if value equals '02', then the eligible's CHIP Code (ELG.003.054) must be in ['2', '3']4. (Federal Funding under Title XIX) if value equals '01' then the eligible's CHIP Code (ELG.003.054) must be '1'5. Conditional6. If Type of Claim is in ['1','2','5','A','B','E','U','V','Y'] and the Total Medicaid Paid Amount is populated on the corresponding claim header, then value must be reported.7. If Type of Claim is in ['4','D'] and the Service Tracking Payment Amount on the relevant record is populated, then value must be reported.8. When Type of Claim is in [‘1’, ‘A’], value must be populated |
| 09/21/2023 |
3.13.0 |
CIP.003.265 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional4. Value must exist in the NPPES NPI data file |
| 09/21/2023 |
3.13.0 |
CIP.003.260 |
UPDATE |
Coding requirement |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID |
1. Value must be 30 characters or less2. Conditional3. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier or4. When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID5. When Type of Claim in ['1','3','A','C’] then associated Provider Medicaid Enrollment Status Code (PRV.007.100) must be in ['01', '02', '03', '04', '05', '06'] (active) |
| 09/01/2023 |
3.12.0 |
CIP.003.255 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim (CE) value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. If associated Type of Claim value equals '3, C, W', then value is mandatory and must be provided4. Conditional |
| 08/09/2023 |
3.11.0 |
CIP.003.254 |
UPDATE |
Definition |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
| 08/09/2023 |
3.11.0 |
CIP.003.252 |
UPDATE |
Definition |
The maximum amount displayed at the claim line level as determined by the payer as being "allowable" under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed
care encounters the Allowed Amount is determined by the managed care organization. |
The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
| 08/09/2023 |
3.11.0 |
CIP.003.251 |
UPDATE |
Definition |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the
managed care plan. |
The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
| 09/21/2023 |
3.13.0 |
CIP.003.238 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CIP.003.237 |
UPDATE |
Segment key field identifier |
Not Applicable |
4 |
| 08/28/2023 |
3.12.0 |
CIP.003.236 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CIP.003.235 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 07/13/2023 |
3.10.0 |
CIP.003.234 |
UPDATE |
Coding requirement |
1. Mandatory2. For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN3. For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN4. Value must be 20 characters or less5. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
1. Mandatory2. Value must be 20 characters or less3. When Type of Claim (CIP.002.100) = 4, D or X (lump sum payment) value must begin with an '&' |
| 08/14/2023 |
3.12.0 |
CIP.003.233 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/10/2023 |
3.11.0 |
CIP.002.294 |
UPDATE |
Definition |
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 for covered services on the claim. Do not subtract out any payments made toward the
deductible. |
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. |
| 08/10/2023 |
3.11.0 |
CIP.002.293 |
UPDATE |
Definition |
The total coinsurance amount on a claim that the beneficiary is obligated to pay for covered services. This is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered service on the claim. Do not subtract out any payments made toward the
copayment. |
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. |
| 08/21/2023 |
3.12.0 |
CIP.002.229 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.221 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type (PRV.005.007) equal to '2' 3. Value must exist in the NPPES NPI data file4. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.220 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Conditional4. When Type of Claim is in ['4', 'D', 'X'], value must not be populated |
| 08/23/2023 |
3.12.0 |
CIP.002.219 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Optional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Copayment Amount4. Situational |
| 08/23/2023 |
3.12.0 |
CIP.002.218 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/23/2023 |
3.12.0 |
CIP.002.217 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Third Party Coinsurance Amount4. Conditional |
Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. When populated, value must have an associated Third Party Coinsurance Amount 4. Conditional |
| 08/23/2023 |
3.12.0 |
CIP.002.216 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Optional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.213 |
UPDATE |
Necessity |
Optional |
Situational |
| 08/28/2023 |
3.12.0 |
CIP.002.213 |
UPDATE |
Coding requirement |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Optional |
1. Value must be in Copay Waived Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Situational |
| 09/07/2023 |
3.12.0 |
CIP.002.210 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CIP.002.208 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 09/07/2023 |
3.12.0 |
CIP.002.206 |
UPDATE |
Definition |
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. |
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/ies on behalf of the beneficiary. |
| 08/01/2023 |
3.11.0 |
CIP.002.204 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Border State Indicator List (VVL)4. Conditional |
| 09/21/2023 |
3.13.0 |
CIP.002.203 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Split Claim Indicator List (VVL).4. Conditional |
| 07/12/2023 |
3.10.0 |
CIP.002.202 |
UPDATE |
Definition |
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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed
explanation of the reason for the payment amount. |
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. |
| 07/12/2023 |
3.10.0 |
CIP.002.194 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must not be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be populated, if Outlier Code (CIP.002.197) equals '00' or '09'4. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.190 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Value must have an associated Provider Identifier Type equal to '2'3. Conditional |
1. Value must be 10 digits2. Value must have an associated Provider Identifier Type equal to '2'3. Value must exist in the NPPES NPI data file4. Conditional |
| 08/15/2023 |
3.12.0 |
CIP.002.184 |
UPDATE |
Coding requirement |
1. Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)2. Conditional3. Value must have an associated Provider Identifier Type equal to '2' |
1. Value must be 10 digits2. Conditional3. Value must have an associated Provider Identifier Type equal to '2'4. Value must exist in the NPPES NPI File |
| 08/15/2023 |
3.12.0 |
CIP.002.178 |
UPDATE |
Coding requirement |
1. Value must be associated with a populated Waiver Type (CE)2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
1. Value must be associated with a populated Waiver Type2. Value must be 20 characters or less3. (1115 demonstration waivers) If value begins with "11-W-" or "21-W-", the associated Claim Waiver Type value must be 01 or in [21-30]4. (1915(b) or 1915(c) waivers) If value begins with the two-letter state abbreviation followed by a period (.), the associated Claim Waiver Type value must be in [02-20, 32, 33]5. Conditional |
| 08/28/2023 |
3.12.0 |
CIP.002.176 |
UPDATE |
Coding requirement |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Value must be 1 character6. Conditional |
1. Value must be in Health Home Provider Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If there is an associated Health Home Entity Name value, then value must be "1"5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.169 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.168 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.166 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.165 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.164 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.163 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.162 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.161 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.160 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code (CE)4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
1. Value must be 8 characters in the form "CCYYMMDD"2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)3. Must have an associated Occurrence Code4. Must be greater than or equal to Occurrence Code Effective Date5. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.139 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Healthcare Acquired Condition Indicator List (VVL).4. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.138 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Forced Claim Indicator List (VVL)4. Conditional |
| 08/14/2023 |
3.12.0 |
CIP.002.137 |
UPDATE |
Coding requirement |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number (CE) or Adjustment Claim Line Number (CE) instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
1. Value must be a positive integer2. Value must be between 0:9999 (inclusive)3. Value must not include commas or other non-numeric characters4. Value must be equal to the number of claim lines (e.g. Original Claim Line Number or Adjustment Claim Line Number instances) reported in the associated claim record being reported5. Value must be 4 characters or less6. Mandatory |
| 06/14/2023 |
3.9.0 |
CIP.002.132 |
UPDATE |
Definition |
The field denotes whether the payment amount was determined at the claim header or line/detail level. |
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. |
| 08/01/2023 |
3.11.0 |
CIP.002.128 |
UPDATE |
Coding requirement |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. Value must be 1 character5. If value equals '1', then Total Medicare Coinsurance amount must not be populated.6. If value equals '0', then Crossover Indicator must equals '0'7. If value equals '1', then Crossover Indicator must equals '1'8. Conditional |
1. Value must be in Medicare Combined Deductible Indicator List (VVL)2. Value must be 1 character3. Value must be in [0, 1] or not populated4. If value equals '1', then Total Medicare Coinsurance amount must not be populated.5. If value equals '0', then Crossover Indicator must equals '0'6. If value equals '1', then Crossover Indicator must equals '1'7. Conditional |
| 06/01/2023 |
3.8.0 |
CIP.002.127 |
UPDATE |
Coding requirement |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Conditional |
1. Value must be in Funding Source Non-Federal Share List (VVL)2. Value must be 2 characters3. Only required if Type-of-claim is not equal to '3', 'C', 'W', '6'4. Conditional |
| 05/31/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Necessity |
Mandatory |
Conditional |
| 05/31/2023 |
3.8.0 |
CIP.002.126 |
UPDATE |
Coding requirement |
1. Value must be in Funding Code List (VVL)2. Value must be 1 character3. Mandatory |
Value must be in Funding Code List (VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.125 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Fixed Payment Indicator List (VVL)4. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.121 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Value must be 1 character5. Conditional |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in Other Insurance Indicator List (VVL)4. Conditional |
| 08/15/2023 |
3.12.0 |
CIP.002.118 |
UPDATE |
Coding requirement |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount (CE) - (Total Medicare Coinsurance Amount (CE) + Total Medicare Deductible Amount (CE))4. Conditional |
1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )3. Value must be less than associated Total Billed Amount - (Total Medicare Coinsurance Amount + Total Medicare Deductible Amount)4. Conditional |
| 08/09/2023 |
3.11.0 |
CIP.002.104 |
UPDATE |
Definition |
The field denotes the claims payment system from which the claim was extracted. |
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. |
| 08/09/2023 |
3.11.0 |
CIP.002.100 |
UPDATE |
Definition |
A code to indicate what type of payment is covered in this 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” for an S-CHIP sub-capitated encounter record. |
| 01/05/2023 |
3.2.0 |
CIP.002.099 |
UPDATE |
Definition |
The date Medicaid paid this claim or adjustment. |
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. |
| 09/21/2023 |
3.13.0 |
CIP.002.098 |
UPDATE |
Segment key field identifier |
Not Applicable |
5 |
| 09/21/2023 |
3.13.0 |
CIP.002.069 |
UPDATE |
Medicaid valid value info |
Values are generated by combining two types of information: Position 1-2, State/Group generating DRG: If state specific system, fill with two digit US postal code representation for state.If CMS Grouper, fill with 'HG'.If any other system, fill with 'XX'.Position 3-4, fill with the number that represents the DRG version used (01-98).For example, 'HG15' would represent CMS Grouper version 15. If version is unknown, fill with '99'. |
|
| 09/21/2023 |
3.13.0 |
CIP.002.068 |
UPDATE |
Medicaid valid value info |
If the first two characters of the diagnosis related group indicator is 'HG' which indicates a CMS DRG Group code was assigned, then the value for the diagnosis related group must be from the following list of valid values. |
|
| 08/15/2023 |
3.12.0 |
CIP.002.031 |
UPDATE |
Coding requirement |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character |
1. Value must be in Diagnosis Code Flag List(VVL)2. Value must be 1 character3. Conditional |
| 08/01/2023 |
3.11.0 |
CIP.002.025 |
UPDATE |
Coding requirement |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Value must be 1 character5. Conditional6. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
1. Value must be 1 character2. Value must be in [0, 1] or not populated3. Value must be in 1115A Demonstration Indicator List (VVL)4. Conditional5. When value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated |
| 08/28/2023 |
3.12.0 |
CIP.002.020 |
UPDATE |
Coding requirement |
1. Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional |
Value must be 50 characters or less2. Value must not contain a pipe or asterisk symbols3. If associated Adjustment Indicator value is 0, then value must not be populated4. Conditional5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated |
| 09/21/2023 |
3.13.0 |
CIP.002.019 |
UPDATE |
Segment key field identifier |
Not Applicable |
2 |
| 08/14/2023 |
3.12.0 |
CIP.002.018 |
UPDATE |
Coding requirement |
1. Value must be unique within record segment over all records associated with a given Record ID (CE)2. Value must be 11 digits or less3. Mandatory |
1. Value must be unique within record segment over all records associated with a given Record ID2. Value must be 11 digits or less3. Mandatory |
| 08/21/2023 |
3.12.0 |
CIP.001.014 |
UPDATE |
Coding requirement |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Optional |
1. Value must be 500 characters or less2. Value must not contain a pipe or asterisk symbols3. Situational |
| 09/21/2023 |
3.13.0 |
CIP.001.012 |
UPDATE |
Coding requirement |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory |
1. Value must be in SSN Indicator List (VVL)2. Value must be 1 character3. Mandatory4. When populated, value must equal SSN Indicator (ELG.001.012) |
| 08/14/2023 |
3.12.0 |
CIP.001.010 |
UPDATE |
Coding requirement |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be equal to or after associated Start of Time Period (CE)6. Mandatory |
1. Value must be 8 characters in the form "CCYYMMDD"2. Value of the CC component must be "20"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be equal to or after associated Start of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CIP.001.009 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created (CE)5. Value must be before associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be equal to or earlier than associated Date File Created5. Value must be before associated End of Time Period6. Mandatory |
| 08/14/2023 |
3.12.0 |
CIP.001.008 |
UPDATE |
Coding requirement |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period (CE)6. Mandatory |
1. Value of the CC component must be "20"2. Value must be 8 characters in the form "CCYYMMDD"3. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)4. Value must be less than current date5. Value must be equal to or after the value of associated End of Time Period6. Mandatory |
| 08/28/2023 |
3.12.0 |
CIP.001.002 |
UPDATE |
Coding requirement |
1. Value must be 10 characters or less2. Value must not include the pipe ("|") symbol3. Mandatory |
1. Value must be 10 characters or less2. Value must be in the Data Dictionary Version List (VVL)3. Mandatory |
| 12/22/2022 |
3.1.0 |
Data Elements |
UPDATE |
Description |
Specifications for all the data elements including valid values and related rules and measures. |
Specifications for all the data elements including valid values, related rules, and measures. |
| 12/22/2022 |
3.1.0 |
Data Elements |
UPDATE |
Description |
Specifications for the data quality measures performed on a file. |
Specifications for all the data elements including valid values and related rules and measures. |
|
03/12/2025
|
3.35.0 |
ELIGIBILITY-GROUP (ELG087)
|
Add |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION ELIGIBILITY-GROUP | 20250301 | 99991231 | 77 | Other optional eligibility for reasonable classifications of children under 21 |
|
03/12/2025
|
3.35.0 |
ADDR-COUNTY (ELG072)
|
Delete |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION ADDR-COUNTY | 01/01/0001 | 12/31/9999 | 113 | Shannon County, South Dakota | |
N/A |
|
11/08/2024
|
3.31.0 |
XIX-MBESCBES-CATEGORY-OF-SERVICE (CIP270, CLT224, COT211, CRX150)
|
Add |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|48|ARP Section 9813 Qualified Community Based Mobile Crisis Intervention – 85% |
|
11/08/2024
|
3.31.0 |
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY (TPL067)
|
Update |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY|00010101|99991231|5|Worker's Compensation |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY|00010101|99991231|5|Workers' Compensation |
|
09/13/2024
|
3.29.0 |
ELG.087
|
Update |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-GROUP|00010101|99991231|59|Medically Needy Aged, Blind or Disabled|Individuals who are age 65 or older, blind or disabled, who are not eligible as categorically needy, who meet income and resource standards specified by the State, or who meet the income standard using medical and remedial care expenses to offset excess i |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-GROUP|00010101|99991231|59|Medically Needy Aged, Blind or Disabled|Individuals who are age 65 or older, blind or disabled, who are not eligible as categorically needy, who meet income and resource standards specified by the State, or who meet the income standard using medical and remedial care expenses to offset excess income. |
|
09/13/2024
|
3.29.0 |
ELG.087
|
Update |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-GROUP|00010101|99991231|69|Individuals with mental health conditions who do not qualify for Medicaid due to the severity or duration of their disability or due to other eligibility factors; and/or those who are otherwise eligible but require benefits or services that are not compar |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-GROUP|00010101|99991231|69| Individuals with mental health conditions who do not qualify for Medicaid due to the severity or duration of their disability or due to other eligibility factors; and/or those who are otherwise eligible but require benefits or services that are not comparable to those provided to other Medicaid beneficiaries. |
|
09/13/2024
|
3.29.0 |
ELG.087
|
Update |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-GROUP|00010101|99991231|70|Individuals of child bearing age who require family planning services and supplies and for which the state does not choose to, or cannot provide, optional eligibility coverage under the Individuals Eligible for Family Planning Services eligibility group ( |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-GROUP|00010101|99991231|70| Individuals of child bearing age who require family planning services and supplies and for which the state does not choose to, or cannot provide, optional eligibility coverage under the Individuals Eligible for Family Planning Services eligibility group (1902(a)(10)(A)(ii)(XXI)). |
|
06/07/2024
|
3.26.0 |
PRV057, ELG072
|
Update |
Data Dictionary - Valid Values |
Shannon County, South Dakota and 113 county code |
Shannon County, South Dakota, was renamed as Oglala Lakota County and the county code changed from 113 to 102. |
|
04/17/2024
|
3.24.0 |
VV End-Dates for WAIVER-TYPE
|
Update |
Data Dictionary - Valid Values |
VV End-Dates for WAIVER-TYPE was 12/31/9999 for the following WAIVER-TYPE Valid Values: 02-19 & 21. |
VV End-Dates for WAIVER-TYPE has been updated with ‘10/31/2028’ for the following WAIVER-TYPE Valid Values: 02-19 & 21. |
|
03/15/2024
|
3.21.0 |
Rule-1378
|
Update |
Data Dictionary - Valid Values |
not a valid value within CMS |
CLAIM-PYMT-REM-CODE |
|
03/15/2024
|
3.21.0 |
REBATE-ELIGIBLE-INDICATOR - 0
|
Update |
Data Dictionary - Valid Values |
NDC is not eligible for drug rebate program. (Manufacturer does not have a rebate agreement.) |
NDC is not eligible for drug rebate program. (Manufacturer does not have a rebate agreement.) Drug meets the definition of a covered outpatient drug (COD), but manufacturer does not participate in the rebate program. |
|
03/15/2024
|
3.21.0 |
REBATE-ELIGIBLE-INDICATOR - 1
|
Update |
Data Dictionary - Valid Values |
NDC is eligible for drug rebate program |
NDC is eligible for drug rebate program NDC is listed on the MDP |
|
03/15/2024
|
3.21.0 |
REBATE-ELIGIBLE-INDICATOR - 2
|
Update |
Data Dictionary - Valid Values |
NDC is exempt from the drug rebate program (biological and medical devices) |
NDC is exempt from the drug rebate program (biological and medical devices) these are prescribed drugs that do not meet the definition of a COD. There are several examples, the easiest is insect repellant. State release 178 provides more details. https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/rx-releases/state-releases/state-rel-178.pdf |
|
03/15/2024
|
3.21.0 |
PROV-CLASSIFICATION-CODE-TYPE-1
|
Update |
Data Dictionary - Valid Values |
reference files containing provider taxonomy are out of sync |
Valid Values updated |
|
03/15/2024
|
3.21.0 |
PROV-TAXONOMY
|
Update |
Data Dictionary - Valid Values |
reference files containing provider taxonomy are out of sync |
Valid Values updated |
|
03/01/2024
|
3.20.0 |
ADJUSTMENT-IND and LINE-ADJUSTMENT-IND
CIP026
|
Update |
Data Dictionary - Valid Values |
Original Claim/Encounter |
Original Claim/Encounter/Payment - Indicates that this is the first (and, when applicable, only) fully adjudicated transaction in a claim family (one or more claims with the related ICN-ORIG and/or ICN-ADJ and typically the same MSIS ID and provider ID(s) also). |
|
03/01/2024
|
3.20.0 |
ADJUSTMENT-IND and LINE-ADJUSTMENT-IND
CIP026
|
Update |
Data Dictionary - Valid Values |
Void of a prior submission |
Void/Reversal/Cancel of a prior submission Use this code to convey that the purpose of the transaction is to void/reverse/cancel a previously paid/approved claim/encounter/payment where the claim/encounter/payment is not being replaced by a new paid/approved version of the claim/encounter/payment. Typically, this would be the last claim/encounter/payment that would ever be associated with a given claim family. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being voided. CMS expects a void transaction to also have the same MSIS ID and provider ID(s) as the claim/encounter/payment being voided/reversed/cancelled. |
|
03/01/2024
|
3.20.0 |
ADJUSTMENT-IND and LINE-ADJUSTMENT-IND
CIP026
|
Update |
Data Dictionary - Valid Values |
Debit Adjustment (positive supplemental) |
Replacement/Resubmission of a previously paid/approved claim/encounter/payment - Use when the purpose of the transaction is to replace a previously paid/approved claim/encounter/payment with a new paid/approved version of the claim/encounter/payment. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being replaced. CMS expects a replacement transaction to also have the same MSIS ID and provider ID(s) as the claim/encounter/payment being replaced/resubmitted. |
|
03/01/2024
|
3.20.0 |
ADJUSTMENT-IND and LINE-ADJUSTMENT-IND
CIP026
|
Update |
Data Dictionary - Valid Values |
Credit Gross Adjustment |
Credit Gross Adjustment - Use this code to indicate an aggregate provider-level recoupment of payments (e.g., not attributable to a single beneficiary). Amounts on these claims should be expressed as negative numbers. If a credit gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely replace the preceding related gross adjustment. If the ICNs of a credit gross adjustment are not related to any other gross adjustments (credit or debit) then the credit gross adjustment will always be treated as a distinct financial transaction. |
|
03/01/2024
|
3.20.0 |
ADJUSTMENT-IND and LINE-ADJUSTMENT-IND
CIP026
|
Update |
Data Dictionary - Valid Values |
Debit Gross Adjustment |
Debit Gross Adjustment - Use this code to indicate an aggregate provider-level payment to a provider (e.g., not attributable to a single beneficiary). Amounts on these claims should be expressed as positive numbers. If a debit gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely replace the preceding related gross adjustment. If the ICNs of a debit gross adjustment are not related to any other gross adjustments (credit or debit) then the debit gross adjustment will always be treated as a distinct financial transaction. |
|
03/01/2024
|
3.20.0 |
LINE-ADJUSTMENT-IND CIP239
|
Update |
Data Dictionary - Valid Values |
Original Claim/Encounter |
Original Claim/Encounter/Payment - Indicates that this is the first (and, when applicable, only) fully adjudicated transaction in a claim family (one or more claims with the related ICN-ORIG and/or ICN-ADJ and typically the same MSIS ID and provider ID(s) also). |
|
03/01/2024
|
3.20.0 |
LINE-ADJUSTMENT-IND CIP239
|
Update |
Data Dictionary - Valid Values |
Void of a prior submission |
Void/Reversal/Cancel of a prior submission Use this code to convey that the purpose of the transaction is to void/reverse/cancel a previously paid/approved claim/encounter/payment where the claim/encounter/payment is not being replaced by a new paid/approved version of the claim/encounter/payment. Typically, this would be the last claim/encounter/payment that would ever be associated with a given claim family. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being voided. CMS expects a void transaction to also have the same MSIS ID and provider ID(s) as the claim/encounter/payment being voided/reversed/cancelled. |
|
03/01/2024
|
3.20.0 |
LINE-ADJUSTMENT-IND CIP239
|
Update |
Data Dictionary - Valid Values |
Debit Adjustment (positive supplemental) |
Replacement/Resubmission of a previously paid/approved claim/encounter/payment - Use when the purpose of the transaction is to replace a previously paid/approved claim/encounter/payment with a new paid/approved version of the claim/encounter/payment. These records must have the same ICN-ORIG or ICN-ADJ as the claim/encounter being replaced. CMS expects a replacement transaction to also have the same MSIS ID and provider ID(s) as the claim/encounter/payment being replaced/resubmitted. |
|
03/01/2024
|
3.20.0 |
LINE-ADJUSTMENT-IND CIP239
|
Update |
Data Dictionary - Valid Values |
Credit Gross Adjustment |
Credit Gross Adjustment - Use this code to indicate an aggregate provider-level recoupment of payments (e.g., not attributable to a single beneficiary). Amounts on these claims should be expressed as negative numbers. If a credit gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely replace the preceding related gross adjustment. If the ICNs of a credit gross adjustment are not related to any other gross adjustments (credit or debit) then the credit gross adjustment will always be treated as a distinct financial transaction. |
|
03/01/2024
|
3.20.0 |
LINE-ADJUSTMENT-IND CIP239
|
Update |
Data Dictionary - Valid Values |
Debit Gross Adjustment |
Debit Gross Adjustment - Use this code to indicate an aggregate provider-level payment to a provider (e.g., not attributable to a single beneficiary). Amounts on these claims should be expressed as positive numbers. If a debit gross adjustment is reported with an ICN that is related to an ICN(s) of another gross adjustment (credit or debit) then CMS will interpret this to mean that the credit gross adjustment with the more recent adjudication date should completely replace the preceding related gross adjustment. If the ICNs of a debit gross adjustment are not related to any other gross adjustments (credit or debit) then the debit gross adjustment will always be treated as a distinct financial transaction. |
|
02/01/2024
|
3.18.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
HCPCS Code Set PROCEDURE-CODE.psv as of 08/23/2023 |
HCPCS Code Set Update PROCEDURE-CODE.psv as of 01/26/2024 |
|
09/08/2023
|
3.12.0 |
COT123
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
PLACE-OF-SERVICE|20231001|99991231|27|Outreach Site/ Street| A non-permanent location on the street or found environment, not described by any other POS code, where health professionals provide preventive, screening, diagnostic, and/or treatment services to unsheltered homeless individuals. |
|
09/08/2023
|
3.12.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update latest ICD-10-procedure-code Valid Value file |
PROCEDURE-CODE.psv |
|
09/08/2023
|
3.12.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update Latest ICD-10-diagnosis-code Valid Values file |
DIAGNOSIS-CODE.psv |
|
09/08/2023
|
3.12.0 |
CIP004, CLT004, COT004, CRX004, ELG004, MCR004, PRV004, TPL004
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
FILE-ENCODING-SPECIFICATION|00010101|99991231|FIX|The file follows a fixed length format. |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
|||||| |
|
09/08/2023
|
3.12.0 |
CIP004, CLT004, COT004, CRX004, ELG004, MCR004, PRV004, TPL004
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
FILE-ENCODING-SPECIFICATION|00010101|99991231|PSV|The file follows a pipe-delimited format. |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
FILE-ENCODING-SPECIFICATION|00010101|99991231|PSV|The file follows a pipe-separated value format. |
|
09/08/2023
|
3.12.0 |
CIP257, CLT211, COT186, CRX134
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
TYPE-OF-SERVICE|00010101|99991231|005|Professional laboratory services, Technical laboratory services| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
TYPE-OF-SERVICE|00010101|99991231|005|Professional laboratory services| |
|
07/14/2023
|
3.10.0 |
ELG097
|
ADD |
Data Dictionary |
N/A |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG097|RESTRICTED-BENEFITS-CODE|(Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’)| |
|
07/14/2023
|
3.10.0 |
ELG270
|
ADD |
Data Dictionary |
N/A |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG270|LOCKED-IN-SRVCS|Must be a 3 digit value from the Type-of-Service valid value list| |
|
07/14/2023
|
3.10.0 |
ELG040
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG040|CITIZENSHIP-IND|Value must be in [0, 1] or not populated| |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG040|CITIZENSHIP-IND|Value must be in [0, 1, 2] or not populated| |
|
07/14/2023
|
3.10.0 |
CIP202
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
CIP202|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
CIP202|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.|| |
|
07/14/2023
|
3.10.0 |
CLT144
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
CLT144|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detaile dexplanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
CLT144|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.|| |
|
07/14/2023
|
3.10.0 |
COT126
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
COT126|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
COT126|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.|| |
|
07/14/2023
|
3.10.0 |
CRX081
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
CRX081|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))"| |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT|
CRX081|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.|| |
|
07/14/2023
|
3.10.0 |
CIP194
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
CIP194|DRG-OUTLIER-AMT|Value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'| |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
CIP194|DRG-OUTLIER-AMT|Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10'| |
|
07/14/2023
|
3.10.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
Update latest HCPCS Valid Value file |
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update |
|
07/14/2023
|
3.10.0 |
CIP022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CIP022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CIP022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CIP022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CIP022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CIP022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CIP234
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CIP234|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CIP234|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CIP234
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CIP234|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CIP234|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CLT022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CLT022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CLT022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CLT022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CLT022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CLT022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CLT187
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CLT187|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CLT187|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CLT187
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CLT187|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CLT187|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
COT022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
COT022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
COT022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
COT022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
COT022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
COT022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
COT157
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
COT157|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
COT157|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
COT157
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
COT157|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
COT157|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CRX022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CRX022|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CRX022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CRX022
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CRX022|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CRX022|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CRX111
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CRX111|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CRX111|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
CRX111
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
CRX111|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
CRX111|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG019
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG019|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG019|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG019
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG019|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG019|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG033
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG033|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG033|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG064
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG064|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG064|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG064
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG064|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG064|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG082
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG082|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG082|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG082
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG082|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG082|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG106
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG016|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG106|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG106
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG016|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG106|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG117
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG117|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG117|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG117
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG117|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG117|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG129
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG129|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG129|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG129
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG129|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG129|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG139
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG139|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG139|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG139
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG139|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG139|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG149
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG149|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG149|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG149
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG149|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG149|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG162
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG162|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG162|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG162
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG162|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG162|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG171
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG171|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG171|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG171
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG171|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG171|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG181
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG181|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG181|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG181
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG181|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG181|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG191
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG191|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG191|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG191
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG191|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG191|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG203
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG203|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG203|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG203
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG203|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG203|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG212
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG212|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG212|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG212
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG212|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG212|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG223
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG223|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG223|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG223
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG223|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG223|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG232
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG232|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG232|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG232
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG232|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG232|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG241
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG241|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG241|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG241
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG241|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG241|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG251
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG251|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG251|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG251
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG251|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG251|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG260
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG260|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG260|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG260
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
ELG260|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
ELG260|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
TPL019
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
TPL019|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
TPL019|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
TPL019
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
TPL019|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
TPL019|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
TPL032
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
TLP032|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
TPL032|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
TPL032
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
TLP032|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
TPL032|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
TPL066
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
TLP066|MSIS-IDENTIFICATION-NUM|For SSN States (i.e. SSN Indicator = 1), value must be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
TPL066|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
TPL066
|
UPDATE |
Data Dictionary |
DE No|DE Name|Coding Requirement|
TLP066|MSIS-IDENTIFICATION-NUM|For Non-SSN States (i.e. SSN Indicator = 0), value must not be equal to eligible individual's SSN| |
DE No|DE Name|Coding Requirement|
TPL066|MSIS-IDENTIFICATION-NUM|| |
|
07/14/2023
|
3.10.0 |
ELG038
|
UPDATE |
Data Dictionary |
DE No|DE Name|Definition|
ELG038|INCOME-CODE|A code indicating the family income level. |
DE No|DE Name|Definition|
ELG038|INCOME-CODE|A code indicating the federal poverty level range in which the family income falls.
If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
|
07/14/2023
|
3.10.0 |
ELG269
|
UPDATE |
Data Dictionary |
DE No|DE Name|Definition|
ELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed usingmultiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group. |
DE No|DE Name|Definition|
ELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|This data element provides the beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the income that applies to their primary eligibility group.
A beneficiary’s income is applicable unless it is not required by the eligibility group for which they were determined eligible. For example, the eligibility groups for children with adoption assistance, foster care, or guardianship care under title IV-E and optional eligibility for individuals needing treatment for breast or cervical cancer do not have a Medicaid income test. Additionally, for individuals receiving SSI, states with section 1634 agreements with the Social Security Administration (SSA) and states that use SSI financial methodologies for Medicaid determinations do not conduct separate Medicaid financial eligibility for this group. |
|
06/23/2023
|
3.9.0 |
PRV120
|
UPDATE |
Data Dictionary |
DE NO||DATA ELEMENT NAME COMPUTING|||DEFINITION
PRV120|AFFILIATED-PROGRAM-ID|||A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.If Affiliated Program Type = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in which a provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal Waiver ID in which a provider isallowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the value in Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in Affiliated Program ID is an identifier for something other than a health plan, waiver, or health home entity. |
DE NO||DATA ELEMENT NAME COMPUTING|||DEFINITION
PRV120|AFFILIATED-PROGRAM-ID|||A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates. |
|
06/02/2023
|
3.8.0 |
PRV119
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
AFFILIATED-PROGRAM-TYPE|00010101|99991231|7|Fee-For-Service - (This value is used to identify providers that are affiliated directly with the state’s Medicaid or CHIP agency (or their fiscal intermediary) and reimbursed by the Medicaid or CHIP agency on a FFS basis. The value in the AFFILIATED-PROGRAM-ID data element contains the ANSI state code of the state in which the provider is enrolled to provide services including through the state plan and a waiver.) |
|
05/12/2023
|
3.7.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update latest Provider Taxonomy Codes valid value file |
https://x12.org/codes |
|
05/12/2023
|
3.7.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update latest ADJUSTMENT-REASON-CODE valid value file |
https://x12.org/codes |
|
05/12/2023
|
3.7.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update latest Claim Status Codes valid value file |
https://x12.org/codes |
|
05/12/2023
|
3.7.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update latest Claim Status Category Codes valid value file |
https://x12.org/codes |
|
05/12/2023
|
3.7.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update latest CPT valid value file |
https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies |
|
05/12/2023
|
3.7.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
ADD Zip-Code valid value file |
https://www.unitedstateszipcodes.org/zip-code-database/ |
|
04/21/2023
|
3.6.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
Update the latest CPT file
|
https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19-vaccines-and-monoclonal-antibodies |
|
03/31/2023
|
3.5.0 |
ELG095
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-CHANGE-REASON|00010101|99991231|03|Income reduced - (typically not a reason for termination)| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-CHANGE-REASON|00010101|99991231|03|Income reduced - (do not use - typically not a reason for termination)| |
|
03/31/2023
|
3.5.0 |
ELG095
|
ADD |
Data Dictionary - Valid Values |
N/A
|
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-CHANGE-REASON|00010101|99991231|05|No longer in the foster care system - (do not use - typically not a reason for termination)| |
|
03/31/2023
|
3.5.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update Quarterly HCPCS valid values |
HCPCS Quarterly Update | CMS |
|
03/10/2023
|
3.4.0 |
ELG034
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
MARITAL-STATUS|00010101|99991231|15|Legally Married (to opposite sex)|
MARITAL-STATUS|00010101|99991231|16|Legally Married (to same sex)|
MARITAL-STATUS|00010101|99991231|17|Legally Married, spouse present|
MARITAL-STATUS|00010101|99991231|18|Legally Married, spouse absent|
MARITAL-STATUS|00010101|99991231|19|Legally Married|
MARITAL-STATUS|00010101|99991231|20|Partnered or in Civil Union (to opposite sex)|
MARITAL-STATUS|00010101|99991231|21|Partnered (Registered Domestic Partner) or in Civil Union (to same sex)|
MARITAL-STATUS|00010101|99991231|22|Partnered (Registered Domestic Partner) or in Civil Union, spouse present|
MARITAL-STATUS|00010101|99991231|23|Partnered (Registered Domestic Partner) or in Civil Union, spouse absent|
MARITAL-STATUS|00010101|99991231|24|Partnered (Registered Domestic Partner) or in Civil Union|
MARITAL-STATUS|00010101|99991231|25|Partnered (Registered Domestic Partner)|
MARITAL-STATUS|00010101|99991231|26|Civil Union|
MARITAL-STATUS|00010101|99991231|27|Legally Married, Partnered, or in Civil Union|
MARITAL-STATUS|00010101|99991231|28|Legally separated (and still legally married)|
MARITAL-STATUS|00010101|99991231|29|Legally separated|
MARITAL-STATUS|00010101|99991231|30|Annulled (and not currently married or partnered)|
MARITAL-STATUS|00010101|99991231|31|Separated (and currently married or partnered)|
MARITAL-STATUS|00010101|99991231|32|Separated|
MARITAL-STATUS|00010101|99991231|33|Single, widowed, or divorced| |
|
03/10/2023
|
3.4.0 |
ELG095
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-CHANGE-REASON|00010101|99991231|01|Excess income|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|02|Excess assets|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|03|Income reduced|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|05|No longer in the foster care system|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|15|Moved to a different state|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|17|Lack of verifications|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|19|Suspension due to incarceration|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|20|Residence in an Institution for Mental Disease (IMD)| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-CHANGE-REASON|00010101|99991231|01|Income Requirement not met - do not use for changes in household composition|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|02|Asset requirement not met - do not use for changes in household composition|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|03|Income reduced - (typically not a reason for termination)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|05|N/A|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|15|Residency requirement not met (e.g., individual moved to a different state, individual has entered or been discharged from an otherwise unspecified facility or institution)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|17|Lack of verifications (e.g., unable to successfully verify citizenship status, immigration status, income, or other information from an application; if unverifiable due to non-response, document as "Failure to respond)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|19|Suspension/termination due to incarceration - use when the state is able to distinguish a more granular reason than just residency requirement not met|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|20|Disqualification for residence in an Institution for Mental Disease (IMD) - use when the state is able to distinguish a more granular reason than just residency requirement not met| |
|
03/10/2023
|
3.4.0 |
ELG095
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILITY-CHANGE-REASON|00010101|99991231|23|Terminated due to Incorrect Granting of Eligibility (e.g., someone is given eligibility in error and then eligibility has to be retracted/terminated)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|24|Household or family composition criteria not met (e.g., someone was incorrectly included or excluded from the household or family composition) - do not use for changes in income|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|25|Non-financial program requirements not met (e.g. child support not paid, failure of drug tests, failure to apply for SSN, etc.)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|26|No longer meets categorical eligibility requirements.|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|27|End of pregnancy/postpartum coverage period - should only be used if the beneficiary did not obtain coverage through another coverage group like parent/caretaker relative|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|28|Time limited eligibility expired (e.g., Transitional Medical Assistance (TMA)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|29|Closed as duplicate|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|30|Medical/health status or condition or level of care requirements no longer met - for reasons other than no longer being institutionalized or no longer meeting disability requirements (e.g., completed breast and/or cervical cancer treatment, incarcerated individual no longer requires temporary inpatient level of care)|
ELIGIBILITY-CHANGE-REASON|00010101|99991231|31|Change in federal or state law or policy (e.g., a state or federal program is completely discontinued and not replaced by an equivalent or transitional program; unwinding of the Families First Coronavirus Response Act coverage of COVID testing for otherwise uninsured individuals who would have otherwise continued to be eligible if they had been re-determined eligible for at least the same program had the program not been terminated)| |
|
03/10/2023
|
3.4.0 |
ELG034
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG034|MARITAL-STATUS|A code to classify eligible individual's marital/domestic-relationship status. An eligible individual who is younger than 12 years should have a marital status of never married orunknown. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).| |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG034|MARITAL-STATUS|A code to classify eligible individual's marital/domestic-relationship status. This element should be reported by the state when the information is material to eligibility (i.e., institutionalization).
Because there is no specific statutory or regulatory basis for defining marital status codes, they are being defined in a way that is as flexible for states and data users as possible. States can report at whatever level of granularity is available to them in their system and a data user can choose to use them as-is or roll the values up in broader categories depending on whichever approach best meets their needs. CMS periodically reviews the values reported to MARITAL-STATUS-OTHER-EXPLANATION to determine if states are appropriately using it only when there is no existing MARITAL-STATUS value that reflects the state’s marital status description for an individual AND to determine whether it is necessary to add additional T-MSIS MARITAL-STATUS values to reflect commonly used state martial status descriptions for which there is no existing T-MSIS MARITAL-STATUS value.| |
|
03/10/2023
|
3.4.0 |
ELG095
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another.| |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. Do not populate if at the time someone loses Medicaid eligibility they become eligible for and enrolled in CHIP. Also do not populate if at the time someone loses CHIP eligibility they become eligible for and enrolled in Medicaid.| |
|
03/10/2023
|
3.4.0 |
ELG074
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG074|TYPE-OF-LIVING-ARRANGEMENT|A free-form text field to describe the type of living arrangement used for the eligibility determination process. The field will remain a free-form text data element until MACPro develops a list of valid values. When it becomes available, T-MSIS will align with MACPro valid value lists.| |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG074|TYPE-OF-LIVING-ARRANGEMENT|A free-form text field to describe the type of living arrangement used for the eligibility determination process.| |
|
02/17/2023
|
3.3.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
Update the latest OCCURRENCE-CODE |
Code Sets from CMS
UB_04_Data_Files___ALL_CODES_as_of_07_01_2022_FIN__3_.xlsx |
|
06/24/2022
|
3.0.0 |
ELG270/ LOCKED-IN-SRVCS
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
ELG270|LOCKED-IN-SRVCS |X(3)|ELIGIBLE|LOCK-IN-INFORMATION-ELG00009 |
|
08/21/2020
|
2.4.0 |
MANAGED-CARE-PLAN-TYPE (ELG193, MCR024)
|
UPDATE |
Data Dictionary - Valid Values |
|Data Element Name|Valid Value|Description|Effective Date|End Date|
|MANAGED-CARE-PLAN-TYPE|70|Health/Medical Home|01/01/0001|12/31/9999| |
|Data Element Name|Valid Value|Description|Effective Date|End Date|
|MANAGED-CARE-PLAN-TYPE|70|Health/Medical Home|01/01/0001|09/30/2020| |
|
06/24/2022
|
3.0.0 |
CRX167/ INGREDIENT-COST-SUBMITTED
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX167|INGREDIENT-COST-SUBMITTED|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX168/ INGREDIENT-COST-PAID-AMT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX168|INGREDIENT-COST-PAID-AMT|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX169/ DISPENSE-FEE-PAID-AMT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX169|DISPENSE-FEE-PAID-AMT|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX170/ PROFESSIONAL-SERVICE-FEE-SUBMITTED
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX170|PROFESSIONAL-SERVICE-FEE-SUBMITTED|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX171/ PROFESSIONAL-SERVICE-FEE-PAID-AMT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX171|PROFESSIONAL-SERVICE-FEE-PAID-AMT|S9(11)V99|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
05/08/2020
|
2.4.0 |
BEGINNING-DATE-OF-SERVICE (COT033-0003)
|
UPDATE |
Data Dictionary |
The beginning date of service must occur before or be the same as the end of time period. |
The beginning date of service must occur before or be the same as the end of time period for all claims except capitation payments and service tracking payments. |
|
05/08/2020
|
2.4.0 |
BEGINNING-DATE-OF-SERVICE (COT033-0005)
|
UPDATE |
Data Dictionary |
Date must occur before or be the same as adjudication date. |
Date must occur before or be the same as adjudication date for all claims except capitation payments and service tracking payments. |
|
05/08/2020
|
2.4.0 |
ENDING-DATE-OF-SERVICE (COT034-0004)
|
UPDATE |
Data Dictionary |
ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. |
ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE for all claims except capitation payments and service tracking payments |
|
05/08/2020
|
2.4.0 |
ENDING-DATE-OF-SERVICE (COT034-0007)
|
UPDATE |
Data Dictionary |
Date must occur before or be the same as End of Time Period. |
Date must occur before or be the same as End of Time Period for all claims except capitation payments and service tracking payments. |
|
05/08/2020
|
2.4.0 |
BEGINNING-DATE-OF-SERVICE (COT166-0004)
|
UPDATE |
Data Dictionary |
Date must occur before or be the same as adjudication date. |
Date must occur before or be the same as adjudication date for all claims except capitation payments and service tracking payments. |
|
05/08/2020
|
2.4.0 |
ENDING-DATE-OF-SERVICE (COT167-0004)
|
UPDATE |
Data Dictionary |
ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE. |
ENDING-DATE-OF-SERVICE must be on or before the ADJUDICATION-DATE for all claims except capitation payments and service tracking payments |
|
05/08/2020
|
2.4.0 |
ENDING-DATE-OF-SERVICE (COT167-0007)
|
UPDATE |
Data Dictionary |
Date must occur before or be the same as End of Time Period. |
Date must occur before or be the same as End of Time Period for all claims except capitation payments and service tracking payments. |
|
06/19/2020
|
2.4.0 |
XIX-MBESCBES-CATEGORY-OF-SERVICE (COT211)
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Data Element Name|Valid Value|Description |Effective Date |End Date|
|XIX-MBESCBES-CATEGORY-OF-SERVICE (COT211)|45|Health Homes for Substance-Use-Disorder Enrollees per section 1006 of the SUPPORT for Patients and Communities Act|01/01/0001|12/31/9999| |
|
06/24/2022
|
3.0.0 |
CIP249/ REVENUE-CENTER-QUANTITY-ACTUAL
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CIP249|IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
DE No|Data Element Name
CIP249|REVENUE-CENTER-QUANTITY-ACTUAL |
|
06/24/2022
|
3.0.0 |
CIP250/ REVENUE-CENTER-QUANTITY-ALLOWED
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
DE No|Data Element Name
CIP250|REVENUE-CENTER-QUANTITY-ALLOWED |
|
06/24/2022
|
3.0.0 |
CLT202/ REVENUE-CENTER-QUANTITY-ACTUAL
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CLT202|IP-LT-QUANTITY-OF-SERVICE-ACTUAL |
DE No|Data Element Name
CLT202|REVENUE-CENTER-QUANTITY-ACTUAL |
|
06/24/2022
|
3.0.0 |
CLT203/ REVENUE-CENTER-QUANTITY-ALLOWED
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CLT203|IP-LT-QUANTITY-OF-SERVICE-ALLOWED |
DE No|Data Element Name
CLT203|REVENUE-CENTER-QUANTITY-ALLOWED |
|
06/24/2022
|
3.0.0 |
COT184
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT
COT184|OT-RX-CLAIM-QUANTITY-ALLOWED|The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.|For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units.The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. |
|DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT
COT184|SERVICE-QUANTITY-ALLOWED|The maximum allowable quantity of a service that may be rendered per date of service or per month.|For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units.The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. |
|
06/24/2022
|
3.0.0 |
COT183
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
COT183|OT-RX-CLAIM-QUANTITY-ACTUAL |
DE No|Data Element Name
COT183|SERVICE-QUANTITY-ACTUAL |
|
06/24/2022
|
3.0.0 |
COT184
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
COT184|OT-RX-CLAIM-QUANTITY-ACTUAL |
DE No|Data Element Name
COT184|SERVICE-QUANTITY-ALLOWED |
|
06/24/2022
|
3.0.0 |
CRX132
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENT
CRX132|OT-RX-CLAIM-QUANTITY-ACTUAL||The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span.|The value in OT-RX-CLAIM-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE. |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENT
CRX132|PRESCRIPTION-QUANTITY-ACTUAL||The quantity of a drug that is dispensed for a prescription as reported by National Drug Code on the claim line.|The value in PRESCRIPTION-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE. |
|
06/24/2022
|
3.0.0 |
CRX131
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENT
CRX131|OT-RX-CLAIM-QUANITY-ALLOWED||The maximum allowable quantity of a drug or service that may be dispensed per prescription per date of service or per month. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.|NOTE: One prescription for 100 250 milligram tablets results in OT-RX-CLAIM-QUANTITY-ALLOWED =100. |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION |CODING REQUIREMENT
CRX131|PRESCRIPTION-QUANTITY-ALLOWED||The maximum allowable quantity of a drug that may be dispensed per prescription per date of service. Quantity limits are applied to medications when the majority of appropriate clinical utilizations will be addressed within the quantity allowed.|NOTE: One prescription for 100 250 milligram tablets results in PRESCRIPTION-QUANTITY-ALLOWED =100. |
|
06/24/2022
|
3.0.0 |
CRX132
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX132|OT-RX-CLAIM-QUANTITY-ACTUAL |
DE No|Data Element Name
CRX132|PRESCRIPTION-QUANTITY-ACTUAL |
|
06/24/2022
|
3.0.0 |
CRX131
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX131|OT-RX-CLAIM-QUANITY-ALLOWED |
DE No|Data Element Name
CRX131|PRESCRIPTION-QUANTITY-ALLOWED |
|
05/08/2020
|
2.4.0 |
CITIZENSHIP-VERIFICATION-FLAG (ELG041)
|
ADD |
Data Dictionary - Valid Values |
N/A |
This data element conditionally required when the individual is a U.S. Citizen |
|
05/08/2020
|
2.4.0 |
CITIZENSHIP-VERIFICATION-FLAG (ELG041)
|
UPDATE |
Data Dictionary |
Necessity | Required |
Necessity | Conditional |
|
05/29/2020
|
2.4.0 |
UNIT-OF-MEASURE (CRX133)
|
UPDATE |
Data Dictionary |
Code | Description
F2 | International Unit
GR | Gram
ML | Milliliter
ME | Miligram
UN | Unit |
Code | Description
EA | Each
F2 | International Unit
GM | Grams
GR | Gram
ML | Milliliter
ME | Milligram
UN | Unit |
|
05/08/2020
|
2.4.0 |
IMMIGRATION-VERIFICATION-FLAG (ELG043)
|
UPDATE |
Data Dictionary - Valid Values |
Code | Description
1 | Yes |
Code | Description
1 | Enrolled in Medicaid pending citizenship verification |
|
05/08/2020
|
2.4.0 |
IMMIGRATION-VERIFICATION-FLAG (ELG043)
|
UPDATE |
Data Dictionary - Valid Values |
Code | Description
0 | No |
Code | Description
0 |Citizenship Verified |
|
07/31/2020
|
2.4.0 |
DTL-METRIC-DEC-QTY (CRX144)
|
UPDATE |
Data Dictionary |
|Data Element Name|Coding Requirement|
|DTL-METRIC-DEC-QTY|Must be numeric| |
|Data Element Name|Coding Requirement|
|DTL-METRIC-DEC-QTY|Must be numeric. Only populate on compound drug claims. Should pass through the “Compound Ingredient Quantity” from the NCPDP claims form, field 448-ED.| |
|
12/13/2019
|
2.3.0 |
CONCEPTION-TO-BIRTH-IND (ELG094)
|
UPDATE |
Data Dictionary |
The CHIP-CODE must equal “3” (Individual was not Medicaid-Expansion CHIP eligible, but was included in a separate title XXI CHIP program) or “4” (Individual was both Medicaid eligible and Separate CHIP eligible.) |
The CHIP-CODE must equal “3” (Individual was not Medicaid-Expansion CHIP eligible, but was included in a separate title XXI CHIP program). |
|
03/27/2020
|
2.4.0 |
ELG-IDENTIFIERS
|
ADD |
Data Dictionary |
N/A |
Update Data Dictionary document for ELG-IDENTIFIERS segment
Update Data Dictionary Appendices document for ELG-IDENTIFIER-TYPE data element
Update Data Dictionary Data Validation Rule document with all rules of ELG-IDENTIFIERS segment
Update Data Dictionary Record Layout for ELG-IDENTIFIERS
Update Data Dictionary Segment Relationship doc for ELG-IDENTIFIERS |
|
03/27/2020
|
2.4.0 |
REASON-FOR-CHANGE
|
ADD |
Data Dictionary - Valid Values |
N/A |
MERGE - Merge Beneficiaries
UNMERGE - Unmerge Beneficiaries
LSE - Large System Enhancement
TCAM - Transition between CHIP and Medicaid |
|
04/17/2020
|
2.4.0 |
ELG083
|
UPDATE |
Data Dictionary |
If multiple MSIS-CASE-NUMs exist at the state-level, and T-MSIS only allows one Case Number in current T-MSIS DD, please enter the Case Number with the longest eligibility days in that particular month. |
N/A |
|
04/17/2020
|
2.4.0 |
CRX129
|
UPDATE |
Data Dictionary |
Necessity | Required |
Necessity | Conditional |
|
04/17/2020
|
2.4.0 |
COT123
|
UPDATE |
Data Dictionary |
PLACE-OF-SERVICE (COT123): A code indicating where the service was performed. CMS 1500 values are used for this data element. |
PLACE-OF-SERVICE (COT123): A data element corresponding with line 24b on the CMS-1500 that indicates where the services took place. This is a pass-through data element that should not be modified or derived when missing unless otherwise specified. |
|
04/17/2020
|
2.4.0 |
COT123
|
UPDATE |
Data Dictionary |
Coding Requirement | Leave field blank for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122) |
PLACE-OF-SERVICE (COT123): “A data element corresponding with line 24b on the CMS-1500 that indicates where the services took place. This is a pass-through data element that should not be modified or derived when missing unless otherwise specified.” |
|
06/24/2022
|
3.0.0 |
CIP270/ XIX-MBESCBES-CATEGORY-OF-SERVICE
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
X(4) |
SIZE
X(5) |
|
06/24/2022
|
3.0.0 |
CLT224/ XIX-MBESCBES-CATEGORY-OF-SERVICE
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
X(4) |
SIZE
X(5) |
|
06/24/2022
|
3.0.0 |
COT211/ XIX-MBESCBES-CATEGORY-OF-SERVICE
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
X(4) |
SIZE
X(5) |
|
06/24/2022
|
3.0.0 |
CRX150/ XIX-MBESCBES-CATEGORY-OF-SERVICE
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
X(4) |
SIZE
X(5) |
|
05/08/2020
|
2.4.0 |
RESTRICTED-BENEFITS-CODE (ELG097)
|
UPDATE |
Data Dictionary - Valid Values |
Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005. PRTF grants assist States to help provide community alternatives to psychiatric resident treatment facilities for children. |
Individual is eligible for Medicaid and entitled to benefits under the Psychiatric Residential Treatment Facilities Demonstration Grant Program (PRTF), as enacted by the Deficit Reduction Act of 2005. |
|
05/08/2020
|
2.4.0 |
RESTRICTED-BENEFITS-CODE (ELG097)
|
UPDATE |
Data Dictionary - Valid Values |
Individual is eligible for Medicaid or CHIP but only entitled to restricted benefits for pregnancy-related services. |
Individual is eligible for Medicaid or CHIP but is only entitled to restricted benefits for pregnancy-related services, including services that do and those that do not meet the Minimum Essential Coverage standard. |
|
05/08/2020
|
2.4.0 |
RESTRICTED-BENEFITS-CODE (ELG097)
|
UPDATE |
Data Dictionary - Valid Values |
Individual is eligible for Medicaid or Medicaid-Expansion CHIP but, for reasons other than alien, dual-eligibility or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy or other criteria). |
Individual is eligible for Medicaid or Medicaid-Expansion CHIP, but for reasons other than alien, dual-eligibility, or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based upon substance abuse, medically needy, or other criteria) that meet the standard for Minimum Essential Coverage. |
|
05/08/2020
|
2.4.0 |
RESTRICTED-BENEFITS-CODE (ELG097)
|
ADD |
Data Dictionary - Valid Values |
N/A |
Individual is eligible for Medicaid or Medicaid-Expansion CHIP, but for reasons other than alien, dual-eligibility, or pregnancy-related status, is only entitled to restricted benefits (e.g., restricted benefits based on substance abuse, medically needy, or other criteria) that do not meet the standard for Minimum Essential Coverage |
|
03/27/2020
|
2.4.0 |
ELG-IDENTIFIER-TYPE
|
ADD |
Data Dictionary - Valid Values |
N/A |
Identifier Type Name
1 Medicaid Card ID
2 Old MSIS Identification Number |
|
08/21/2020
|
2.4.0 |
MEDICAID-PAID-AMT (COT178)
|
UPDATE |
Data Dictionary - Valid Values |
|DE|Data Element Name|Definition|Coding Requirement|CR NO|
|COT178|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim detail level.| If TYPE-OF-CLAIM = 3, C, W (encounter record) this field should be populated with the amount that the provider billed the managed care plan.|COT178-0001| |
|COT178|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim detail level.|Not Applicable|COT178-0001| |
|
07/10/2020
|
2.4.0 |
PAYMENT-LEVEL-IND (CIP132, CLT082, COT068, CRX058)
|
UPDATE |
Data Dictionary |
|CR NO|Coding Requirement|
|CIP132-0002|Payment fields at either the claim header or line on encounter records should be blank.|
|CLT082-0002|Payment fields at either the claim header or line on encounter records should be blank.|
|COT068-0002|Payment fields at either the claim header or line on encounter records should be blank.|
|CRX058-0002|Payment fields at either the claim header or line on encounter records should be blank.| |
|CR NO|Coding Requirement|
|CIP132-0002|Not Applicable|
|CLT082-0002|Not Applicable|
|COT068-0002|Not Applicable|
|CRX058-0002|Not Applicable| |
|
05/08/2020
|
2.4.0 |
TYPE-OF-CLAIM
|
UPDATE |
Data Dictionary - Valid Values |
Code | Description
Z | Denied Claimes |
N/A |
|
04/17/2020
|
2.4.0 |
RESTRICTED-BENEFITS-CODE
ELG097
|
ADD |
Data Dictionary - Valid Values |
N/A |
Data Element Name| DE ID| Code| Description| Effective Date| End Date|
RESTRICTED-BENEFITS-CODE| ELG097| F| Individual is eligible for Medicaid but is only entitled to restricted benefits for medical assistance for COVID-19 diagnostic products and any visit described as a COVID–19 testing-related service for which payment may be made under the State plan during any portion of the public health emergency period, beginning March 18, 2020 as described in Sections 1902(a)(10)(A)(ii)(XXIII), 1902(ss) and clause XVIII in the matter following 1902(a)(10)(G) of the Social Security Act.| 3/18/2020| 12/31/9999| |
|
04/17/2020
|
2.4.0 |
PROGRAM-TYPE
CIP129, CLT079, COT065, CRX055
|
ADD |
Data Dictionary - Valid Values |
N/A |
Data Element Name| DE ID| Code| Description| Effective Date| End Date|
PROGRAM-TYPE| CIP129, CLT079, COT065, CRX055| 17| COVID-19 Testing Services (1905(a)(3) and 2103(c))| 3/18/2020| 12/31/9999| |
|
04/17/2020
|
2.4.0 |
TYPE-OF-SERVICE
CIP257, CLT211, COT186, CRX134
|
ADD |
Data Dictionary - Valid Values |
N/A |
Data Element Name| DE ID| Code| Description| Effective Date| End Date|
TYPE-OF-SERVICE| CIP257, CLT211, COT186, CRX134
| 136| In vitro diagnostic products (as defined in section 809.3(a) of title 21, Code of Federal Regulations) administered during any portion of the emergency period defined in paragraph (1)(B) of section 1135(g) beginning on or after the date of the enactment of this subparagraph for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, and the administration of such in vitro diagnostic products| 3/18/2020| 12/31/9999|
TYPE-OF-SERVICE| CIP257, CLT211, COT186, CRX134
| 137| COVID–19 testing-related services|3/18/2020| 12/31/9 999| |
|
04/17/2020
|
2.4.0 |
BENEFIT-TYPE
CIP268, CLT218, COT209, CRX148
|
ADD |
Data Dictionary - Valid Values |
N/A |
Data Element Name| DE ID |Code |Description| Effective Date| End Date|
BENEFIT-TYPE |CIP268, CLT218, COT209, CRX148| 107| In vitro diagnostic products (as defined in section 809.3(a) of title 21, Code of Federal Regulations) administered during any portion of the emergency period defined in paragraph (1)(B) of section 1135(g) beginning on or after the date of the enactment of this subparagraph for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, and the administration of such in vitro diagnostic products| 3/18/2020| 12/31/9999|
BENEFIT-TYPE| CIP268, CLT218, COT209, CRX148| 108| COVID–19 testing-related s ervices| 3/18/2020| 12/31/9999| |
|
04/17/2020
|
2.4.0 |
ELIGIBILITY-GROUP
ELG087
|
ADD |
Data Dictionary - Valid Values |
N/A |
Data Element Name| DE ID| Code| Description| Effective Date| End Date|
ELIGIBILITY-GROUP| ELG087| 76| Uninsured Individual eligible for COVID-19 testing| 3/18/2020| 12/31/9999| |
|
07/10/2020
|
2.4.0 |
VETERAN-IND (ELG039)
|
UPDATE |
Data Dictionary |
|Definition|Necessity|Coding Requirement|
|A flag indicating if the individual served in the active military, naval or air service|Required|Value must be equal to a valid value.| |
|Definition|Necessity|Coding Requirement|
A flag indicating if a non-citizen is exempt from the 5-year bar on benefits because they are a veteran or an active member of the military, naval or air service|Conditional|this field should only be populated for beneficiaries who have a non-citizen IMMIGRATION-STATUS (i.e., IMMIGRATION-STATUS = “1”, “2”, or “3”).| |
|
12/04/2020
|
2.4.0 |
OCCURRENCE-CODE-01 to OCCURRENCE-CODE-10
|
UPDATE |
Data Dictionary |
OCCURRENCE-CODE-01 to OCCURRENCE-CODE-10
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1104cp.pdf |
OCCURRENCE-CODE-01 to OCCURRENCE-CODE-10
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1795A3.pdf |
|
07/10/2020
|
2.4.0 |
AFFILIATED-PROGRAM-TYPE (PRV119)
|
UPDATE |
Data Dictionary - Valid Values |
|Data Element Name|Valid Value|Description|Effective Date|End Date|
|AFFILIATED-PROGRAM-TYPE|1|Health Plan (NHP-ID) – The value in the AFFILIATED-PROGRAM-ID data element contains the National Health Plan Identifier of health plan in which the provider is enrolled to provide services including through the state plan and a waiver.|01/01/0001|12/31/9999| |
N/A |
|
09/11/2020
|
2.4.0 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT (CIP 269, CLT 219, COT 210, CRX 149)
|
UPDATE |
Data Dictionary - Valid Values |
|Code|Description|Effective Date|End Date|
|03|Federal funding under ACA|00010101|99991231| |
|Code|Description|Effective Date|End Date|
|03|Federal funding under ACA|00010101|20200430| |
|
06/24/2022
|
3.0.0 |
CRX141/ DISPENSE-FEE-SUBMITTED
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX141|DISPENSE-FEE |
DE No|Data Element Name
CRX141|DISPENSE-FEE-SUBMITTED |
|
06/24/2022
|
3.0.0 |
CRX162/ PRESCRIPTION-ORIGIN-CODE
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX162|PRESCRIPTION-ORIGIN-CODE|X(1)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
09/11/2020
|
2.4.0 |
PROV-CLASSIFICATION-CODE
|
UPDATE |
Data Dictionary - Valid Values |
|Code|Current DDv2.3 definition|
|62|Psychologist, Clinical|
|68|Psychologist, Clinical| |
|Code|definition|
|62|Psychologist (Billing Independently)|
|68|Clinical Psychologist| |
|
09/11/2020
|
2.4.0 |
MANAGED-CARE-PLAN-TYPE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Code|Description|
|19|Individual is enrolled in Long-Term Services & Supports (LTSS) and Mental Health (MH) PIHP|
|20|Other| |
|
09/11/2020
|
2.4.0 |
MANAGED-CARE-PLAN-TYPE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Code|Description|Effective Date|End Date|
|19|Individual is enrolled in Long-Term Services & Supports (LTSS) and Mental Health (MH) PIHP|00010101|99991231| |
|
09/11/2020
|
2.4.0 |
CIP254,
CLT208, COT178, CRX125
|
UPDATE |
Data Dictionary |
Current Coding Requirement:
For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. |
Proposed Coding requirement:
For claims where Medicaid payment is only available at the header level, report the entire payment amount on the MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim. |
|
10/02/2020
|
2.4.0 |
LINE-NUM-ADJ
LINE-ADJUSTMENT-IND
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Coding Requirement|CR No|
|CIP238|LINE-NUM-ADJ|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.
Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number. |Not Applicable|
|CIP239|LINE-ADJUSTMENT-IND|If there is a line adjustment number, then there must be a line-adjustment indicator.|CIP239-0002|
|CLT191|LINE-NUM-ADJ|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.
Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.|CLT191-0002|
|CLT192|LINE-ADJUSTMENT-IND|If there is a line adjustment number, then there must be a line-adjustment indicator.|CLT192-0002|
|CLT192|LINE-ADJUSTMENT-IND|If there is a line adjustment reason, then there must be a line adjustment indicator.|CLT192-0003
|COT161|LINE-NUM-ADJ|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.
Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.|COT161-0002|
|COT162|LINE-ADJUSTMENT-IND|If there is a line adjustment number, then there must be a line-adjustment indicator.|COT162-0002|
|COT162|LINE-ADJUSTMENT-IND|If there is a line adjustment reason, then there must be a line adjustment indicator.|COT162-003|
|CRX115|LINE-NUM-ADJ|This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.
Otherwise, if there is a line adjustment indicator, then there should be a line adjustment number.|CRX115-002|
|CRX116|LINE-ADJUSTMENT-IND|If there is a line adjustment number, then there must be a line-adjustment indicator.|CRX116-002| |
|DE No|Data Element Name|Coding Requirement|CR No|
|CIP238|LINE-NUM-ADJ|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.|Not Applicable|
|CIP239|LINE-ADJUSTMENT-IND|Not Applicable.|CIP239-0002|
|CLT191|LINE-NUM-ADJ|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.|CLT191-0002|
|CLT192|LINE-ADJUSTMENT-IND|Not Applicable.|CLT192-0002|
|CLT192|LINE-ADJUSTMENT-IND|Not Applicable.|CLT192-0003
|COT161|LINE-NUM-ADJ|This field should be left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.|COT161-0002|
|COT162|LINE-ADJUSTMENT-IND|Not Applicable.|COT162-0002|
|COT162|LINE-ADJUSTMENT-IND|Not Applicable.|COT162-003|
|CRX115|LINE-NUM-ADJ|This field should be 8-filled, left blank or space-filled if the ADJUSTMENT-INDICATOR = 0.|CRX115-002|
|CRX116|LINE-ADJUSTMENT-IND|Not Applicable.|CRX116-002| |
|
09/11/2020
|
2.4.0 |
PROV-CLASSIFICATION-CODE
|
UPDATE |
Data Dictionary - Valid Values |
|Code|Definition|
|62|Psychologist, Clinical|
|68|Psychologist, Clinical| |
|Code|Definition|
|62|Psychologist (Billing Independently)|
|68|Clinical Psychologist| |
|
11/13/2020
|
2.4.0 |
ELG156-0003
|
UPDATE |
Data Dictionary |
If a complete, valid end date is not available or is unknown, leave blank, or space-fill". |
N/A |
|
06/24/2022
|
3.0.0 |
CIP290/ BEGINNING-DATE-OF-SERVICE
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP290|BEGINNING-DATE-OF-SERVICE|9(8)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP291
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP291|ENDING-DATE-OF-SERVICE|Mandatory|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. For capitation premium payments, the date on
which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.|Value must be 8 characters in the form "CCYYMMDD"
The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value
Value must be greater than or equal to associated Beginning Date of Service value
When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value
Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
Value must be equal to or greater than associated Date of Birth (ELG.002.024) value|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP291/ ENDING-DATE-OF-SERVICE
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP291| ENDING-DATE-OF-SERVICE|9(8)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
11/13/2020
|
2.4.0 |
PROCEDURE-CODE-MOD
|
UPDATE |
Data Dictionary - Valid Values |
|Valid Value|Effective Date|End Date|Value|Name|Description|
|PROCEDURE-CODE-MOD|20170101|99991231|PO|Excepted off-campus service|Excepted service provided at an off-campus, outpatient, provider-based department of a hospital| |
|Valid Value|Effective Date|End Date|Value|Name|Description|
|PROCEDURE-CODE-MOD|20150101|99991231|PO|Excepted off-campus service|Excepted service provided at an off-campus, outpatient, provider-based department of a hospital| |
|
10/02/2020
|
2.4.0 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT (CIP 269, CLT 219, COT 210, CRX 149)
|
UPDATE |
Data Dictionary - Valid Values |
|Code|Description|Effective Date|End Date|
|03|Federal funding under ACA|00010101|20200430| |
|Code|Description|Effective Date|End Date|
|03|Federal funding under ACA|00010101|20200930| |
|
11/13/2020
|
2.4.0 |
NEW-REFILL-IND
|
UPDATE |
Data Dictionary - Valid Values |
N/A |
|Valid Value|Effective Date| End Date|Code|Description|
|NEW-REFILL-IND|00010101|99991231|99|Number of Refill(s)| |
|
12/04/2020
|
2.4.0 |
TYPE-OF-SERVICE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|*VALUE_SET_ID*|*EFFECTIVE_DATE*|*END_DATE*|*VALUE*|*NAME*|*DESCRIPTION*|
|TYPE-OF-SERVICE| 20201001|99991231|145|Medication Assisted Treatment (MAT) services and drugs for evidenced-based treatment of Opioid Use Disorder (OUD) in accordance with section 1905(a)(29) of the Social Security Act|Effective October 1, 2020, state Medicaid programs are required to provide coverage of Medication Assisted Treatment (MAT) services and drugs under a new mandatory benefit. The SUPPORT Act of 2018 (P.L. 115-271) amended the Social Security Act (the Act) to add this new mandatory benefit. The purpose of the new mandatory MAT benefit found at section 1905(a)(29) of the Act is to increase access to evidenced-based treatment for Opioid Use Disorder (OUD) for all Medicaid beneficiaries and to allow patients to seek the best course of treatment and particular medications that may not have been previously covered.
CMS interprets sections 1905(a)(29) and 1905(ee) of the Act to require that, as of October 1, 2020, states must include as part of the new MAT mandatory benefit all forms of drugs and biologicals that the Food and Drug Administration (FDA) has approved or licensed for MAT to treat OUD. More specifically, under the new mandatory MAT benefit, states are required to cover such FDA approved or licensed drugs and biologicals used for indications for MAT to treat OUD. States currently cover many of these MAT drugs and biologicals (for all medically-accepted indications) under the optional benefit for prescribed drugs described at section 1905(a)(12) of the Act.|
TYPE-OF-SERVICE value ‘145’ is applicable to the T-MSIS OT and RX files. Section 1905(a)(29) of the Social Security Act stipulates that the benefit applies to the period of October 1, 2020 through September 30, 2025, however states may continue to adjudicate and submit claims to T-MSIS for this type of service beyond September 30, 2025 for dates of service prior to September 30, 2025. This value may be end-dated at some point in the future after it is clear that there will be no more claims submitted to T-MSIS with it. State T-MSIS team members are encouraged to reach out to their state policy experts to determine how this type of service has been incorporated into the state’s Medicaid program. |
|
12/04/2020
|
2.4.0 |
HCPCS-RATE (COT220)
|
UPDATE |
Data Dictionary |
|Definition|Necessity|Coding Requirement|
|For outpatient hospital facility claims, HCPCS/CPT is captured here. This data element is expected to capture data from HIPAA 837I claim loop 2400 SV202 or UB-04 FL 44 (only if the value represents a HCPCS/CPT). If HCPCS-RATE is populated then PROCEDURE-CODE should not be populated.|Conditional|Value must be equal to a valid value.| |
|Definition|Necessity|Coding Requirement|
|Not to be populated|Not Applicable|Do not populate| |
|
12/04/2020
|
2.4.0 |
TOT-BILLED-AMT
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|CIP112 |TOT-BILLED-AMT| Not Applicable |Not Applicable |If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000".|
|CLT063 |TOT-BILLED-AMT| Not Applicable |Not Applicable |If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000".|
|COT048 |TOT-BILLED-AMT| Not Applicable |Not Applicable |If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000".|
|CRX039 |TOT-BILLED-AMT| Not Applicable |Not Applicable |If TYPE-OF-CLAIM = "4", then TOT-BILLED-AMT must = "00000000".| |
N/A |
|
12/04/2020
|
2.4.0 |
439-E4 (Reason For Service Code)
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Valid Value|Effective Date|End Date|Value|Description|
|Drug-Utilization-Code-E4|00010101|99991231|TD|Therapeutic - Code indication that a simultaneous use of different primary generic chemical entities that have the same therapeutic effect was detected.|
|Drug-Utilization-Code-E4|00010101|99991231|SR|Suboptimal Regimen - Code indicating incorrect, inappropriate, or less than optimal dosage regimen specified for the drug in question.| |
|
03/19/2021
|
3.0.0 |
TYPE-OF-SERVICE
|
UPDATE |
Data Dictionary - Valid Values |
N/A |
|Data Element|Effective Date|End Date|Value|Name|
|TYPE-OF-SERVICE|00010101|99991231|146|Inpatient Psychiatric Services for beneficiaries between the ages of 22 and 64 who receive services in an institution for mental disease (IMD)| |
|
06/24/2022
|
3.0.0 |
COT228/ ORDERING-PROV-NUM
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT228|ORDERING-PROV-NUM|X(30)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT229/ ORDERING-PROV-NPI-NUM
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT229|ORDERING-PROV-NPI-NUM|X(10)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
12/04/2020
|
2.4.0 |
CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT (CIP269-0002, CLT219-0002, COT210-0002, CRX149-0002)
|
UPDATE |
Data Dictionary |
CIP269-0002 : If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI.
CLT219-0002: If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI.
COT210-0002: If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI.
CRX149-0002: If an individual is not eligible for S-CHIP, then any associated claims records should not have reimbursed with federal funding under Title XXI. |
CIP269: (federal Funding under Title XXI) if value equals ‘02’, then the eligible’s CHIP Code (ELG.003.054) must be in ['2', '3']
CLT219: (federal Funding under Title XXI) if value equals ‘02’, then the eligible’s CHIP Code (ELG.003.054) must be in ['2', '3']
COT210: (federal Funding under Title XXI) if value equals ‘02’, then the eligible’s CHIP Code (ELG.003.054) must be in ['2', '3']
CRX149: I(federal Funding under Title XXI) if value equals ‘02’, then the eligible’s CHIP Code (ELG.003.054) must be in ['2', '3'] |
|
12/04/2020
|
2.4.0 |
CIP177-0003, CLT128-0003, COT110-0003, and CRX068-0004
|
UPDATE |
Data Dictionary |
coding requirements say: "An ineligible individual cannot have a category for federal reimbursement for Medicaid or CHIP (CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT <> 01,02)" |
N/A |
|
01/27/2021
|
3.0.0 |
PROCEDURE-CODE-FLAG
|
UPDATE |
Data Dictionary - Valid Values |
ICD-10 - CM PCS |
ICD-10 - PCS |
|
08/13/2021
|
3.0.0 |
OPERATING-AUTHORITY (MCR067)
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|OPERATING-AUTHORITY|00010101|99991231|16|Concurrent 1915(a)/1915(j) - programs, or portions thereof, operating under both 1915(a) and 1915(j) authorities|
|OPERATING-AUTHORITY|00010101|99991231|17|Concurrent 1932(a)/1915(j) - programs, or portions thereof, operating under both 1932(a) and 1915(j) authorities|
|OPERATING-AUTHORITY|00010101|99991231|18|Concurrent 1915(b)/1915(j) - programs, or portions thereof, operating under both 1915(b) and 1915(j) authorities|
|OPERATING-AUTHORITY|00010101|99991231|19|Concurrent 1115/1915(j) - programs, or portions thereof, operating under both 1115 and 1915(j) authorities|
|OPERATING-AUTHORITY|00010101|99991231|20|Concurrent 1915(a)/1915(k) - programs, or portions thereof, operating under both 1915(a) and 1915(k) authorities|
|OPERATING-AUTHORITY|00010101|99991231|21|Concurrent 1932(a)/1915(k) - programs, or portions thereof, operating under both 1932(a) and 1915(k) authorities|
|OPERATING-AUTHORITY|00010101|99991231|22|Concurrent 1915(b)/1915(k) - programs, or portions thereof, operating under both 1915(b) and 1915(k) authorities|
|OPERATING-AUTHORITY|00010101|99991231|23|Concurrent 1115/1915(k) - programs, or portions thereof, operating under both 1115 and 1915(k) authorities| |
|
06/24/2022
|
3.0.0 |
STATE-SPEC-ELIG-GROUP
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|CODING REQUIREMENT|
ELG093|STATE-SPEC-ELIG-GROUP|If value is in the range [ 000000 .. 999999 ], then associated Date of Death value must not be before the start of the reporting period.| |
DE No|Data Element Name|CODING REQUIREMENT|
ELG093|STATE-SPEC-ELIG-GROUP|| |
|
05/13/2022
|
3.0.0 |
ELG087
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|
ELG087|ELIGIBILITY-GROUP|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE=7 and STATE-PLAN-OPTION-TYPE="06". |
DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|
ELG087|ELIGIBILITY-GROUP|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7". |
|
05/13/2022
|
3.0.0 |
ELG097
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|
ELG097|RESTRICTED-BENEFITS-CODE|| |
DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|
ELG097|RESTRICTED-BENEFITS-CODE|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7".| |
|
05/13/2022
|
3.0.0 |
ELG163
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|
ELG163|STATE-PLAN-OPTION-TYPE|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with RESTRICTED-BENEFITS-CODE=7 and STATE-PLAN-OPTION-TYPE="06”.| |
DE NO| DATA ELEMENT NAME|CODING REQUIREMENT|
ELG163|STATE-PLAN-OPTION-TYPE|Beneficiaries reported with ELIGIBILITY-GROUP="72", "73", "74", "75" are expected to be covered by an alternative benefit plan and should be reported with STATE-PLAN-OPTION-TYPE="06” and either RESTRICTED-BENEFITS-CODE=”1” or "7".| |
|
02/26/2021
|
3.0.0 |
XIX-MBESCBES-CATEGORY-OF-SERVICE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Valid Value ID|Effective Date|End Date|Value|Description|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46|OUD Medicaid Assisted Treatment – Drugs|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46A1| OUD MAT DRUG REBATE/National Agreement|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46A2|OUD MAT DRUG REBATE/State Sidebar|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46A3| OUD MAT DRUG REBATE MCO /National Agreement|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46A4| OUD MAT DRUG REBATE MCO /State Sidebar|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46A5| OUD MAT DRUG REBATE/Increased ACA Offset Fee for Service - 100%|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46A6| OUD MAT DRUG REBATE/Increased ACA Offset MCO – 100%|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20201001|99991231|46B| OUD Medicaid Assisted Treatment Services| |
|
05/13/2022
|
3.0.0 |
COT123
|
UPDATE |
Data Dictionary - Valid Values |
Replace VVL.178 - Place of Service Code List |
https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set |
|
02/26/2021
|
3.0.0 |
IMMIGRATION-VERIFICATION-FLAG
|
UPDATE |
Data Dictionary - Valid Values |
|Value ID|Value|Description|
|IMMIGRATION-VERIFICATION-FLAG|0|No|
|IMMIGRATION-VERIFICATION-FLAG|1|Yes| |
|Value ID|Value|Description|
|IMMIGRATION-VERIFICATION-FLAG|0|Immigration Status Verified|
|IMMIGRATION-VERIFICATION-FLAG|1|Enrolled in Medicaid pending immigration verification| |
|
06/24/2022
|
3.0.0 |
CIP107/ ALLOWED-CHARGE-SRC
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP107|ALLOWED-CHARGE-SRC| X(1)|CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 |
N/A |
|
02/26/2021
|
3.0.0 |
RECORD-ID
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|DESCRIPTION|
|RECORD-ID|00010101|99991231|ELG00022|ELG-IDENTIFIERS| |
|
02/26/2021
|
3.0.0 |
TYPE-OF-HOSPITAL
|
UPDATE |
Data Dictionary - Valid Values |
|Value ID|Effective Date|End Date|Value|Description|
|TYPE-OF-HOSPITAL|0010101|99991231|99|Unknown| |
*End date valid value '99'* |
|
02/26/2021
|
3.0.0 |
AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR|00010101|99991231|0|Not applicable| |
|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR|00010101|99991231|1|No, Individual does not have CDIB| |
|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR|00010101|20200214|2|Yes, Individual does have CDIB| | |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR|00010101|99991231|0|Individual does not meet the definition of an American Indian/Alaska Native.| |
|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR|00010101|99991231|1|Individual meets the definition of an American Indian/Alaska Native.| |
No update is required for value '2'. This value is end dated on 2/24/2020. |
|
02/26/2021
|
3.0.0 |
CITIZENSHIP-VERIFICATION-FLAG
|
UPDATE |
Data Dictionary - Valid Values |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|CITIZENSHIP-VERIFICATION-FLAG|00010101|99991231|0|No| |
|CITIZENSHIP-VERIFICATION-FLAG|00010101|99991231|1|Yes| | |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|CITIZENSHIP-VERIFICATION-FLAG|00010101|99991231|0|Citizenship Verified| |
|CITIZENSHIP-VERIFICATION-FLAG|00010101|99991231|1|Enrolled in Medicaid pending citizenship verification| | |
|
06/24/2022
|
3.0.0 |
PRV110/ SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
X(12) |
SIZE
X(30) |
|
03/19/2021
|
3.0.0 |
ELIGIBILITY-GROUP
|
UPDATE |
Data Dictionary - Valid Values |
|Data Element|Effective Date|End Date|Value|Name|
|ELIGIBILITY-GROUP|00010101|99991231|10|Non-pregnant individuals aged 19 through 64, not otherwise mandatorily eligible, with income at or below 133% FPL.| |
N/A |
|
03/19/2021
|
3.0.0 |
XIX-MBESCBES-CATEGORY-OF-SERVICE
|
UPDATE |
Data Dictionary - Valid Values |
|Data Element|Effective Date|End Date|Value|Name|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|50|Total| |
N/A |
|
03/19/2021
|
3.0.0 |
XXI-MBESCBES-CATEGORY-OF-SERVICE
|
UPDATE |
Data Dictionary - Valid Values |
|Data Element|Effective Date|End Date|Value|Name|
|XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|48|Balance|
|XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|49|Less: Collections|
|XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|50|Total| |
N/A |
|
04/09/2021
|
3.0.0 |
CHIP-CODE (ELG054)
|
UPDATE |
Data Dictionary |
CHIP-CODE (ELG054) v2.3 Definition:
A code used to distinguish among Medicaid, Medicaid Expansion, and Separate CHIP populations |
A code used to distinguish among Medicaid, Medicaid Expansion CHIP, and Separate CHIP populations |
|
04/30/2021
|
3.0.0 |
DIAGNOSIS-POA-FLAG
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
DIAGNOSIS-POA-FLAG|00010101|99991231|N|Diagnosis was not present at time of inpatient admission|
DIAGNOSIS-POA-FLAG|00010101|99991231|U|Documentation insufficient to determine if condition was present at the time of inpatient admission|
DIAGNOSIS-POA-FLAG|00010101|99991231|W|Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.|
DIAGNOSIS-POA-FLAG|00010101|99991231|Y|Diagnosis was present at time of inpatient admission| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
DIAGNOSIS-POA-FLAG|00010101|99991231|N|Diagnosis was not present at time of inpatient admission|
DIAGNOSIS-POA-FLAG|00010101|99991231|U|Documentation insufficient to determine if condition was present at the time of inpatient admission|
DIAGNOSIS-POA-FLAG|00010101|99991231|W|Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.|
DIAGNOSIS-POA-FLAG|00010101|99991231|Y|Diagnosis was present at time of inpatient admission|
DIAGNOSIS-POA-FLAG|00010101|99991231|1|Unreported/Not used. Exempt from POA reporting.| |
|
04/09/2021
|
3.0.0 |
MEDICAID-BASIS-OF-ELIGIBILITY
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
MEDICAID-BASIS-OF-ELIGIBILITY|00010101|99991231|00|Individual was not eligible for Medicaid at any time during the month| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
MEDICAID-BASIS-OF-ELIGIBILITY|00010101|99991231|00|Individual was not eligible for Medicaid (or Medicaid-expansion CHIP) at any time during the month, and Individual was eligible for separate CHIP| |
|
04/30/2021
|
3.0.0 |
DRUG-UTILIZATION-CODE
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|SC|Suboptimal Compliance|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|SD|Suboptimal Drug/Indication|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|SE|Side Effect|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|SF|Suboptimal Dosage Form|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|SX|Drug-Gender|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|TN|Laboratory Test Needed|
DRUG-UTILIZATION-CODE-E4|00010101|99991231|TP|Payer/Processor Question| |
|
04/30/2021
|
3.0.0 |
XIX-MBESCBES-CATEGORY-OF-SERVICE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Valid Value|Effective Date|End Date|Name|
|2C|00010101|99991231|Certified Community Behavior Health Clinic Payments|
|18A5|00010101|99991231|Medicaid MCO - Certified Community Behavior Health Clinic Payments|
|18B1e|00010101|99991231|Medicaid PAHP - Certified Community Behavior Health Clinic Payments|
|18B2e|00010101|99991231|Medicaid PIHP - Certified Community Behavior Health Clinic Payments|
|46|00010101|99991231|OUD Medicaid Assisted Treatment – Drugs|
|46A1|00010101|99991231|OUD MAT DRUG REBATE/National Agreement|
|46A2|00010101|99991231|OUD MAT DRUG REBATE/State Sidebar|
|46A3|00010101|99991231|OUD MAT DRUG REBATE MCO /National Agreement|
|46A4|00010101|99991231|OUD MAT DRUG REBATE MCO /State Sidebar|
|46A5|00010101|99991231|OUD MAT DRUG REBATE/Increased ACA Offset Fee for Service - 100%|
|46A6|00010101|99991231|OUD MAT DRUG REBATE/Increased ACA Offset MCO – 100%|
|46B|00010101|99991231|OUD Medicaid Assisted Treatment Services| |
|
05/13/2022
|
3.0.0 |
CIP202, CLT144, COT126, CRX081
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME|DEFINITION|
CIP202|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.|
CLT144|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.|
COT126|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.|
CRX081|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount. The RA number is not the check number.| |
DE NO| DATA ELEMENT NAME|DEFINITION|
CIP202|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|
CLT144|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|
COT126|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|
CRX081|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.| |
|
04/30/2021
|
3.0.0 |
PROCEDURE-CODE-FLAG
|
UPDATE |
Data Dictionary - Valid Values |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|PROCEDURE-CODE-FLAG|00010101|99991231|06|HCPCS (Both National and Regional HCPCS)| |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|PROCEDURE-CODE-FLAG|00010101|99991231|06|HCPCS Level II and CDT| |
|
06/24/2022
|
3.0.0 |
CLAIM-STATUS-CATEGORY
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Coding Requirement|
|CIP103,CLT.055,COT.040,CRX.031|CLAIM-STATUS-CATEGORY|(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2" |
|DE No|Data Element Name|Coding Requirement|
|CIP103,CLT055,COT040,CRX031|CLAIM-STATUS-CATEGORY|(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2" |
|
05/13/2022
|
3.0.0 |
CRX144
|
UPDATE |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX144|DTL-METRIC-DEC-QTY|Conditional|Metric decimal quantity of the product with the appropriate unit of measure (each, gram, or milliliter).|1. Value must be numeric, 2. Value may include up to 7 digits to the left of the decimal point, and 3 digits to the right, e.g. 1234567.890, 3. Value must be populated when Compound Drug Indicator (CRX.002.086) equals 1, 4.Conditional|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
05/13/2022
|
3.0.0 |
CRX098
|
UPDATE |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX098|THIRD-PARTY-COINSURANCE-AMOUNT-PAID|Optional|The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.|1. Value must be between -99999999999.99 and 99999999999.99, 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50 ), 3.Optional|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
12/17/2021
|
3.0.0 |
PRIMARY-LANGUAGE-CODE (ELG046)
|
UPDATE |
Data Dictionary |
|DE NO|DEFINITION|
|ELG046|A code indicating the language the individual speaks other than English at home.| |
|DE NO|DEFINITION|
|ELG046|A code indicating the language that is the individuals' preferred spoken or written language.| |
|
06/24/2022
|
3.0.0 |
CIP201/ BMI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP201|BMI|S9(5)V9|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT143/ BMI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT143|BMI|S9(5)V9|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT125/ BMI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT125|BMI|S9(5)V9|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CRX103/ DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX103|DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-RX-CRX00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT220/ HCPCS-RATE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT220|HCPCS-RATE|X(14)|CLAIMOT|CLAIM-LINE-RECORD-OT-COT00003 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP131/ NATIONAL-HEALTH-CARE-ENTITY-ID
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP131|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT081/ NATIONAL-HEALTH-CARE-ENTITY-ID
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT081|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT067/ NATIONAL-HEALTH-CARE-ENTITY-ID
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT067|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CRX057/ NATIONAL-HEALTH-CARE-ENTITY-ID
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX057|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CRX078/ PRESCRIBING-PROV-SPECIALTY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX078|PRESCRIBING-PROV-SPECIALTY|X(2)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CRX076/ PRESCRIBING-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX076|PRESCRIBING-PROV-TAXONOMY|X(12)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CRX077/ PRESCRIBING-PROV-TYPE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX077|PRESCRIBING-PROV-TYPE|X(2)|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP253/ TPL-AMT
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP253|TPL-AMT|S9(11)V99 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT137/ REFERRING-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT137|REFERRING-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT138/ REFERRING-PROV-TYPE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT138|REFERRING-PROV-TYPE|X(2)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT139/ REFERRING-PROV-SPECIALTY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT139|REFERRING-PROV-SPECIALTY|X(2)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT169/ UNDER-DIRECTION-OF-PROV-NPI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT169|UNDER-DIRECTION-OF-PROV-NPI|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT170/ UNDER-DIRECTION-OF-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT170|UNDER-DIRECTION-OF-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT171/ UNDER-SUPERVISION-OF-PROV-NPI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT171|UNDER-SUPERVISION-OF-PROV-NPI|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT172/ UNDER-SUPERVISION-OF-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT172|UNDER-SUPERVISION-OF-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP193/ REFERRING-PROV-SPECIALTY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP193|REFERRING-PROV-SPECIALTY|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT121/ REFERRING-PROV-SPECIALTY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT121|REFERRING-PROV-SPECIALTY|X(2)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP191/ REFERRING-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP191|REFERRING-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT119/ REFERRING-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT119|REFERRING-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP192/ REFERRING-PROV-TYPE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP192|REFERRING-PROV-TYPE|X(2)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT120/ REFERRING-PROV-TYPE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT120|REFERRING-PROV-TYPE|X(2)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP262/ SERVICING-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP262|SERVICING-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT214/ SERVICING-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT214|SERVICING-PROV-TAXONOMY|X(12)|CLAIMLT|CLAIM-LINE-RECORD-LT-CLT00003 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP224/ UNDER-DIRECTION-OF-PROV-NPI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP224|UNDER-DIRECTION-OF-PROV-NPI|X(10)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT148/ UNDER-DIRECTION-OF-PROV-NPI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT148|UNDER-DIRECTION-OF-PROV-NPI|X(10)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP225/ UNDER-DIRECTION-OF-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP225|UNDER-DIRECTION-OF-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT149/ UNDER-DIRECTION-OF-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT149|UNDER-DIRECTION-OF-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP226/ UNDER-SUPERVISION-OF-PROV-NPI
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP226|UNDER-SUPERVISION-OF-PROV-NPI|X(10)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP227/ UNDER-SUPERVISION-OF-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP227|UNDER-SUPERVISION-OF-PROV-TAXONOMY|X(12)|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT151/ UNDER-SUPERVISION-OF-PROV-TAXONOMY
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT151|UNDER-SUPERVISION-OF-PROV-TAXONOMY|X(12)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
ELG194/ NATIONAL-HEALTH-CARE-ENTITY-ID
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
ELG194|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|ELIGIBLE|MANAGED-CARE-PARTICIPATION-ELG00014 |
N/A |
|
06/24/2022
|
3.0.0 |
ELG195/ NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
ELG195|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE|X(1)|ELIGIBLE|MANAGED-CARE-PARTICIPATION-ELG00014 |
N/A |
|
06/24/2022
|
3.0.0 |
TPL092/ NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
TPL092|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE|X(1)|TPL|TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
N/A |
|
06/24/2022
|
3.0.0 |
TPL093/ NATIONAL-HEALTH-CARE-ENTITY-ID
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
TPL093|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|TPL|TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
N/A |
|
06/24/2022
|
3.0.0 |
TPL094/ NATIONAL-HEALTH-CARE-ENTITY-NAME
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
TPL094|NATIONAL-HEALTH-CARE-ENTITY-NAME|X(50)|TPL|TPL-ENTITY-CONTACT-INFORMATION-TPL00006 |
N/A |
|
05/13/2022
|
3.0.0 |
CIP184, CLT006, COT006, CRX006, ELG006, MCR006, PRV006, TPL006, CIP127, CLT077, COT063, CRX054, ELG111, TPL044, TPL045, CIP093, CIP088, PRV043, PRV064, PRV076, PRV129, COT191
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME|NECESSITY|
CIP184|ADMITTING-PROV-NPI-NUM||
CLT006|FILE-NAME||
CRX006|FILE-NAME||
ELG006|FILE-NAME||
MCR006|FILE-NAME||
PRV006|FILE-NAME||
TPL006|FILE-NAME||
CIP127|FUNDING-SOURCE-NONFEDERAL-SHARE||
CLT077|FUNDING-SOURCE-NONFEDERAL-SHARE||
COT063|FUNDING-SOURCE-NONFEDERAL-SHARE||
CRX054|FUNDING-SOURCE-NONFEDERAL-SHARE||
ELG111|HEALTH-HOME-ENTITY-EFF-DATE||
TPL044|POLICY-OWNER-FIRST-NAME||
TPL045|POLICY-OWNER-LAST-NAME||
CIP093|PROCEDURE-CODE-DATE-6||
CIP088|PROCEDURE-CODE-FLAG-5||
PRV043|PROV-LOCATION-ID||
PRV064|PROV-LOCATION-ID||
PRV076|PROV-LOCATION-ID||
PRV129|PROV-LOCATION-ID||
COT191|SERVICING-PROV-TAXONOMY|| |
DE NO| DATA ELEMENT NAME|NECESSITY|
CIP184|ADMITTING-PROV-NPI-NUM|Conditional|
CLT006|FILE-NAME|Mandatory|
CRX006|FILE-NAME|Mandatory|
ELG006|FILE-NAME|Mandatory|
MCR006|FILE-NAME|Mandatory|
PRV006|FILE-NAME|Mandatory|
TPL006|FILE-NAME|Mandatory|
CIP127|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|
CLT077|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|
COT063|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|
CRX054|FUNDING-SOURCE-NONFEDERAL-SHARE|Conditional|
ELG111|HEALTH-HOME-ENTITY-EFF-DATE|Mandatory|
TPL044|POLICY-OWNER-FIRST-NAME|Mandatory|
TPL045|POLICY-OWNER-LAST-NAME|Mandatory|
CIP093|PROCEDURE-CODE-DATE-6|Conditional|
CIP088|PROCEDURE-CODE-FLAG-5|Conditional|
PRV043|PROV-LOCATION-ID|Mandatory|
PRV064|PROV-LOCATION-ID|Mandatory|
PRV076|PROV-LOCATION-ID|Mandatory|
PRV129|PROV-LOCATION-ID|Mandatory|
COT191|SERVICING-PROV-TAXONOMY|Conditional| |
|
06/24/2022
|
3.0.0 |
N/A
|
UPDATE |
Data Dictionary |
ELG00005.R.4 (FD2) an eligibility determinant segment (ELIGIBILITY-DETERMINANTS - ELG00005) with Primary Eligibility Group Indicator = 1 must exist for each timespan for which a person is eligible for Medicaid or CHIP. |
ELG00005.R.4 (FD2) an eligibility determinant segment (ELG005) with Primary Eligibility Group Indicator = “1” must exist for each timespan for which a person is eligible for Medicaid or CHIP. |
|
06/24/2022
|
3.0.0 |
HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|ELG131|HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION|A free-text field to capture the description of the other chronic condition (or conditions) when value 'H' (Other) appears in the HEALTH-HOME-CHRONIC-CONDITION.| |
|DE No|Data Element Name|Definition|
|ELG131|HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION|A free-text field to capture the description of the other chronic condition (or conditions) when value “H” (Other) appears in the Health Home Chronic Condition data element.| |
|
06/24/2022
|
3.0.0 |
REASON-FOR-CHANGE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|ELG266|REASON-FOR-CHANGE|A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for ELG-IDENTIFIER-TYPE '2-Old
MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID' or 'Unmerge'.| |
|DE No|Data Element Name|Definition|
|ELG266|REASON-FOR-CHANGE|A code to identify the reason for changing the MSIS Identification Number of a beneficiary and only required for Eligibile Identifier Type = '2-Old MSIS Identification Number'. For example, If MSIS Identification Number of a beneficiary is being changed due to 'Merge with other MSIS ID' or 'Unmerge'.| |
|
06/24/2022
|
3.0.0 |
LICENSE-TYPE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|PRV067|LICENSE-TYPE|A code to identify the kind of license or accreditation number that is captured in the LICENSE-OR-ACCREDITATION-NUMBER data element.| |
|DE No|Data Element Name|Definition|
|PRV067|LICENSE-TYPE|A code to identify the kind of license or accreditation number that is captured in the License or Accreditation Number data element.| |
|
06/24/2022
|
3.0.0 |
LICENSE-OR-ACCREDITATION-NUMBER
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|PRV069|LICENSE-OR-ACCREDITATION-NUMBER|A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the LICENSE-ISSUING-ENTITY-ID data element.| |
|DE No|Data Element Name|Definition|
|PRV069|LICENSE-OR-ACCREDITATION-NUMBER|A data element to capture the license or accreditation number issued to the provider by the licensing entity or accreditation body identified in the License Issuing Entity ID data element.| |
|
06/24/2022
|
3.0.0 |
PROV-IDENTIFIER-ISSUING-ENTITY-ID
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|PRV078|PROV-IDENTIFIER-ISSUING-ENTITY-ID|
A free text field to capture the identity of the entity that issued the provider identifier in the PROV-IDENTIFIER data element. For (State Tax ID), if associated Provider Identifier Type (DE) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (DE) value is equal to 8, then
value must be the name of the entity that issued the identifier.| |
|DE No|Data Element Name|Definition|
|PRV078|PROV-IDENTIFIER-ISSUING-ENTITY-ID| A free text field to capture the identity of the entity that issued the provider identifier in the Provider Identifier (PRV.005.081) data element. For (State Tax ID), if associated Provider Identifier Type (PRV.005.077) value is equal to 6, then value must be the name of the state's taxation division. For (Other), if associated Provider Identifier Type (PRV.005.077) value is equal to 8, then value must be the name of the entity that issued the identifier.| |
|
06/24/2022
|
3.0.0 |
PROV-IDENTIFIER
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|PRV081|PROV-IDENTIFIER|A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is defined in the corresponding value in the PROVIDER-IDENTIFIER-TYPE data element.| |
|DE No|Data Element Name|Definition|
|PRV081|PROV-IDENTIFIER|A data element to capture the various ways used to distinguish providers from one another on claims and other interactions between providers and other entities. The specific type of identifier is defined in the corresponding value in the Provider Identifier Type data element.| |
|
06/24/2022
|
3.0.0 |
BILLING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP180|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CIP180|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.| |
|
06/24/2022
|
3.0.0 |
BILLING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CLT131|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CLT131|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.| |
|
06/24/2022
|
3.0.0 |
BILLING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|COT113|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|COT113|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.| |
|
06/24/2022
|
3.0.0 |
BILLING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CRX071|BILLING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CRX071|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.| |
|
06/24/2022
|
3.0.0 |
ADMITTING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CLT174|ADMITTING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CLT174|ADMITTING-PROV-NPI-NUM|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.| |
|
06/24/2022
|
3.0.0 |
ADMITTING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP184|ADMITTING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CIP184|ADMITTING-PROV-NPI-NUM|The National Provider ID (NPI) of the doctor responsible for admitting a patient to a hospital or other inpatient health facility.| |
|
06/24/2022
|
3.0.0 |
HEALTH-HOME-PROVIDER-NPI
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP221|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|
|CLT167|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|
|COT146|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|
|CRX104|HEALTH-HOME-PROVIDER-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CIP221|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.|
|CLT167|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.|
|COT146|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.|
|CRX104|HEALTH-HOME-PROVIDER-NPI|The National Provider ID (NPI) of the health home provider.| |
|
06/24/2022
|
3.0.0 |
REFERRING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP190|REFERRING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|
|CLT136|REFERRING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|
|COT118|REFERRING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CIP190|REFERRING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|
|CLT136|REFERRING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.|
|COT118|REFERRING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who recommended the servicing provider to the patient.| |
|
06/24/2022
|
3.0.0 |
PRESCRIBING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CRX075|PRESCRIBING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CRX075|PRESCRIBING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who prescribed a medication to a patient.| |
|
06/24/2022
|
3.0.0 |
DISPENSING-PRESCRIPTION-DRUG-PROV-NPI
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CRX102|DISPENSING-PRESCRIPTION-DRUG-PROV-NPI|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CRX102|DISPENSING-PRESCRIPTION-DRUG-PROV-NPI|The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug.| |
|
06/24/2022
|
3.0.0 |
SERVICING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CLT213|SERVICING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|
|COT190|SERVICING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CLT213|SERVICING-PROV-NPI-NUM|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.|
|COT190|SERVICING-PROV-NPI-NUM|The NPI of the health care professional who delivers or completes a particular medical service or non-surgical procedure. The Servicing Provider NPI Number is required when rendering provider is different than the attending provider and state or federal regulatory requirements call for a "combined claim" (i.e., a claim that includes both facility and professional components). Examples are Medicaid clinic bills or critical access hospital claims.| |
|
06/24/2022
|
3.0.0 |
OPERATING-PROV-NPI-NUM
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP265|OPERATING-PROV-NPI-NUM|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).| |
|DE No|Data Element Name|Definition|
|CIP265|OPERATING-PROV-NPI-NUM|The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary.| |
|
06/24/2022
|
3.0.0 |
ADMITTING-DIAGNOSIS-CODE
|
UPDATE |
Data Dictionary |
|DE NO|DATA ELEMENT NAME| DEFINITION|
|CIP030|ADMITTING-DIAGNOSIS-CODE|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".| |
|DE NO|DATA ELEMENT NAME| DEFINITION|
|CIP030|ADMITTING-DIAGNOSIS-CODE|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.| |
|
06/24/2022
|
3.0.0 |
ADMITTING-DIAGNOSIS-CODE
|
UPDATE |
Data Dictionary |
|DE NO|DATA ELEMENT NAME| DEFINITION|
|CLT027|ADMITTING-DIAGNOSIS-CODE|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".| |
|DE NO|DATA ELEMENT NAME| DEFINITION|
|CLT027|ADMITTING-DIAGNOSIS-CODE|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician. Since the Admitting Diagnosis is formulated before all tests and examinations are complete, it may be stated in the form of a problem or symptom and it may differ from any of the final diagnoses recorded in the medical record.| |
|
06/24/2022
|
3.0.0 |
ELG045/ ENGL-PROF-CODE
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
ELG045|PRIMARY-LANGUAGE-ENGL-PROF-CODE |
DE No|Data Element Name
ELG045|ENGL-PROF-CODE |
|
06/24/2022
|
3.0.0 |
DISABILITY-TYPE-CODE
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG224 |DISABILITY-TYPE-CODE |Obsolete |
1.(LV) value must be in Disability Type Code List (VVL)
2.(S) value must be 2 characters
3.(N) conditional |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG224 |DISABILITY-TYPE-CODE |
A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act.|
1.(LV) value must be in Disability Type Code List (VVL)
2.(S) value must be 2 characters
3.(N) mandatory |
|
06/24/2022
|
3.0.0 |
AFFILIATED-PROGRAM-TYPE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|PRV119|AFFILIATED-PROGRAM-TYPE| A code to identify the category of program that the provider is affiliated.
see Affiliated Program Type List (VVL.004)
(health plan federal assigned) if associated Affiliated Program Type (DE) value is 1, then value must be the federal-assigned plan ID of the health plan in which a provider is enrolled to provide services.
(health plan state assigned) if associated Affiliated Program Type (DE) value is 2, then value must be the state-assigned plan ID of the health plan in which a provider is enrolled to provide services.
(waiver) if associated Affiliated Program Type (DE) value is 3, then value must be the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries. (health home entity) if associated Affiliated
Program Type (DE) value is 4, then value must be the name of a health home in which a provider is participating.
(other) if associated Affiliated Program
Type (DE) value is 5, then value must be an identifier for something other than a health plan, waiver, or health home entity.| |
|DE No|Data Element Name|Definition|
|PRV119|AFFILIATED-PROGRAM-TYPE|A code to identify the category of program that the provider is affiliated.| |
|
06/24/2022
|
3.0.0 |
AFFILIATED-PROGRAM-ID
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|PRV120|AFFILIATED-PROGRAM-ID
A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.
(health plan federal
assigned) if associated Affiliated Program Type (DE) value is 1, then value must be the federal-assigned plan ID of the health plan in which a provider
is enrolled to provide services.
(health plan state assigned) if associated Affiliated Program Type (DE) value is 2, then value must be the state-assigned
plan ID of the health plan in which a provider is enrolled to provide services.
(waiver) if associated Affiliated Program Type (DE) value is 3, then value
must be the core Federal Waiver ID in which a provider is allowed to deliver services to eligible beneficiaries.
(health home entity) if associated Affiliated
Program Type (DE) value is 4, then value must be the name of a health home in which a provider is participating.
(other) if associated Affiliated Program
Type (DE) value is 5, then value must be an identifier for something other than a health plan, waiver, or health home entity. |
|DE No|Data Element Name|Definition|
|PRV120|AFFILIATED-PROGRAM-ID
A data element to identify the Medicaid/CHIP programs, waivers and demonstrations in which the provider participates.
If Affiliated Program
Type = 2 (Health Plan State-assigned health plan ID), then the value in Affiliated Program ID is the state-assigned plan ID of the health plan in which
a provider is enrolled to provide services. If Affiliated Program Type = 3 (Waiver), then the value in Affiliated Program ID is the core Federal Waiver
ID in which a provider is
allowed to deliver services to eligible beneficiaries. If Affiliated Program Type = 4 (Health Home Entity), then the value
in Affiliated Program ID is the name of a health home in which a provider is participating. If Affiliated Program Type = 5 (Other), then the value in Affiliated
Program ID is an identifier for something other than a health plan,
waiver, or health home entity. |
|
06/24/2022
|
3.0.0 |
COVERAGE-TYPE
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME DEFINITION|
|TPL058|COVERAGE-TYPE|This code identifies the relationship of the policy holder to the Medicaid/CHIP beneficiary.
see Policy Owner Code List (VVL.099)| |
|DE NO| DATA ELEMENT NAME|DEFINITION|
|TPL058|COVERAGE-TYPE |Code indicating the level of coverage being provided under this policy for the insured by the TPL carrier.| |
|
06/24/2022
|
3.0.0 |
DRG-DESCRIPTION
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP029|DRG-DESCRIPTION|Description of the associated state-specific DRG code. If using standard MS-DRG classification system, a DRG Description is not required.| |
|DE No|Data Element Name|Definition|
|CIP029|DRG-DESCRIPTION|Description of the associated state-specific DRG code. If using standard MS-DRG classification system, leave blank.| |
|
06/24/2022
|
3.0.0 |
DIAGNOSIS-RELATED-GROUP-IND
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP069|DIAGNOSIS-RELATED-GROUP-IND|An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values.| |
|DE No|Data Element Name|Definition|
|CIP069|DIAGNOSIS-RELATED-GROUP-IND|An indicator identifying the grouping algorithm used to assign Diagnosis Related Group (DRG) values.Values are generated by combining two types of information:
Position 1-2, State/Group generating DRG:
If state specific system, fill with two digit US postal code representation for state.
If CMS Grouper, fill with 'HG'.
If any other system, fill with 'XX'.
Position 3-4, fill with the number that represents the DRG version used (01-98).
For example, 'HG15" would
represent CMS Grouper version 15. If version is unknown, fill with '99".| |
|
06/24/2022
|
3.0.0 |
DRG-OUTLIER-AMT
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition| CODING REQUIREMENT
CIP194 |DRG-OUTLIER-AMT|The additional payment on a claim that is associated with either a cost outlier or length of stay outlier.Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category. |1.(GS) value must satisfy the requirements of US Dollar Amount (DT)
2.(N) conditional
3.(FD1) value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' |
|DE No|Data Element Name|Definition| CODING REQUIREMENT
CIP194 |DRG-OUTLIER-AMT|The additional payment on a claim that is associated with either a cost outlier or length of stay outlier.Outlier payments compensate hospitals paid on a fixed amount per Medicare "diagnosis related group" discharge with extra dollars for patient stays that substantially exceed the typical requirements for patient stays in the same DRG category |1.(GS) value must satisfy the requirements of US Dollar Amount (DT)
2.(FD1) value must not be populated, if Outlier Code (CIP.002.197) equals '00' or '09'
3.(N) conditional |
|
06/24/2022
|
3.0.0 |
OUTLIER-CODE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition| CODING REQUIREMENT|
|CIP197|OUTLIER-CODE| This code indicates the Type of Outlier Code or DRG Source. The field identifies two mutually exclusive conditions. The first, for PPS providers(codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), denotes the
source for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code
1.(LV) value must be in Outlier Code List (VVL)
2.(FD1) (Day Outlier) If Outlier Code is 01, then Outlier Days (CIP.002.198) must be populated.
3.(S) value must be 2 characters
4.(N) conditional
5.(FD1) if value equals '00' or '09', then DRG Outlier Amount (CIP.002.194) must not be populated| |
|DE No|Data Element Name|Definition| CODING REQUIREMENT|
|CIP197|OUTLIER-CODE| This code indicates the Type of Outlier Code or DRG Source. The field identifies two mutually exclusive conditions. The first, for PPS providers (codes 0, 1, and 2), classifies stays of exceptional cost or length (outliers). The second, for non-PPS providers (codes 6, 7, 8, and 9), denotes thesource for developing the DRG. https://www.resdac.org/cms-data/variables/medpar-drgoutlier-stay-code
1.(LV) value must be in Outlier Code List (VVL)
2.(S) value must be 2 characters
3.(FD1) value is mandatory if either DRG Outlier Amount (CIP.002.194) or Outlier Days (CIP.002.198) are populated
4.(N) conditional| |
|
06/24/2022
|
3.0.0 |
ORIGINATION-ADDR-LN2
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION|
|COT200|ORIGINATION-ADDR-LN2|The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.| |
|DE NO| DATA ELEMENT NAME| DEFINITION|
|COT200|ORIGINATION-ADDR-LN2|The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.| |
|
06/24/2022
|
3.0.0 |
ORIGINATION-STATE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition| CODING REQUIREMENT|
|COT202|ORIGINATION-STATE|The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a healthcare provider to a health care provider for healthcare services or vice versa.|
1.Value must be in State Code List (VVL)
2. Value must be 2 characters
3. conditional
4. (transportation claim) value is mandatory and must be provided for all transportation claims| |
|DE No|Data Element Name|Definition| CODING REQUIREMENT|
|COT202|ORIGINATION-STATE|The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a health care provider to a health care provider for healthcare services or vice versa.|
1.Value must be in State Code List (VVL)
2. Value must be 2 characters
3.(N) conditional| |
|
06/24/2022
|
3.0.0 |
DESTINATION-STATE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
COT207|DESTINATION-STATE |The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa.|
1.(GS) value must satisfy the requirements of Address State (CE)
2.(FD1) (transportation claim) value is mandatory and must be provided for all transportation claims
3.(N) conditional| |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
COT207|DESTINATION-STATE|The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa.|
1.(GS) value must satisfy the requirements of Address State (CE)| |
|
06/24/2022
|
3.0.0 |
DESTINATION-ZIP-CODE
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION|
|COT208|DESTINATION-ZIP-CODE|Description: U.S. ZIP Code component of an address associated with a given entity (e.g. person, organization, agency, etc.)| |
|DE NO| DATA ELEMENT NAME| DEFINITION|
|COT208|DESTINATION-ZIP-CODE|The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.| |
|
06/24/2022
|
3.0.0 |
DRUG-UTILIZATION-CODE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|CODING REQUIREMENT|
CRX143|DRUG-UTILIZATION-CODE|
1.(S) value must be 6 characters or less
2.(S) characters 1 and 2 (2-character string) may be in Drug Utilization Result of Service Code List (VVL), or spaces in cases where code is unused or not available
3.(S) characters 3 and 4 (2-character string) may be in Drug Utilization Professional Service Code List (VVL), or spaces in cases where code is unused or not available
4.(S) characters 5 and 6 (2-character string) may be in Drug Utilization Reason For Service Code List (VVL), or not populated in cases where code is unused or not available
5.(N) mandatory| |
DE No|Data Element Name|CODING REQUIREMENT|
CRX143|DRUG-UTILIZATION-CODE|
1.(S) value must be 6 characters or less
2.(S) characters 1 and 2 (2-character string) must be in Drug Utilization Reason of Service Code List (VVL)
3.(S) characters 3 and 4 (2-character string) must be in Drug Utilization Professional Service Code List (VVL)
4.(S) characters 5 and 6 (2-character string) must be in Drug Utilization Result For Service Code List (VVL)
5.(N) mandatory| |
|
07/23/2021
|
3.0.0 |
TOT-COPAY-AMT (CIP.002.115)
|
UPDATE |
Data Dictionary |
"If associated Crossover Indicator value is '0' (not a crossover claim), then value should not be populated."
AND
"(Medicare Enrolled) if associated Dual Eligible Code (ELG.005.085) value is in ["01", "02", "03", "04", "05", "06", "08", "09", or "10"], then value is mandatory and must be provided" |
N/A |
|
05/21/2021
|
3.0.0 |
BILLING-PROV-NUM
(COT.002.112)
|
UPDATE |
Data Dictionary |
When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider ID
or
When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1' |
N/A |
|
06/11/2021
|
3.0.0 |
TOT-BILLED-AMT
|
UPDATE |
Data Dictionary |
"If associated Type of Claim value is 2, 4, 5, B, D, or E, then value should not be populated" |
N/A |
|
06/11/2021
|
3.0.0 |
ELG.016.214
|
ADD |
Data Dictionary |
N/A |
If associated Race (ELG.016.213) value is not in [ "010", "015" ], then value must be null. |
|
06/24/2022
|
3.0.0 |
COT145/ CAPITATED-PAYMENT-AMT-REQUESTED
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT145|CAPITATED-PAYMENT-AMT-REQUESTED|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT144/ DATE-CAPITATED-AMOUNT-REQUESTED
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT144|DATE-CAPITATED-AMOUNT-REQUESTED|9(8)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
ELG215/AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
ELG215|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR |
DE No|Data Element Name
ELG215|AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR |
|
07/02/2021
|
3.0.0 |
AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR (ELG215)
|
UPDATE |
Data Dictionary - Valid Values |
Valid Value '0' Description: Individual does not meet the definition of an American Indian/Alaskan Native.
Valid Value '1' Description: Individual meets the definition of an American Indian/Alaskan Native. |
Valid Value '0' Description: Individual does not meet the definition of an American Indian/Alaska Native.
Valid Value '1' Description: Individual meets the definition of an American Indian/Alaska Native. |
|
07/02/2021
|
3.0.0 |
RACE (ELG213)
|
UPDATE |
Data Dictionary - Valid Values |
Valid Value '003' Description: American Indian or Alaskan Native |
Valid Value '003' Description: American Indian or Alaska Native |
|
06/24/2022
|
3.0.0 |
ELG-IDENTIFIER-ISSUING-ENTITY-ID
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG262|ELG-IDENTIFIER-ISSUING-ENTITY-ID|This data element is reserved for future use.|
1.(S) value must be 18 characters or less
2.(N) optional| |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG262|ELG-IDENTIFIER-ISSUING-ENTITY-ID|This data element is reserved for future use|
1.(S) value must be 18 characters or less| |
|
07/23/2021
|
3.0.0 |
TOT-BILLED-AMT (CIP.002.112)
|
UPDATE |
Data Dictionary |
“If associated Type of Claim value is 2, 4, 5, B, D, or E, then value should not be populated" |
N/A |
|
08/13/2021
|
3.0.0 |
TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|1|Rural Health Clinic (RHC)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|2|Hospital Based or Independent Renal Dialysis Facility|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|3|Free Standing Provider-Based Federally Qualified Health Center (FQHC)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|4|Other Rehabilitation Facility (ORF)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|5|Comprehensive Outpatient Rehabilitation Facility (CORF)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|6|Community Mental Health Center (CMHC)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|20100401|99991231|7|Federally Qualified Health Center (FQHC) (Effective 4/1/10)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|20120401|99991231|8|Licensed Freestanding Emergency Medical Facility (Effective 4/1/12)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-CLINICS|00010101|99991231|9|OTHER| |
|
08/13/2021
|
3.0.0 |
TYPE-OF-BILL-2-FACILITY-TYPE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|1|Hospital|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|2|Skilled Nursing|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|3|Home Health|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|4|Religious Nonmedical (Hospital)|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|20051001|5|Reserved for national assignment (discontinued effective 10/1/05).|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|6|Intermediate Care|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|7|Clinic or Hospital Based Renal Dialysis Facility (requires special information in second digit below).|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|8|Special facility or hospital ASC surgery (requires special information in second digit below).|
|TYPE-OF-BILL-2-FACILITY-TYPE|00010101|99991231|9|Reserved for National Assignment| |
|
08/13/2021
|
3.0.0 |
TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|1|Inpatient|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|2|Inpatient|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|3|Outpatient|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|4|Other|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|5|Intermediate Care - Level I|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|6|Intermediate Care - Level II|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|20051001|7|Reserved for national assignment (discontinued effective 10/1/05).|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|8|Swing Bed (may be used to indicate billing for SNF level of care in a hospital with an approved swing bed agreement).|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-OTHER|00010101|99991231|9|Reserved for National Assignment| |
|
08/13/2021
|
3.0.0 |
TYPE-OF-BILL-4-FREQUENCY
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|0|Nonpayment/Zero Claims|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|1|Admit Through Discharge Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|2|Interim-First Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|3|Interim-Continuing Claims (Not valid for PPS Bills)|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|A|Admission/Election Notice|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|B|Hospice/Medicare Coordinated Care Demonstration/Religious Nonmedical Health Care Institution Termination/Revocation Notice|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|C|Hospice Change of Provider Notice|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|D|Hospice/Medicare Coordinated Care Demonstration/Religious Nonmedical Health Care Institution Void/Cancel|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|E|Hospice Change of Ownership|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|F|Beneficiary Initiated Adjustment Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|G|CWF Initiated Adjustment Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|H|CMS Initiated Adjustment Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|I|FI Adjustment Claim (Other than QIO or Provider|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|J|Initiated Adjustment Claim-Other|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|K|OIG Initiated Adjustment Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|M|MSP Initiated Adjustment Claim|
|TYPE-OF-BILL-4-FREQUENCY|00010101|99991231|P|QIO Adjustment Claim| |
|
08/13/2021
|
3.0.0 |
MEDICAID-PAID-AMT
|
UPDATE |
Data Dictionary |
|Definition|
|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For claims where Medicaid payment is only available at the header level, report the entire payment amount on the T-MSIS record corresponding to the line item with the highest charge or the 1st detail. Zero fill Medicaid Amount Paid on all other MSIS records created from the original claim.| |
|Definition|
|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.| |
|
08/13/2021
|
3.0.0 |
TYPE-OF-SERVICE (
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-SERVICE|00010101|99991231|147|Residential Pediatric Recovery Center (RPRC): A center or facility that furnishes items and services for which medical assistance is available under the State plan to infants with the diagnosis of neonatal abstinence syndrome without any other significant medical risk factors.| |
|
06/24/2022
|
3.0.0 |
PRV046
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|
PRV046|ADDR-TYPE |
DE NO| DATA ELEMENT NAME COMPUTING|
PRV046|PROV-ADDR-TYPE |
|
06/24/2022
|
3.0.0 |
ELG065
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|
ELG065|ADDR-TYPE |
DE NO| DATA ELEMENT NAME COMPUTING|
ELG065|ELIGIBLE-ADDR-TYPE |
|
05/13/2022
|
3.0.0 |
CRX143
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME|DEFINITION|
CRX143|DRUG-UTILIZATION-CODE|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (44-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service. The NCPDP "Results of Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service.
Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.| |
DE NO| DATA ELEMENT NAME|DEFINITION|
CRX143|DRUG-UTILIZATION-CODE|A code indicating the conflict, intervention and outcome of a prescription presented for fulfillment. The T-MSIS Drug Utilization Code data element is composite field comprised of three distinct NCPDP data elements: "Reason for Service Code" (439-E4); "Professional Service Code" (440-E5); and "Result of Service Code" (441-E6). All 3 of these NCPDP fields are situationally required and independent of one another. Pharmacists may report none, one, two or all three. NCPDP situational rules call for one or more of these values in situations where the field(s) could result in different coverage, pricing, patient financial responsibility, drug utilization review outcome, or if the information affects payment for, or documentation of, professional pharmacy service.The NCPDP "Reason for Service Code" (bytes 1 & 2 of the T-MSIS Drug Utilization Code) explains whether the pharmacist filled the prescription, filled part of the prescription, etc. The NCPDP "Professional Service Code" (bytes 3 & 4 of the T-MSIS Drug Utilization Code) describes what the pharmacist did for the patient. The NCPDP "Result of Service Code" (bytes 5 & 6 of the T-MSIS Drug Utilization Code) describes the action the pharmacist took in response to a conflict or the result of a pharmacist's professional service.
Because the T-MSIS Drug Utilization Code data element is a composite field, it is necessary for the state to populate all six bytes if any of the three NCPDP fields has a value. In such situations, use 'spaces' as placeholders for not applicable codes.| |
|
01/07/2022
|
3.0.0 |
ELG260
|
UPDATE |
Data Dictionary |
|FILE SEGMENT NAME WITH RECORD ID COMPUTING|
|ELIGIBLE-IDENTIFIER-ELG00022| |
|FILE SEGMENT NAME WITH RECORD ID COMPUTING|
|ELIGIBLE-IDENTIFIERS-ELG00022| |
|
06/24/2022
|
3.0.0 |
MFP-QUALIFIED-RESIDENCE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG152|MFP-QUALIFIED-RESIDENCE|A code describing type of qualified institution at the time of transition to the community for an eligible MFP Demonstration participant.| |
DE No|Data Element Name|Definition|CODING REQUIREMENT|
ELG152|MFP-QUALIFIED-RESIDENCE|A code indicating the type of qualified residence.| |
|
08/13/2021
|
3.0.0 |
TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|1|Hospice (Nonhospital Based)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|2|Hospice (Hospital Based)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|3|Ambulatory Surgical Center Services to Hospital Outpatients|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|4|Free Standing Birthing Center|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|5|Critical Access Hospital|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|6|Residential Facility|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|20210101|99991231|7|Freestanding Non-residential Opioid Treatment Program (Effective 1/1/21)|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|8|Reserved for National Assignment|
|TYPE-OF-BILL-3-BILL-CLASSIFICATION-FACILITY|00010101|99991231|9|OTHER| |
|
10/15/2021
|
3.0.0 |
HCPCS
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|HCPCS|20210603|99991231|Q0244|Casirivi and imdevi 1200 mg |Injection, casirivimab and imdevimab, 1200 mg|
|HCPCS|20210506|99991231|M0244|Casirivi and imdevi inj hm|Intravenous infusion or subcuteaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency|
|HCPCS|20210624|99991231|Q0249|Tocilizumab for COVID-19|Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg|
|HCPCS|20210624|99991231|M0249|Adm Tocilizu COVID-19 1st|Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose|
|HCPCS|20210624|99991231|M0250|Adm Tocilizu COVID-19 2nd|Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose|
|HCPCS|20210506|99991231|M0246|Bamlan and etesev infus home|Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency|
|HCPCS|20210506|99991231|Q0247|Sotrovimab|Injection, sotrovimab, 500 mg|
|HCPCS|20210506|99991231|M0247|Sotrovimab infusion|Intravenous infusion, sotrovimab, includes infusion and post administration monitoring|
|HCPCS|20210506|99991231|M0248|Sotrovimab inf, home admin|Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency|
|HCPCS|20210506|999912311|M0201|Covid-19 vaccine home admin|Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient's home|
|HCPCS|20201109|20210416|Q0239|Bamlanivimab-xxxx|Injection, bamlanivimab, 700 mg|
|HCPCS|20201109|20210416|M0239|Bamlanivimab-xxxx infusion|Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring|
|HCPCS|20210730|99991231|Q0240|Casirivi and imdevi 600mg|Injection, casirivimab and imdevimab, 600 mg|
|HCPCS|20210730|99991231|M0240|Casiri and imdev repeat|Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses|
|HCPCS|20210730|99991231|M0241|Casiri and imdev repeat hm|Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency, subsequent repeat doses|
|HCPCS|20201121|99991231|Q0243|Casirivimab and imdevimab|Injection, casirivimab and imdevimab, 2400 mg|
|HCPCS|20201121|99991231|M0243|Casirivi and imdevi inj|Intravenous infusion or subcuteaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring|
|HCPCS|20210209|99991231|M0245|Bamlan and etesev infusion|Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring|
|HCPCS|20210209|99991231|Q0245|Bamlanivimab and etesevima|Injection, bamlanivimab and etesevimab, 2100 mg| |
|
09/03/2021
|
3.0.0 |
TYPE-OF-SERVICE
|
UPDATE |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|TYPE-OF-SERVICE|00010101|99991231|147|Residential Pediatric Recovery Center (RPRC): A center or facility that furnishes items and services for which medical assistance is available under the State plan to infants with the diagnosis of neonatal abstinence syndrome without any other significant medical risk factors.| |
|
10/15/2021
|
3.0.0 |
CITIZENSHIP-IND
|
UPDATE |
Data Dictionary - Valid Values |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|CITIZENSHIP-IND|00010101|99991231|1|U.S. Citizen|
|CITIZENSHIP-IND|00010101|99991231|2|U.S. National| |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|CITIZENSHIP-IND|00010101|99991231|1|U.S. Citizen (If the state’s eligibility determination system does not distinguish between U.S. citizens and U.S. nationals who are not U.S. citizens, then use this value for all U.S. citizens and U.S. nationals (see 42 CFR 435 and 436.).)|
|CITIZENSHIP-IND|00010101|99991231|2|U.S. National (If the state’s eligibility determination system does distinguish between U.S. citizens and U.S. nationals who are not U.S. citizens, then use this value for U.S. nationals who are not U.S. citizens (see 42 CFR 435 and 436.).)| |
|
10/15/2021
|
3.0.0 |
CLAIM-STATUS-CATEGORY
(CIP103)
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|CIP103 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"|
|CLT055 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"|
|COT040 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"|
|CRX031 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 858, 654 ], then value must be "F2"| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|CIP103 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"|
|CLT055 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"|
|COT040 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"|
|CRX031 |CLAIM-STATUS-CATEGORY| Not Applicable |Not Applicable |(Denied Claim) if associated Type of Claim equals Z or associated Claim Status is in [ 26, 87, 542, 585, 654 ], then value must be "F2"| |
|
12/03/2021
|
3.0.0 |
RACE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|RACE|00010101|99991231|018|Other| |
|
12/03/2021
|
3.0.0 |
RACE (ELG213)
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|ELG213|RACE| Not Applicable |Not Applicable |A code indicating the individual's race either in accordance with requirements of Section 4302 of the Affordable Care Act classifications Race Code clarifications: If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown." If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," "Unspecified" or "Unknown."NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese).NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|ELG213|RACE| Not Applicable |Not Applicable |A code indicating the individual's race in accordance with requirements of Section 4302 of the Affordable Care Act classifications Race Code clarifications: If state has beneficiaries coded in their database as "Asian" with no additional detail, then code them in T-MSIS as "Asian Unknown" (valid value "011"). DO NOT USE "Other Asian," "Unspecified" or "Unknown." If state has beneficiaries coded in their database as "Native Hawaiian or Other Pacific Islander" with no additional detail, then code them in T-MSIS as "Native Hawaiian and Other Pacific Islander Unknown" (valid value "016"). DO NOT USE "Native Hawaiian," "Other Pacific Islander," "Unspecified" or "Unknown." If state has beneficiaries coded in their database as “Other” with no additional detail or in a category that is not available in the code set provided, then code them in T-MSIS as “Other” (valid value “018”), but only use “Other” if the use of “Other Asian” or “Other Pacific Islander” are not appropriate. DO NOT USE “Unspecified” or “Unknown”. The “Other” valid value was added to T-MSIS to better align T-MSIS with the single-streamlined application and to accommodate some atypical states, despite the requirements of Section 4302 of the ACA.NOTE 1: The "Other Asian" category in T-MSIS (valid value "010") should be used in situations in which an individual's specific Asian subgroup is not available in the code set provided (e.g., Malaysian, Burmese).NOTE 2: The "Unspecified" category in T-MSIS (valid value "017") should be used with an individual who explicitly did not provide information or refused to answer a question.| |
|
06/24/2022
|
3.0.0 |
ELG271/ ETHNICITY-OTHER
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
ELG271|ETHNICITY-OTHER |X(25)|ELIGIBLE|ETHNICITY-INFORMATION-ELG00015 |
|
10/15/2021
|
3.0.0 |
PROV-IDENTIFIER-TYPE
(PRV077)
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|PROV-IDENTIFIER-TYPE|00010101|99991231|9|Old State Provider ID |
|
12/03/2021
|
3.0.0 |
PROV-CLASSIFICATION-TYPE = 3 (Provider Type Code)
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|PROV-CLASSIFICATION-TYPE = 3 (Provider Type Code)|00010101|99991231|58|Institutions for Mental Disease| |
|
12/17/2021
|
3.0.0 |
PROV-SPECIALTY
|
ADD |
Data Dictionary - Valid Values |
add valid value to file PROV-SPECIALTY.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
PROV-SPECIALTY|00010101|99991231|88|Unknown Supplier/Provider Specialty| |
|
11/05/2021
|
3.0.0 |
PROV-CLASSIFICATION-TYPE = 4
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|89|Disposable medical supplies|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|90|Critical access hospital services - IP|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|91|Skilled care - hospital residing|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|92|Exceptional care - hospital residing|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|93|Non-acute care - hospital residing|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|120|Capitated payments for primary care case management (PCCM)|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|123|Disproportionate share hospital (DSH) payments|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|127|Indian Health Service (IHS) - Family Plan|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|132|Supplemental payment - inpatient|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|133|Supplemental payment - nursing|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|134|Supplemental payment - outpatient|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|135|EHR payments to provider|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|136|In vitro diagnostic products (as defined in section 809.3(a) of title 21, Code of Federal Regulations) administered during any portion of the emergency period defined in paragraph (1)(B) of section 1135(g) beginning on or after the date of the enactment of this subparagraph for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19, and the administration of such in vitro diagnostic products|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|137|COVID–19 testing-related services|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|138|Per member per month (PMPM) payments for health home services|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|143|Per member per month (PMPM) payments for other payments|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|144|Payments to individuals for personal assistance services under 1915(j)|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|145|Medication Assisted Treatment (MAT) services and drugs for evidenced-based treatment of Opioid Use Disorder (OUD) in accordance with section 1905(a)(29) of the Social Security Act|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|146|Inpatient Psychiatric Services for beneficiaries between the ages of 22 and 64 who receive services in an institution for mental disease (IMD)|
|PROV-CLASSIFICATION-TYPE = 4 (Authorized Category of Service Code)|00010101|99991231|147|Residential Pediatric Recovery Center (RPRC): A center or facility that furnishes items and services for which medical assistance is available under the State plan to infants with the diagnosis of neonatal abstinence syndrome without any other significant medical risk factors.| |
|
12/03/2021
|
3.0.0 |
ELIGIBILITY-CHANGE-REASON
|
UPDATE |
Data Dictionary - Valid Values |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|ELIGIBILITY-CHANGE-REASON|00010101|99991231|09|No longer in need of long-term care services resides| |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|ELIGIBILITY-CHANGE-REASON|00010101|99991231|09|No longer in need of long-term care services| |
|
06/24/2022
|
3.0.0 |
CIP296/ IHS-SERVICE-IND
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP296|IHS-SERVICE-IND|X(1)||CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 |
|
06/24/2022
|
3.0.0 |
CLT243/ IHS-SERVICE-IND
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT243|IHS-SERVICE-IND|X(1)|CLAIMLT|CLAIM-LINE-RECORD-LT-CLT00003 |
|
06/24/2022
|
3.0.0 |
COT234/ IHS-SERVICE-IND
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT234|IHS-SERVICE-IND|X(1)|CLAIMOT|CLAIM-LINE-RECORD-OT-COT00003 |
|
06/24/2022
|
3.0.0 |
CRX172/ IHS-SERVICE-IND
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX172|IHS-SERVICE-IND|X(1)|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
12/17/2021
|
3.0.0 |
PROCEDURE-CODE-MOD
|
UPDATE |
Data Dictionary - Valid Values |
|Modifier|Effective Date|End Date|Description|
|DD|20210101|99991231|FROM Diagnostic or therapeutic site TO Diagnostic or therapeutic site|
|DE|20210101|99991231|FROM Diagnostic or therapeutic site TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|DG|20210101|99991231|FROM Diagnostic or therapeutic site TO Hospital based ESRD facility|
|DH|20210101|99991231|FROM Diagnostic or therapeutic site TO Hospital|
|DI|20210101|99991231|FROM Diagnostic or therapeutic site TO Site of transfer|
|DJ|20210101|99991231|FROM Diagnostic or therapeutic site TO Freestanding ESRD facility|
|DN|20210101|99991231|FROM Diagnostic or therapeutic site TO Skilled nursing facility|
|DP|20210101|99991231|FROM Diagnostic or therapeutic site TO Physician’s office|
|DR|20210101|99991231|FROM Diagnostic or therapeutic site TO Residence|
|DS|20210101|99991231|FROM Diagnostic or therapeutic site TO Scene of accident or acute event|
|DX|20210101|99991231|FROM Diagnostic or therapeutic site TO Intermediate stop at Physician’s office on way to Hospital| |
|Modifier|Effective Date|End Date|Description|
|DD|00010101|99991231|FROM Diagnostic or therapeutic site TO Diagnostic or therapeutic site|
|DE|00010101|99991231|FROM Diagnostic or therapeutic site TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|DG|00010101|99991231|FROM Diagnostic or therapeutic site TO Hospital based ESRD facility|
|DH|00010101|99991231|FROM Diagnostic or therapeutic site TO Hospital|
|DI|00010101|99991231|FROM Diagnostic or therapeutic site TO Site of transfer|
|DJ|00010101|99991231|FROM Diagnostic or therapeutic site TO Freestanding ESRD facility|
|DN|00010101|99991231|FROM Diagnostic or therapeutic site TO Skilled nursing facility|
|DP|00010101|99991231|FROM Diagnostic or therapeutic site TO Physician’s office|
|DR|00010101|99991231|FROM Diagnostic or therapeutic site TO Residence|
|DS|00010101|99991231|FROM Diagnostic or therapeutic site TO Scene of accident or acute event|
|DX|00010101|99991231|FROM Diagnostic or therapeutic site TO Intermediate stop at Physician’s office on way to Hospital| |
|
12/17/2021
|
3.0.0 |
PROCEDURE-CODE-MOD
|
UPDATE |
Data Dictionary - Valid Values |
|Modifier|Effective Date|End Date|Description|
|EG|20210101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Hospital based ESRD facility|
|EH|20210101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Hospital|
|EI|20210101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Site of transfer|
|EN|20210101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Skilled nursing facility|
|ES|20210101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Scene of accident or acute event|
|GI|20210101|99991231|FROM Hospital based ESRD facility TO Site of transfer|
|ID|20210101|99991231|FROM Site of transfer TO Diagnostic or therapeutic site|
|IE|20210101|99991231|FROM Site of transfer TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|IG|20210101|99991231|FROM Site of transfer TO Hospital based ESRD facility|
|IH|20210101|99991231|FROM Site of transfer TO Hospital|
|II|20210101|99991231|FROM Site of transfer TO Site of transfer|
|IJ|20210101|99991231|FROM Site of transfer TO Freestanding ESRD facility|
|IN|20210101|99991231|FROM Site of transfer TO Skilled nursing facility|
|IP|20210101|99991231|FROM Site of transfer TO Physician’s office| |
|Modifier|Effective Date|End Date|Description|
|EG|00010101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Hospital based ESRD facility|
|EH|00010101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Hospital|
|EI|00010101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Site of transfer|
|EN|00010101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Skilled nursing facility|
|ES|00010101|99991231|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Scene of accident or acute event|
|GI|00010101|99991231|FROM Hospital based ESRD facility TO Site of transfer|
|ID|00010101|99991231|FROM Site of transfer TO Diagnostic or therapeutic site|
|IE|00010101|99991231|FROM Site of transfer TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|IG|00010101|99991231|FROM Site of transfer TO Hospital based ESRD facility|
|IH|00010101|99991231|FROM Site of transfer TO Hospital|
|II|00010101|99991231|FROM Site of transfer TO Site of transfer|
|IJ|00010101|99991231|FROM Site of transfer TO Freestanding ESRD facility|
|IN|00010101|99991231|FROM Site of transfer TO Skilled nursing facility|
|IP|00010101|99991231|FROM Site of transfer TO Physician’s office| |
|
12/17/2021
|
3.0.0 |
PROCEDURE-CODE-MOD
|
UPDATE |
Data Dictionary - Valid Values |
|Modifier|Effective Date|End Date|Description|
|IR|20210101|99991231|FROM Site of transfer TO Residence|
|IS|20210101|99991231|FROM Site of transfer TO Scene of accident or acute event|
|IX|20210101|99991231|FROM Site of transfer TO Intermediate stop at Physician’s office on way to Hospital|
|JH|20210101|99991231|FROM Freestanding ESRD facility TO Hospital|
|JI|20210101|99991231|FROM Freestanding ESRD facility TO Site of transfer|
|JJ|20210101|99991231|FROM Freestanding ESRD facility TO Freestanding ESRD facility|
|JN|20210101|99991231|FROM Freestanding ESRD facility TO Skilled nursing facility|
|JP|20210101|99991231|FROM Freestanding ESRD facility TO Physician’s office|
|JR|20210101|99991231|FROM Freestanding ESRD facility TO Residence|
|JS|20210101|99991231|FROM Freestanding ESRD facility TO Scene of accident or acute event|
|JX|20210101|99991231|FROM Freestanding ESRD facility TO Intermediate stop at Physician’s office on way to Hospital|
|ND|20210101|99991231|FROM Skilled nursing facility TO Diagnostic or therapeutic site|
|NE|20210101|99991231|FROM Skilled nursing facility TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|NG|20210101|99991231|FROM Skilled nursing facility TO Hospital based ESRD facility| |
|Modifier|Effective Date|End Date|Description|
|IR|00010101|99991231|FROM Site of transfer TO Residence|
|IS|00010101|99991231|FROM Site of transfer TO Scene of accident or acute event|
|IX|00010101|99991231|FROM Site of transfer TO Intermediate stop at Physician’s office on way to Hospital|
|JH|00010101|99991231|FROM Freestanding ESRD facility TO Hospital|
|JI|00010101|99991231|FROM Freestanding ESRD facility TO Site of transfer|
|JJ|00010101|99991231|FROM Freestanding ESRD facility TO Freestanding ESRD facility|
|JN|00010101|99991231|FROM Freestanding ESRD facility TO Skilled nursing facility|
|JP|00010101|99991231|FROM Freestanding ESRD facility TO Physician’s office|
|JR|00010101|99991231|FROM Freestanding ESRD facility TO Residence|
|JS|00010101|99991231|FROM Freestanding ESRD facility TO Scene of accident or acute event|
|JX|00010101|99991231|FROM Freestanding ESRD facility TO Intermediate stop at Physician’s office on way to Hospital|
|ND|00010101|99991231|FROM Skilled nursing facility TO Diagnostic or therapeutic site|
|NE|00010101|99991231|FROM Skilled nursing facility TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|NG|00010101|99991231|FROM Skilled nursing facility TO Hospital based ESRD facility| |
|
12/17/2021
|
3.0.0 |
PROCEDURE-CODE-MOD
|
UPDATE |
Data Dictionary - Valid Values |
|Modifier|Effective Date|End Date|Description|
|NH|20210101|99991231|FROM Skilled nursing facility TO Hospital|
|NI|20210101|99991231|FROM Skilled nursing facility TO Site of transfer|
|NJ|20210101|99991231|FROM Skilled nursing facility TO Freestanding ESRD facility|
|NN|20210101|99991231|FROM Skilled nursing facility TO Skilled nursing facility|
|NP|20210101|99991231|FROM Skilled nursing facility TO Physician’s office|
|NS|20210101|99991231|FROM Skilled nursing facility TO Scene of accident or acute event|
|NX|20210101|99991231|FROM Skilled nursing facility TO Intermediate stop at Physician’s office on way to Hospital|
|PD|20210101|99991231|FROM Physician’s office TO Diagnostic or therapeutic site|
|PE|20210101|99991231|FROM Physician’s office TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|PG|20210101|99991231|FROM Physician’s office TO Hospital based ESRD facility|
|PH|20210101|99991231|FROM Physician’s office TO Hospital|
|PI|20210101|99991231|FROM Physician’s office TO Site of transfer|
|PJ|20210101|99991231|FROM Physician’s office TO Freestanding ESRD facility|
|PN|20210101|99991231|FROM Physician’s office TO Skilled nursing facility|
|PP|20210101|99991231|FROM Physician’s office TO Physician’s office|
|PR|20210101|99991231|FROM Physician’s office TO Residence|
|PX|20210101|99991231|FROM Physician’s office TO Intermediate stop at Physician’s office on way to Hospital
|RG|20210101|99991231|FROM Residence TO Hospital based ESRD facility |
|Modifier|Effective Date|End Date|Description|
|NH|00010101|99991231|FROM Skilled nursing facility TO Hospital|
|NI|00010101|99991231|FROM Skilled nursing facility TO Site of transfer|
|NJ|00010101|99991231|FROM Skilled nursing facility TO Freestanding ESRD facility|
|NN|00010101|99991231|FROM Skilled nursing facility TO Skilled nursing facility|
|NP|00010101|99991231|FROM Skilled nursing facility TO Physician’s office|
|NS|00010101|99991231|FROM Skilled nursing facility TO Scene of accident or acute event|
|NX|00010101|99991231|FROM Skilled nursing facility TO Intermediate stop at Physician’s office on way to Hospital|
|PD|00010101|99991231|FROM Physician’s office TO Diagnostic or therapeutic site|
|PE|00010101|99991231|FROM Physician’s office TO Residential, domiciliary, custodial facility (other than 1819 facility)|
|PG|00010101|99991231|FROM Physician’s office TO Hospital based ESRD facility|
|PH|00010101|99991231|FROM Physician’s office TO Hospital|
|PI|00010101|99991231|FROM Physician’s office TO Site of transfer|
|PJ|00010101|99991231|FROM Physician’s office TO Freestanding ESRD facility|
|PN|00010101|99991231|FROM Physician’s office TO Skilled nursing facility|
|PP|00010101|99991231|FROM Physician’s office TO Physician’s office|
|PR|00010101|99991231|FROM Physician’s office TO Residence|
|PX|00010101|99991231|FROM Physician’s office TO Intermediate stop at Physician’s office on way to Hospital
|RG|00010101|99991231|FROM Residence TO Hospital based ESRD facility |
|
12/17/2021
|
3.0.0 |
PROCEDURE-CODE-MOD
|
UPDATE |
Data Dictionary - Valid Values |
|Modifier|Effective Date|End Date|Description|
|RN|20210101|99991231|FROM Residence TO Skilled nursing facility|
|RS|20210101|99991231|FROM Residence TO Scene of accident or acute event|
|RX|20210101|99991231|FROM Residence TO Intermediate stop at Physician’s office on way to Hospital|
|SI|20210101|99991231|FROM Scene of accident or acute event TO Site of transfer|
|SP|20210101|99991231|FROM Scene of accident or acute event TO Physician’s office|
|SR|20210101|99991231|FROM Scene of accident or acute event TO Residence|
|SX|20210101|99991231|FROM Scene of accident or acute event TO Intermediate stop at Physician’s office on way to Hospital| |
|Modifier|Effective Date|End Date|Description|
|RN|00010101|99991231|FROM Residence TO Skilled nursing facility|
|RS|00010101|99991231|FROM Residence TO Scene of accident or acute event|
|RX|00010101|99991231|FROM Residence TO Intermediate stop at Physician’s office on way to Hospital|
|SI|00010101|99991231|FROM Scene of accident or acute event TO Site of transfer|
|SP|00010101|99991231|FROM Scene of accident or acute event TO Physician’s office|
|SR|00010101|99991231|FROM Scene of accident or acute event TO Residence|
|SX|00010101|99991231|FROM Scene of accident or acute event TO Intermediate stop at Physician’s office on way to Hospital| |
|
12/17/2021
|
3.0.0 |
BILLING-PROV-NUM (COT112)
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |When Type of Service (COT.003.186) not in ('119', ‘120’, ‘122’), then value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'| |
|
12/17/2021
|
3.0.0 |
BILLING-PROV-NUM (COT112)
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |Not Applicable| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |When Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.002.019) Submitting State Provider IDorWhen Type of Claim not in ('Z','3','C','W',"2","B","V"," 4","D","X") then value may match (PRV.005.081) Provider Identifier where the Provider Identifier Type = '1'| |
|
12/17/2021
|
3.0.0 |
BILLING-PROV-NUM (COT112)
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |When Type of Service (COT..003.186) is in ['119', ‘120', '122'] value must match Plan ID Number (COT.002.066)| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT112|BILLING-PROV-NUM| Not Applicable |Not Applicable |Not Applicable| |
|
06/24/2022
|
3.0.0 |
ELG269/ ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
ELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE|9(3)|ELIGIBLE|VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
|
01/07/2022
|
3.0.0 |
ELG086
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|ELG086|PRIMARY-ELIGIBILITY-GROUP-IND| Not Applicable |Not Applicable |A person enrolled in Medicaid/CHIP should always have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.)
It is expected that an enrollee's eligibility group assignment (ELG087 - ELIGIBILITY-GROUP) will change over time as his/her situation changes. Whenever the eligibility group assignment changes (i.e., ELG087 has a different value), a separate ELIGIBILITY-DETERMINANTS record segment must be created. In such situations, there would be multiple ELIGIBILITY-DETERMINANTS record segments, each covering a different effective time span. In such situations, the value in ELG087 would be the primary eligibility group for the effective date span of its respective ELIGIBILITY-DETERMINANTS record segment, and the PRIMARY-ELIGIBILITY-GROUP-IND data element on each of these segments would be set to '1' (YES).| |
|
01/07/2022
|
3.0.0 |
ELG086
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|ELG086|PRIMARY-ELIGIBILITY-GROUP-IND| Not Applicable |Not Applicable |Should a situation arise where a Medicaid/CHIP enrollee has been assigned both a primary and one or more secondary eligibility groups, there would be two or more ELIGIBILITY-DETERMINANTS record segments with overlapping effective time spans - one segment containing the primary eligibility group and the other(s) for the secondary eligibility group(s). To differentiate the primary eligibility group from the secondary group(s), only one segment should be assigned as the primary group using PRIMARY-ELIGIBILITY-GROUP-IND = 1; the others should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = 0.| |
|
12/03/2021
|
3.0.0 |
XIX-MBESCBES-CATEGORY-OF-SERVICE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|XIX-MBESCBES-CATEGORY-OF-SERVICE|20210311|99991231|47|ARP Section 9811 COVID Vaccine/Vaccine Administration| |
|
06/24/2022
|
3.0.0 |
CIP292/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP292|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT |S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP293/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP293|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT |S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP294/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP294|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP295/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP295|COMBINED-BENE-COST-SHARING-PAID-AMOUNT |S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CLT239/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT239|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT240/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT-
CLT240|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT241/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT241|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT242/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT242|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
COT230/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT230|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT231/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT231|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT232/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT232|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT233/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT233|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
CRX163/ TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX163|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX164/ TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX164|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX165/ TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX165|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX166/ COMBINED-BENE-COST-SHARING-PAID-AMOUNT
|
ADD DE |
Data Dictionary - Record Layout |
N/A |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX166|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CIP115/ TOT-COPAY-AMT
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CIP115|TOT-COPAY-AMT|S9(11)V99|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CLT066/ TOT-COPAY-AMT
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CLT066|TOT-COPAY-AMT|S9(11)V99|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT051/ TOT-COPAY-AMT
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
COT051|TOT-COPAY-AMT|S9(11)V99|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
N/A |
|
06/24/2022
|
3.0.0 |
CRX042/ TOT-COPAY-AMT
|
Deprecate DE |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
CRX042|TOT-COPAY-AMT|S9(11)V99|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
N/A |
|
06/24/2022
|
3.0.0 |
COT176/ BENEFICIARY-COPAYMENT-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
COT176|COPAY-AMT |
DE No|Data Element Name
COT176|BENEFICIARY-COPAYMENT-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CRX123/ BENEFICIARY-COPAYMENT-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX123|COPAY-AMT |
DE No|Data Element Name
CRX123|BENEFICIARY-COPAYMENT-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
COT132
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT132|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT132|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
COT130
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT130|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT130|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
COT134
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT134|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT134|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CIP206/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CIP206|BENEFICIARY-COINSURANCE-AMOUNT |
DE No|Data Element Name |
CIP206|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CIP208/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CIP208|BENEFICIARY-COPAYMENT-AMOUNT |
DE No|Data Element Name
CIP208|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CIP210/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CIP210|BENEFICIARY-DEDUCTIBLE-AMOUNT |
DE No|Data Element Name
CIP210|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CLT153/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CLT153|BENEFICIARY-COINSURANCE-AMOUNT |
DE No|Data Element Name
CLT153|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CLT155/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CLT155|BENEFICIARY-COPAYMENT-AMOUNT |
DE No|Data Element Name
CLT155|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CLT157/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CLT157|BENEFICIARY-DEDUCTIBLE-AMOUNT |
DE No|Data Element Name
CLT157|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
COT130/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
COT130|BENEFICIARY-COINSURANCE-AMOUNT |
DE No|Data Element Name
COT130|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
COT132/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
COT132|BENEFICIARY-COPAYMENT-AMOUNT |
DE No|Data Element Name
COT132|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
COT134/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
COT134|BENEFICIARY-DEDUCTIBLE-AMOUNT |
DE No|Data Element Name
COT134|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CRX087/ TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX087|BENEFICIARY-COINSURANCE-AMOUNT |
DE No|Data Element Name
CRX087|TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CRX089/ TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX089|BENEFICIARY-COPAYMENT-AMOUNT |
DE No|Data Element Name
CRX089|TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT |
|
06/24/2022
|
3.0.0 |
CRX092/ TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT
|
Rename DE |
Data Dictionary - Record Layout |
DE No|Data Element Name
CRX092|BENEFICIARY-DEDUCTIBLE-AMOUNT |
DE No|Data Element Name
CRX092|TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT |
|
12/17/2021
|
3.0.0 |
PROCEDURE-CODE-MOD
|
ADD |
Data Dictionary - Valid Values |
add values to the PROCEDURE-CODE-MOD.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
PROCEDURE-CODE-MOD|20070701|99991231|1P|Performance Measure Exclusion Modifier due to Medical Reasons|
PROCEDURE-CODE-MOD|20070701|99991231|2P|Performance Measure Exclusion Modifier due to Patient Reasons|
PROCEDURE-CODE-MOD|20070701|99991231|3P|Performance Measure Exclusion Modifier due to System Reasons | |
|
12/17/2021
|
3.0.0 |
XXI-MBESCBES-CATEGORY-OF-SERVICE
|
ADD |
Data Dictionary - Valid Values |
add values to XXI-MBESCBES-CATEGORY-OF-SERVICE.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|2A|Inpatient Hospital Services - DSH|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|3A|Inpatient Mental Health - DSH|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|3B|Certified Community Behavior Health Clinic Payments|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|8A2|Drug Rebate - State|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|8A3|MCO - National Agreement|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|8A4|MCO - State Sidebar Agreement|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|8A5|Increased ACA OFFSET - Fee for Service - 100%|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|8A6|Increased ACA OFFSET - MCO - 100%|
XXI-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|21A|Home and Community-Based Services - Regular Payment (WAIVER)| |
|
06/24/2022
|
3.0.0 |
ELG270
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
ELG270|LOCKED-IN-SRVCS|Conditional|The type(s) of service that are locked-in|Value must be 3 characters|ELIGIBLE|LOCK-IN-INFORMATION-ELG00009 |
|
06/24/2022
|
3.0.0 |
ELG269
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
ELG269|ELIGIBLE-FEDERAL-POVERTY-LEVEL-PERCENTAGE |Conditional|The beneficiary's or their household's income as a percentage of the federal poverty level. Used to assign the beneficiary to the eligibility group that covered their Medicaid or CHIP benefits. If the beneficiary's income was assessed using multiple methodologies (MAGI and Non-MAGI), report the one that applies to their primary eligibility group.|(LVR) value must be between 0 and 400 inclusively|ELIGIBLE|VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003 |
|
06/24/2022
|
3.0.0 |
ELG271
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
ELG271|ETHNICITY-OTHER|Conditional|A freeform field to document the ethnicity of the beneficiary when the beneficiary identifies themselves as Another Hispanic, Latino, or Spanish origin (ethnicity code 4)|If associated Ethnicity-Code (ELG.015.204) value is in [ "4"], then value must be populated.|ELIGIBLE|ETHNICITY-INFORMATION-ELG00015 |
|
06/24/2022
|
3.0.0 |
ELG194
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
ELG194|NATIONAL-HEALTH-CARE-ENTITY-ID |
N/A |
|
06/24/2022
|
3.0.0 |
ELG195
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
ELG195|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
N/A |
|
06/24/2022
|
3.0.0 |
ELG045
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
ELG045|PRIMARY-LANGUAGE-ENGL-PROF-CODE |
|DE NO| DATA ELEMENT NAME
ELG045|ENGL-PROF-CODE |
|
06/24/2022
|
3.0.0 |
ELG215
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
ELG215|CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR |
|DE NO| DATA ELEMENT NAME
ELG215|AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR |
|
01/07/2022
|
3.0.0 |
ELG233
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|ELG233|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|ELG233|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
|
01/07/2022
|
3.0.0 |
CIP025
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|CIP025|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|CIP025|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
|
01/07/2022
|
3.0.0 |
CLT024
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|CLT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|CLT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
|
01/07/2022
|
3.0.0 |
COT024
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|COT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|COT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
|
01/07/2022
|
3.0.0 |
CRX024
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|CRX024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration.| |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|CRX024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115A demonstration. 1115A is a Center for Medicare and Medicaid Innovation demonstration.| |
|
12/17/2021
|
3.0.0 |
ADJUDICATION-DATE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP098|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|CLT050|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|COT035|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|CRX027|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|CIP286|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|CLT233|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|COT221|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.|
|CRX157|ADJUDICATION-DATE|The date on which the payment status of the claim was finally adjudicated by the state.| |
|DE No|Data Element Name|Definition|
|CIP098|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.|
|CLT050|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.|
|COT035|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.|
|CRX027|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.|
|CIP286|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.|
|CLT233|ADJUDICATION-DATE|TThe 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.|
|COT221|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.|
|CRX157|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.| |
|
12/03/2021
|
3.0.0 |
XXI-MBESCBES-CATEGORY-OF-SERVICE
|
ADD |
Data Dictionary - Valid Values |
N/A |
|VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
|XXI-MBESCBES-CATEGORY-OF-SERVICE|20210311|99991231|26|ARP Section 9821 COVID Vaccine/Vaccine Administration| |
|
06/24/2022
|
3.0.0 |
MCR091/ RECORD-ID,
MCR092/ SUBMITTING-STATE,
MCR093/ RECORD-NUMBER,
MCR094/ STATE-PLAN-ID-NUM,
MCR095/ NATIONAL-HEALTH-CARE-ENTITY-ID,
MCR096/ NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE,
MCR097/ NATIONAL-HEALTH-CARE-ENTITY-NAME,
MCR098/ NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE,
MCR099/ NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE,
MCR0100/ STATE-NOTATION,
MCR0101/ FILLER
|
Deprecate Segment |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
MCR091|RECORD-ID|X(8)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR092|SUBMITTING-STATE|X(2)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR093|RECORD-NUMBER|9(11)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR094|STATE-PLAN-ID-NUM|X(12)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR095|NATIONAL-HEALTH-CARE-ENTITY-ID|X(10)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR096|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE|X(1)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR097|NATIONAL-HEALTH-CARE-ENTITY-NAME|X(50)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR098|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE|9(8)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR099|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE|9(8)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR0100|STATE-NOTATION|X(500)|MNGDCARE |NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR0101|FILLER|X(390)|MNGDCARE|NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008 |
N/A |
|
06/24/2022
|
3.0.0 |
MCR102/ RECORD-ID,
MCR103/ SUBMITTING-STATE,
MCR104/ RECORD-NUMBER,
MCR105/ STATE-PLAN-ID-NUM,
MCR106/ CHPID,
MCR107/ SHPID,
MCR108/ CHPID-SHPID-RELATIONSHIP-EFF-DATE,
MCR109/ CHPID-SHPID-RELATIONSHIP-END-DATE,
MCR110/ STATE-NOTATION,
MCR111/ FILLER
|
Deprecate Segment |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE NAME|FILE SEGMENT
MCR102|RECORD-ID|X(8)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR103|SUBMITTING-STATE|X(2)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR104|RECORD-NUMBER|9(11)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR105|STATE-PLAN-ID-NUM|X(12)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR106|CHPID|X(8)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR107|SHPID|X(10)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR108|CHPID-SHPID-RELATIONSHIP-EFF-DATE|9(8)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR109|CHPID-SHPID-RELATIONSHIP-END-DATE|9(8)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR110|STATE-NOTATION|X(500)|MNGDCARE |CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR111|FILLER|X(431)|MNGDCARE|CHPID-SHPID-RELATIONSHIPS-MCR00009 |
N/A |
|
06/24/2022
|
3.0.0 |
TPL093
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
TPL093|NATIONAL-HEALTH-CARE-ENTITY-ID |
N/A |
|
06/24/2022
|
3.0.0 |
TPL092
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
TPL092|NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE |
N/A |
|
06/24/2022
|
3.0.0 |
TPL094
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
TPL094|NATIONAL-HEALTH-CARE-ENTITY-NAME |
N/A |
|
06/24/2022
|
3.0.0 |
CIP107
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP107|ALLOWED-CHARGE-SRC |
N/A |
|
06/24/2022
|
3.0.0 |
CIP071
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP071|PROCEDURE-CODE-MOD-1 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP075
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP075|PROCEDURE-CODE-MOD-2 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP079
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP079|PROCEDURE-CODE-MOD-3 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP083
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP083|PROCEDURE-CODE-MOD-4 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP087
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP087|PROCEDURE-CODE-MOD-5 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP091
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP091|PROCEDURE-CODE-MOD-6 |
N/A |
|
06/24/2022
|
3.0.0 |
CIP193
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP193|REFERRING-PROV-SPECIALTY |
N/A |
|
06/24/2022
|
3.0.0 |
CIP191
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP191|REFERRING-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CIP192
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP192|REFERRING-PROV-TYPE |
N/A |
|
06/24/2022
|
3.0.0 |
CIP224
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP224|UNDER-DIRECTION-OF-PROV-NPI |
N/A |
|
06/24/2022
|
3.0.0 |
CIP225
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP225|UNDER-DIRECTION-OF-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CIP226
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP226|UNDER-SUPERVISION-OF-PROV-NPI |
N/A |
|
06/24/2022
|
3.0.0 |
CIP227
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP227|UNDER-SUPERVISION-OF-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CIP131
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP131|NATIONAL-HEALTH-CARE-ENTITY-ID |
N/A |
|
06/24/2022
|
3.0.0 |
CIP201
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP201|BMI |
N/A |
|
06/24/2022
|
3.0.0 |
CIP115
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP115|TOT-COPAY-AMT |
N/A |
|
06/24/2022
|
3.0.0 |
CIP253
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP253|TPL-AMT |
N/A |
|
06/24/2022
|
3.0.0 |
CIP262
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CIP262|SERVICING-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CIP208
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP208|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP208|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CIP206
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP206|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP206|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CIP210
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP210|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP210|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CIP249
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CIP249|IP-LT-QUANTITY-OF-SERVICE-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CIP249|REVENUE-CENTER-QUANTITY-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field| |
|
06/24/2022
|
3.0.0 |
CIP250
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED| |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CIP250|REVENUE-CENTER-QUANTITY-ALLOWED|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field |
|
06/24/2022
|
3.0.0 |
CIP290
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP290|BEGINNING-DATE-OF-SERVICE|Mandatory|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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.|Value must be 8 characters in the form "CCYYMMDD"
The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated End of Time Period value
Value must be less than or equal to associated Ending Date of Service value
When Type of Claim is not in ['2', '4', 'B', 'D', 'V'] value must be less than or equal to associated Adjudication Date value
Value must be less than or equal to associated Date of Death (ELG.002.025) value when populated
Value must be less than or equal to at least one of the eligible's Enrollment End Date (ELG.021.254) values
|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP295
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP295|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP293
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP293|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CRX164
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX164|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CIP292
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP292|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT |Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP294
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP294|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMIP|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP296
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CIP296|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 character
Value must be in [0, 1] or not populated|CLAIMIP|CLAIM-LINE-RECORD-IP-CIP00003 |
|
01/28/2022
|
3.0.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
PROV-TAXONOMY.psv v20.1 07/01/2020 |
PROV-TAXONOMY.psv v22.0 - 01/01/2022 |
|
06/24/2022
|
3.0.0 |
SSI-IND
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT
ELG090|SSI-IND| A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).| 1.(LV) value must be in SSI Indicator List (VVL)
2.(S) value must be 1 character
3.(N) conditional
4.(FD1) value must equal '0' when SSI Status equals '003' or is not populated| |
DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT
ELG090|SSI-IND| A flag indicating if the individual receives Supplemental Security Income (SSI) administered via the Social Security Administration (SSA).|1.(GS) value must satisfy the requirements of Boolean (DT)
2.(LV) value must be in SSI Indicator List (VVL)
3.(S) value must be 1 character
4.(N) conditional
5.(FD1) value must equal '0' when SSI status (ELG.005.092) equals '000' or '003' or is not populated
6.(FD1) value must equal '1' when SSI status (ELG.005.092) equals '001' or '002'| |
|
06/24/2022
|
3.0.0 |
SSI-STATE-SUPPLEMENT-STATUS-CODE
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG091|SSI-STATE-SUPPLEMENT-STATUS-CODE|Indicates the individual's State Supplemental Income Status.|
1.(LV) value must be in SSI State Supplement Status Code List (VVL)
2.(FD1) (individual not receiving Federal SSI) If SSI State Supplemental Status Code is "001" or "002", then SSI Status cannot be "000" or "003"
3.(S) value must be 3 characters
4.(N) conditional
5.(FD1) value must not be populated when SSI Status is not populated |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG091|SSI-STATE-SUPPLEMENT-STATUS-CODE|Indicates the individual's State Supplemental Income Status.|
1.(LV) value must be in SSI State Supplement Status Code List (VVL)
2.(S) value must be 3 characters
3.(FD1) (individual not receiving Federal SSI)If value is "001" or "002", then SSI Status (ELG.005.092) must be "001" or "002"
4.(FD1) (Individual not receiving Federal SSI)If value is "001" or "002", then SSI Indicator (ELG.005.090) must be '1'
5.(FD1) value must not be populated or must be '000' when SSI Status (ELG.005.092) is not populated or is '000' |
|
06/24/2022
|
3.0.0 |
SSI-STATUS
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG092|SSI-STATUS|Indicates the individual's SSI Status.|1.(LV) value must be in SSI Status List (VVL)
2.(S) value must be 3 characters
3.(N) conditional
4.(FD1) value must be populated when SSI Indicator equals '1' |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG092|SSI-STATUS|Indicates the individual's SSI Status.|1.(LV) value must be in SSI Status List (VVL)
2.(S) value must be 3 characters
3.(N) conditional
4.(FD1) when value is '001' or '002', then SSI Indicator must be '1'
5. (FD1) when value is '000' or '003' or not populate, then SSI Indicator must be '0' |
|
06/24/2022
|
3.0.0 |
TOT-COPAY-AMT
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP115|TOT-COPAY-AMT|The total amount paid by Medicaid/CHIP enrollee for each office or emergency department visit or purchase of prescription drugs in addition to the amount paid by Medicaid/CHIP.
1.(GS) value must satisfy the requirements of Total Medicare Deductible Amount (CE) |
|DE No|Data Element Name|Definition|
|CIP115|TOT-COPAY-AMT|The total amount paid by Medicaid/CHIP enrollee towards a copayment for the service.
1.(GS) value must satisfy the requirements of Total Copayment Amount (CE) |
|
06/24/2022
|
3.0.0 |
MEDICARE-DEDUCTIBLE-AMT
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CRX127|MEDICARE-DEDUCTIBLE-AMT| The amount paid by Medicaid/CHIP on this claim at the claim line 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 and MEDICARE-COINSURANCE-PAYMENT is not required.|
1.(GS) value must satisfy the requirements of US Dollar Amount (DT)
2.(N) conditional
The amount paid by Medicaid/CHIP on this claim at the claim line 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 and MEDICARE-COINSURANCE-PAYMENT is not required. see US Dollar Amount (TMSIS.DT.000.008) |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CRX127|MEDICARE-DEDUCTIBLE-AMT|
The amount paid by Medicaid/CHIP on this claim at the claim line 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 and Medicare Coinsurance Payment is not required.|
1.(GS) value must satisfy the requirements of US Dollar Amount (DT)
2.(N) conditional
3.(FD1) value should not be populated if associated Crossover Indicator value |
|
06/24/2022
|
3.0.0 |
MEDICARE-COINS-AMT
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|
CRX128|MEDICARE-COINS-AMT|The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the MEDICARE-DEDUCTIBLE-AMT. See US Dollar Amount (DT)|
1.Value must be between -99999999999.99 and 99999999999.99
2.Value must be expressed as a number with 2-digit precision (e.g. 100.50 )
3.(payments can't be separated) value 99998 is an exception to the US Dollar Amount requirements
4.(N) conditional |
DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|
CRX128|MEDICARE-COINS-AMT|The amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare coinsurance at the claim detail level. If the Medicare coinsurance amount can be identified separately from Medicare deductible payments, code that amount in this field. If Medicare coinsurance and deductible payments cannot be separated, populate the Medicare Deductible Amount.|
1. Value must be between -99999999999.99 and 99999999999.99
2. if associated Medicare Combined Deductible Indicator is '1', then value must not be populated (or must be 99998)
3. Value must be expressed as a number with 2-digit precision (e.g. 100.50 )
4. Value must not be populated if Medicare Deductible Amount is not populated
5. Conditional |
|
06/24/2022
|
3.0.0 |
DISPENSE-FEE
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CRX141|DISPENSE-FEE|The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription.
Dispense Fee reflects the amount billed by the provider towards the professional dispensing fee.
If the provider does not break out the professional dispensing
fee on the NCPDP transaction, this field should be left blank in T-MSIS.
There is currently no specific field in T-MSIS to capture either the professional
dispensing fee amount paid, or the amount billed or paid towards ingredient costs.|
1.(S) value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.789
2.(N) mandatory |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CRX141|DISPENSE-FEE|The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription.
Dispense Fee reflects the amount billed by the provider towards the professional dispensing fee.
If the provider does not break out the professional dispensing
fee on the NCPDP transaction, this field should be left blank in T-MSIS.
1.(LVR) value must be between -99999999999.99 and 99999999999.99
2.(S) value must be expressed as a number with 2-digit precision (e.g. 100.50 )
3.(S) value may include up to 6 digits to the left of the decimal point, and 3 digits to the right e.g. 123456.78
4.(N) mandatory |
|
06/24/2022
|
3.0.0 |
PRIMARY-LANGUAGE-ENGL-PROF-CODE
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG045|PRIMARY-LANGUAGE-ENGL-PROF-CODE |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG045|ENGL-PROF-CODE |
|
06/24/2022
|
3.0.0 |
LEVEL-OF-CARE-STATUS
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG088|LEVEL-OF-CARE-STATUS||
1. Value must be in Level of Care Status List (VVL)
2. Value must be 3 characters
3. Conditional |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG088|LEVEL-OF-CARE-STATUS||
1. Value must be in Level of Care Status List (VVL)
2. Value must be 3 characters
3. Mandatory |
|
06/24/2022
|
3.0.0 |
LOCKIN-PROV-NUM
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG140|LOCKIN-PROV-NUM| The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers,
practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System.|
1.Value must be 30 characters or less
2.Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'
3.(N) mandatory
4.(DI) value must match Provider Identifier (PRV.005.081) |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG140|LOCKIN-PROV-NUM|
The State-specific Medicaid Provider Identifier is a state-assigned unique identifier that states should report with all individual providers,
practice groups, facilities, and other entities. This should be the identifier that is used in the state's Medicaid Management Information System.|
1.Value must be 30 characters or less
2.(N) mandatory |
|
06/24/2022
|
3.0.0 |
LOCKIN-PROV-TYPE
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG141|LOCKIN-PROV-TYPE||
1.(LV) value must be in Lockin Provider Type List (VVL)
2.Value must be 2 characters
3.Mandatory |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG141|LOCKIN-PROV-TYPE||
1.(LV) value must be in Provider Type Code List (VVL)
2.Value must be 2 characters
3.Mandatory |
|
06/24/2022
|
3.0.0 |
MFP-REASON-PARTICIPATION-ENDED
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG153|MFP-REASON-PARTICIPATION-ENDED| A code describing why an individual's participation in Money Follows the Person demonstration ended.|
1. (LV) value must be in MFP Reason Participation Ended List (VVL)
2.(S) value must be 2 characters
3.(N) conditional
4.(FD1) value must not be populated when Enrollment End Date equals '9999-12-31' |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG153|MFP-REASON-PARTICIPATION-ENDED| A code describing why an individual's participation in Money Follows the Person demonstration ended.
1. (LV) value must be in MFP Reason Participation Ended List (VVL)
2.(S) value must be 2 characters
3.(N) conditional
4.(FD1) value must not be populated when Enrollment End Date equals '9999-12-31'
5.(FD1) value must be populated when Enrollment End Date does not equal '9999-12-31' |
|
06/24/2022
|
3.0.0 |
LTSS-LEVEL-CARE
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG182|LTSS-LEVEL-CARE||
1.(LV) value must be in LTSS Level Care List (VVL)| |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG182|LTSS-LEVEL-CARE||
1.(LV) value must be in LTSS Level of Care List (VVL)| |
|
06/24/2022
|
3.0.0 |
LTSS-PROV-NUM
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG183|LTSS-PROV-NUM|
A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual.|
1.Value must be 30 characters or less
2. Value must be reported in Provider Identifier (PRV.005.080) with an associated Provider Identifier Type (PRV.005.081) equal to '1'
3.(N) mandatory
4.(DI) value must match Provider Identifier (PRV.005.081)| |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
ELG183|LTSS-PROV-NUM|A unique identification number assigned by the state to the long term care facility furnishing healthcare services to the individual.|
1.Value must be 30 characters or less
2.(N) mandatory| |
|
06/24/2022
|
3.0.0 |
DATE-OF-BIRTH
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
PRV034|DATE-OF-BIRTH|An individual's date of birth.|
1.Value must be 8 characters in the form "CCYYMMDD"
2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
3. (FD1) value must be less than or equal to associated End of Time Period (PRV.001.010)
4. (FD1) value must be less than or equal to associated Date File Created (PRV.001.008)
5. (N) conditional
6. (FDN) the difference between current value and Start of Time Period (PRV.001.009) must be between 18 and 85 years| |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
PRV034|DATE-OF-BIRTH|An individual's date of birth.|
1.Value must be 8 characters in the form "CCYYMMDD"
2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
3.(FD1) value must be less than or equal to associated End of Time Period (PRV.001.010)
4.(N) conditional
5.(FDN) the difference between current value and Start of Time Period (PRV.001.009) must be between 18 and 85 years| |
|
06/24/2022
|
3.0.0 |
POLICY-OWNER-FIRST-NAME
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
TPL044|POLICY-OWNER-FIRST-NAME|Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name).|
1.Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3.(FD1) if TPL Health Insurance Coverage Indicator (TPL.002.020) equals "1", then value is mandatory| |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
TPL044|POLICY-OWNER-FIRST-NAME|Individual's first name; first name component of full name (e.g. First Name, Middle Initial, Last Name).|
1.Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3.(N) Mandatory| |
|
06/24/2022
|
3.0.0 |
POLICY-OWNER-LAST-NAME
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
TPL045|POLICY-OWNER-LAST-NAME|Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name).
1.Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3.(N) Mandatory |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
TPL045|POLICY-OWNER-LAST-NAME|Individual's last name; last name component of full name (e.g. First Name, Middle Initial, Last Name).
1.Value must be 30 characters or less
2. Value must not contain a pipe or asterisk symbols
3.(FD1) if TPL Health Insurance Coverage Indicator (TPL.002.020) equals "1", then value is mandatory |
|
06/24/2022
|
3.0.0 |
TYPE-OF-OTHER-THIRD-PARTY-LIABILITY
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
TPL067|TYPE-OF-OTHER-THIRD-PARTY-LIABILITY|This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed INSURANCE-TYPE-PLAN.|
1.(FDN) If value equals "Other". then Policy Owner (TPL.003.044-047) information is not required
2.(S) value must be 1 character
3.(LV) value must be in Type of Other Third Party Liability List (VVL)
4.(N) mandatory |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
TPL067 |TYPE-OF-OTHER-THIRD-PARTY-LIABILITY|This code identifies the other types of liabilities an individual may have which are not necessarily defined as a health insurance plan listed Insurance Type Plan.|
1.(S) value must be 1 character
2.(LV) value must be in Type of Other Third Party Liability List (VVL)
3.(N) mandatory |
|
06/24/2022
|
3.0.0 |
IP-LT-QUANTITY-OF-SERVICE-ALLOWED
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
CIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED|On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service
being reported was performed.| |
|DE No|Data Element Name|Definition|
CIP250|IP-LT-QUANTITY-OF-SERVICE-ALLOWED| On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service
being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled.| |
|
06/24/2022
|
3.0.0 |
COMPOUND-DRUG-IND
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|
CRX086|COMPOUND-DRUG-IND|Indicator to specify if the drug is compound or not. see Compound Drug Indicator List (VVL.038)|
1.(LV) value must be in Compound Drug Indicator List (VVL)
2.(S) value must be 1 character
3.(N) conditional |
DE NO|DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT|
CRX086|COMPOUND-DRUG-IND Indicator to specify if the drug is compound or not.|
1.(S) value must be 1 character
2.(LV) value must be in [0, 1] or not populated
3.(LV) value must be in Compound Drug Indicator List (VVL)
4.(N) conditional |
|
06/24/2022
|
3.0.0 |
ADMITTING-DIAGNOSIS-CODE
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
CLT027|ADMITTING-DIAGNOSIS-CODE|ICD-9 or ICD-10 diagnosis codes used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnosis codes should be passed through to T-MSIS exactly as they were submitted by the provider on their claim (with the exception of removing the decimal). For example: 210.5 is coded as "2105".
1.(GS) value must satisfy the requirements of Diagnosis Code (CE)| |
|DE No|Data Element Name|Definition|
CLT.027|ADMITTING-DIAGNOSIS-CODE|The ICD-9/10-CM Diagnosis Code provided at the time of admission by the physician.
1.(GS) value must satisfy the requirements of Diagnosis Code (CE)| |
|
06/24/2022
|
3.0.0 |
DATE-OF-BIRTH
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CLT126|DATE-OF-BIRTH| An individual's date of birth.|
1.Value must be 8 characters in the form "CCYYMMDD"
2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
3.(N) mandatory
4.(FD) value must equal Date of Birth (ELG.002.024) when Conception to Birth Indicator (ELG.005.094) does not equal '1' and Eligibility Group (ELG.005.087)
does not equal '64'| |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CLT126|DATE-OF-BIRTH| An individual's date of birth.|
Description: An individual's date of birth.
1.Value must be 8 characters in the form "CCYYMMDD"
2. The date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
3.(N) mandatory| |
|
06/24/2022
|
3.0.0 |
ADMISSION-HOUR
|
UPDATE |
Data Dictionary |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CLT045|ADMISSION-HOUR |The time of admission to a psychiatric or long-term care facility.|
1.(LV) value must be in Hour List (VVL)
2.(S) value must be 2 characters
3.(N) conditional| |
DE NO|DATA ELEMENT NAME| DEFINITION|CODING REQUIREMENT|
CLT045|ADMISSION-HOUR |The time of admission to a psychiatric or long-term care facility.|
1.(LV) value must be in Hour List (VVL)
2.(S) value must be 2 characters
3.(N) conditional
4.(FD1) when populated, Admission Date (CLT.002.044) must be populated| |
|
01/28/2022
|
3.0.0 |
ELG095
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status.| |
|DE NO| DATA ELEMENT NAME |DEFINITION|
|ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a change in an individual's eligibility status. The end date of the segment in which the value is reported must represent the date that the change occurred. The reason for change represents the reason that the segment in which it was reported was closed.| |
|
06/24/2022
|
3.0.0 |
ELG108
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG108|HEALTH-HOME-ENTITY-NAME|A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|
1.(S) value must 100 characters or less
2.(IV) value must not contain a pipe symbol
3.(N) mandatory| |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG108|HEALTH-HOME-ENTITY-NAME|A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|
1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)
2.(S) value must 100 characters or less
3.(N) mandatory| |
|
06/24/2022
|
3.0.0 |
HEALTH-HOME-ENTITY-EFF-DATE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition|CODING REQUIREMENT|
ELG111|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|
1.(GS) value must satisfy the requirements of Date (DT) |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG111|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|
1.(GS) value must satisfy the requirements of Health Home Entity Effective Date (CE) |
|
06/24/2022
|
3.0.0 |
ELG119
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG119|HEALTH-HOME-ENTITY-NAME| A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|
1.(S) value must 100 characters or less
2.(IV) value must not contain a pipe symbol
3.(N) mandatory |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG119|HEALTH-HOME-ENTITY-NAME|
A field to identify the health home SPA in which an individual is enrolled. Because an identification numbering schema has not been established, the entities' names are being used instead.|
1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)
2.(S) value must 100 characters or less
3.(N) mandatory |
|
06/24/2022
|
3.0.0 |
HEALTH-HOME-ENTITY-EFF-DATE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG123|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|
1.Value must be 8 characters in the form "CCYYMMDD"
2.(LV) the date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
2.(N) mandatory |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG123|HEALTH-HOME-ENTITY-EFF-DATE|The date on which the health home entity was approved by CMS to participate in the Health Home Program.|
1.(S) value must be 8 characters in the form 'YYYYMMDD'
2.(LV) the date must be a valid calendar date (i.e. Feb 29th only on the leap year, never April 31st or Sept 31st)
3.(N) mandatory |
|
06/24/2022
|
3.0.0 |
PROV-LOCATION-ID
|
UPDATE |
Data Dictionary |
DE No|Data Element Name| CODING REQUIREMENT|
PRV043|PROV-LOCATION-ID|
1.(IV) value must not contain a pipe symbol
2.(S) value must be 5 characters or less |
DE No|Data Element Name| CODING REQUIREMENT|
PRV043|PROV-LOCATION-ID|
1. (IV) value must not contain a pipe or asterisk symbols
2. (S) value must be 5 characters or less
3. (N) mandatory |
|
06/24/2022
|
3.0.0 |
PROV-LOCATION-ID
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV064|PROV-LOCATION-ID||
1.(IV) value must not contain a pipe symbol
2.(S) value must be 5 characters or less |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV064|PROV-LOCATION-ID||
1. (IV) value must not contain a pipe or asterisk symbols
2. (S) value must be 5 characters or less
3. (N) mandatory |
|
06/24/2022
|
3.0.0 |
PROV-LOCATION-ID
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV.076|PROV-LOCATION-ID||
1.(IV) value must not contain a pipe symbol
2.(S) value must be 5 characters or less |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV.076|PROV-LOCATION-ID||
1. (IV) value must not contain a pipe or asterisk symbols
2. (S) value must be 5 characters or less
3. (N) mandatory |
|
06/24/2022
|
3.0.0 |
PROV-LOCATION-ID
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV129|PROV-LOCATION-ID||
1.(IV) value must not contain a pipe symbol
2.(S) value must be 5 characters or less |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV129|PROV-LOCATION-ID||
1. (IV) value must not contain a pipe or asterisk symbols
2. (S) value must be 5 characters or less
3. (N) mandatory |
|
06/24/2022
|
3.0.0 |
NON-COV-DAYS
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CIP134|NON-COV-DAYS|The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered
days does not refer to days not covered for any other service.
1.Value must be a positive integer
2.Value must be between 0:99999999999 (inclusive)
3.Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CIP134|NON-COV-DAYS|The number of days of inpatient care not covered by the payer for this sequence as qualified by the payer organization. The number of non-covered
days does not refer to days not covered for any other service.
1. (S) value must be 5 digits or less
2.(N) conditional |
|
06/24/2022
|
3.0.0 |
CIP214
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CIP214|HEALTH-HOME-ENTITY-NAME||
1.Value must 50 characters or less
2.Value must not contain a pipe or asterisk symbols
3.Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CIP214|HEALTH-HOME-ENTITY-NAME||
1.1.(IV) value must not contain a pipe or asterisk symbols
2.(S) value must 50 characters or less
3.(N) conditional |
|
06/24/2022
|
3.0.0 |
COT138
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
COT138|HEALTH-HOME-ENTITY-NAME||
1.Value must 50 characters or less
2.Value must not contain a pipe or asterisk symbols
3.Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
COT138|HEALTH-HOME-ENTITY-NAME||
1.1.(IV) value must not contain a pipe or asterisk symbols
2.(S) value must 50 characters or less
3.(N) conditional |
|
06/24/2022
|
3.0.0 |
CRX096
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CRX.096|HEALTH-HOME-ENTITY-NAME||
1.(GS) value must satisfy the requirements of Health Home Entity Name (CE) |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CRX.096|HEALTH-HOME-ENTITY-NAME||
1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)
2.(S) value must 50 characters or less
3.(N) conditional |
|
06/24/2022
|
3.0.0 |
NON-COV-DAYS
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CLT084|NON-COV-DAYS||
1.(GS) value must satisfy the requirements of Non-Covered Days (CE)
2.(S) value must be 5 digits or less |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CLT084|NON-COV-DAYS||
1.(GS) value must satisfy the requirements of Non-Covered Days (CE) |
|
06/24/2022
|
3.0.0 |
CLT161
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CLT.161|HEALTH-HOME-ENTITY-NAME||
1.(GS) value must satisfy the requirements of Health Home Entity Name (CE) |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CLT.161|HEALTH-HOME-ENTITY-NAME||
1.(GS) value must satisfy the requirements of Health Home Entity Name (CE)
2.(S) value must 50 characters or less
3.(N) conditional |
|
06/24/2022
|
3.0.0 |
MARITAL-STATUS-OTHER-EXPLANATION
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG035|MARITAL-STATUS-OTHER-EXPLANATION||
1.(FD1) if associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided
2.(S) value must be 50 characters or less
3.(N) conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG035|MARITAL-STATUS-OTHER-EXPLANATION||
1.(FD1) if associated Marital Status (ELG.003.035) equals '14' (Other), then value is mandatory and must be provided
2.(S) value must be 50 characters or less
3.(IV) value must not contain a pipe or asterisk symbol
4.(N) conditional |
|
06/24/2022
|
3.0.0 |
IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG044|IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE||
1.(GS) value must satisfy the requirements of End Date (CE)
2.(FD1) (U.S. Citizen) if associated Citizenship Indicator (ELG.003.040) value is '1', then value should not be populated
3.(FD1) (Non U.S. Citizen) if associated Citizenship Indicator (ELG.003.040) value is '0', then value should be populated
4.(N) conditional
5.(FD1) (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
ELG044|IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE||
1.(GS) value must satisfy the requirements of Date (CE)
2.(N) conditional
3.(FD1) (U.S. Citizen) value should not be populated when Immigration Status (ELG.003.042) equals '8' |
|
06/24/2022
|
3.0.0 |
TEACHING-IND
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV027|TEACHING-IND||
1.(LV) value must be in Teaching Indicator List (VVL)
2.(S) value must be 1 character
3.(N) conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
PRV027|TEACHING-IND||
1.(LV) value must be in Teaching Indicator List (VVL)
2.(S) value must be 1 character
3. (FD) value must be '0' when Facility Group Individual Code (PRV.002.026) equals '02' or '03'
4.(N) conditional |
|
06/24/2022
|
3.0.0 |
TPL-ENTITY-ADDR-TYPE
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
TPL.076|TPL-ENTITY-ADDR-TYPE||
1.(LV) value must be in TPL Entity Address Type List (VVL)
2.(S) value must be 2 characters
3.(N) conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
TPL.076|TPL-ENTITY-ADDR-TYPE||
1.(LV) value must be in TPL Entity Address Type List (VVL)
2.(S) value must be 2 characters
3.(N) mandatory |
|
06/24/2022
|
3.0.0 |
1115A-DEMONSTRATION-IND
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CIP025|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CIP025|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional
5. Value must be in [0, 1] or not populated |
|
06/24/2022
|
3.0.0 |
1115A-DEMONSTRATION-IND
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
COT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
COT024|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional
5. Value must be in [0, 1] or not populated |
|
06/24/2022
|
3.0.0 |
1115A-DEMONSTRATION-IND
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CRX024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CRX024|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional
5. Value must be in [0, 1] or not populated |
|
06/24/2022
|
3.0.0 |
1115A-DEMONSTRATION-IND
|
UPDATE |
Data Dictionary |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CLT024|1115A-DEMONSTRATION-IND|Indicates that the claim or encounter was covered under the authority of an 1115(A) demonstration. 1115(A) is a Center for Medicare and Medicaid Innovation demonstration|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, the associated 1115A Demonstration Indicator (ELG.018.223) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional |
DE No|Data Element Name|Definition| CODING REQUIREMENT|
CLT024|1115A-DEMONSTRATION-IND|In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115(A) demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115(A) demonstration.|
1. Value must be in 1115A Demonstration Indicator List (VVL)
2.(FD1) when value equals '0', is invalid or not populated, then the associated 1115A Demonstration Indicator (ELG.018.233) must equal '0', is invalid or not populated
3. Value must be 1 character
4. Conditional
5. Value must be in [0, 1] or not populated |
|
05/13/2022
|
3.0.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
PROCEDURE-CODE-MOD|20080101|20201231|ED|Hct>39% or hgb>13g>=3 cycle|Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
PROCEDURE-CODE-MOD|20210101|99991231|ED|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Diagnostic or therapeutic site|
PROCEDURE-CODE-MOD|20080101|20201231|EE|Hct>39% or hgb>13g<3 cycle|Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
PROCEDURE-CODE-MOD|20210101|99991231|EE|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Residential, domiciliary, custodial facility (other than 1819 facility)| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
PROCEDURE-CODE-MOD|00010101|20201231|ED|Hct>39% or hgb>13g>=3 cycle|Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
PROCEDURE-CODE-MOD|20210101|99991231|ED|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Diagnostic or therapeutic site|
PROCEDURE-CODE-MOD|00010101|20201231|EE|Hct>39% or hgb>13g<3 cycle|Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle
PROCEDURE-CODE-MOD|20210101|99991231|EE|FROM Residential, domiciliary, custodial facility (other than 1819 facility) TO Residential, domiciliary, custodial facility (other than 1819 facility)| |
|
06/24/2022
|
3.0.0 |
CLT239
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CLT239|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT241
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CLT241|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT139
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT139|REFERRING-PROV-SPECIALTY |
N/A |
|
06/24/2022
|
3.0.0 |
CLT137
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT137|REFERRING-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CLT138
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT138|REFERRING-PROV-TYPE |
N/A |
|
06/24/2022
|
3.0.0 |
CLT214
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT214|SERVICING-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CLT169
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT169|UNDER-DIRECTION-OF-PROV-NPI |
N/A |
|
06/24/2022
|
3.0.0 |
CLT170
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT170|UNDER-SUPERVISION-OF-PROV-NPI |
N/A |
|
06/24/2022
|
3.0.0 |
CLT171
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT171|UNDER-SUPERVISION-OF-PROV-NPI |
N/A |
|
06/24/2022
|
3.0.0 |
CLT172
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT172|UNDER-SUPERVISION-OF-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CLT081
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT081|NATIONAL-HEALTH-CARE-ENTITY-ID |
N/A |
|
06/24/2022
|
3.0.0 |
CLT143
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT143|BMI |
N/A |
|
06/24/2022
|
3.0.0 |
CLT066
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CLT066|TOT-COPAY-AMT |
N/A |
|
06/24/2022
|
3.0.0 |
CLT242
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CLT242|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT240
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CLT240|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMLT|CLAIM-HEADER-RECORD-LT-CLT00002 |
|
06/24/2022
|
3.0.0 |
CLT243
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CLT243|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 character
Value must be in [0, 1] or not populated|CLAIMLT|CLAIM-LINE-RECORD-LT-CLT00003 |
|
06/24/2022
|
3.0.0 |
CLT155
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT155|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT155|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CLT153
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT153|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT153|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CLT157
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT157|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT157|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CLT202
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CLT202|IP-LT-QUANTITY-OF-SERVICE-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CLT202|REVENUE-CENTER-QUANTITY-ACTUAL|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field |
|
06/24/2022
|
3.0.0 |
CLT203
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CLT203|IP-LT-QUANTITY-OF-SERVICE-ALLOWED|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT and CLAIMRX claims/encounter records, use the OT-RX-CLAIM-QUANTITY-ACTUAL field |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CLT203|REVENUE-CENTER-QUANTITY-ALLOWED|For use with CLAIMIP and CLAIMLT claims. For CLAIMOT claims/encounter records use SERVICE-QUANTITY-ACTUAL and CLAIMRX claims/encounter records use the PRESCRIPTION-QUANTITY-ACTUAL field |
|
06/24/2022
|
3.0.0 |
COT228
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT228|ORDERING-PROV-NUM|Conditional|The Medicaid provider ID of the Ordering Provider is the individual who requested the services or items being reported on this service line. Examples include, but are not limited to, provider ordering diagnostic tests and medical equipment or supplies|Value must be 30 characters or less|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT229
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT229|ORDERING-PROV-NPI-NUM|Conditional|A National Provider Identifier (NPI) is a unique 10-digit identification number issued to health care providers in the United States by CMS. Healthcare providers acquire their unique 10-digit NPIs to identify themselves in a standard way throughout their industry. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number).|Value must be 10 digits, consisting of 9 numeric digits followed by one check digit calculated using the Luhn formula (algorithm)|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT233
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT233|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT231
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT231|TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT230
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT230|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT232
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT232|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMOT|CLAIM-HEADER-RECORD-OT-COT00002 |
|
06/24/2022
|
3.0.0 |
COT234
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
COT234|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 character
Value must be in [0, 1] or not populated|CLAIMOT|CLAIM-LINE-RECORD-OT-COT00003 |
|
09/26/2022
|
3.0.3 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
RESTRICTED-BENEFITS-CODE|20230101|99991231|G|Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status Medicare Part B-ID ESRD Benefit. |
|
06/24/2022
|
3.0.0 |
COT144
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT144|DATE-CAPITATED-AMOUNT-REQUESTED |
N/A |
|
06/24/2022
|
3.0.0 |
COT145
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT145|CAPITATED-PAYMENT-AMT-REQUESTED |
N/A |
|
06/24/2022
|
3.0.0 |
COT121
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT121|REFERRING-PROV-SPECIALTY |
N/A |
|
06/24/2022
|
3.0.0 |
COT119
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT119|REFERRING-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
COT120
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT120|REFERRING-PROV-TYPE |
N/A |
|
06/24/2022
|
3.0.0 |
COT148
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT148|UNDER-DIRECTION-OF-PROV-NPI |
N/A |
|
06/24/2022
|
3.0.0 |
COT149
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT149|UNDER-DIRECTION-OF-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
COT151
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT151|UNDER-SUPERVISION-OF-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
COT067
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT067|NATIONAL-HEALTH-CARE-ENTITY-ID |
N/A |
|
06/24/2022
|
3.0.0 |
COT125
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT125|BMI |
N/A |
|
06/24/2022
|
3.0.0 |
COT220
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT220|HCPCS-RATE |
N/A |
|
06/24/2022
|
3.0.0 |
COT051
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
COT051|TOT-COPAY-AMT |
N/A |
|
06/24/2022
|
3.0.0 |
COT176
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION
COT176|COPAY-AMT |Conditional|The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION
COT176|BENEFICIARY-COPAYMENT-PAID-AMOUNT |Optional|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. |
|
06/24/2022
|
3.0.0 |
CRX167
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX167|INGREDIENT-COST-SUBMITTED |Conditional|The charge to cover the cost of ingredients for the prescription or drug.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX168
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX168|INGREDIENT-COST-PAID-AMT |Conditional|The amount paid by Medicaid or the managed care plan on this claim or adjustment at the claim detail level towards the cost of ingredients for the prescription or drug.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX169
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX169|DISPENSE-FEE-PAID-AMT|Conditional|The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the cost of the pharmacy's professional dispensing fee for the prescription.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 |CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX170
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX170|PROFESSIONAL-SERVICE-FEE-SUBMITTED|Conditional|The charge to cover the clinical services, not otherwise covered under the professional dispensing fee. (Example "not filling a prescription because of therapeutic duplication")|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX171
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX171|PROFESSIONAL-SERVICE-FEE-PAID-AMT|Conditional|The amount paid by Medicaid or the managed care plan on this claim or adjustment towards the costs of clinical services not otherwise covered under the professional dispensing fee.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX166
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX166|COMBINED-BENE-COST-SHARING-PAID-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX163
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX163|TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT|Conditional|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.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX165
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX165|TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT|Conditional|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.|Value must be between -99999999999.99 and 99999999999.99
Value must be expressed as a number with 2-digit precision (e.g. 100.50 )|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX172
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX172|IHS-SERVICE-IND|Mandatory|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.|Value must be 1 character
Value must be in [0, 1] or not populated|CLAIMRX|CLAIM-LINE-RECORD-RX-CRX00003 |
|
06/24/2022
|
3.0.0 |
CRX078
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CRX078|PRESCRIBING-PROV-SPECIALTY |
N/A |
|
06/24/2022
|
3.0.0 |
CRX076
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CRX076|PRESCRIBING-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CRX077
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CRX077|PRESCRIBING-PROV-TYPE |
N/A |
|
06/24/2022
|
3.0.0 |
CRX057
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CRX057|NATIONAL-HEALTH-CARE-ENTITY-ID |
N/A |
|
06/24/2022
|
3.0.0 |
CRX103
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CRX103|DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY |
N/A |
|
06/24/2022
|
3.0.0 |
CRX042
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME
CRX042|TOT-COPAY-AMT |
N/A |
|
06/24/2022
|
3.0.0 |
CRX089
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX089|BENEFICIARY-COPAYMENT-AMOUNT|The amount of money the beneficiary paid towards a co-payment. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX089|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CRX087
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX087|BENEFICIARY-COINSURANCE-AMOUNT|The amount of money the beneficiary paid towards coinsurance. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX087|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CRX092
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX092|BENEFICIARY-DEDUCTIBLE-AMOUNT|The amount of money the beneficiary paid towards an annual deductible. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX092|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/ies on behalf of the beneficiary. |
|
06/24/2022
|
3.0.0 |
CRX123
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION
CRX123|COPAY-AMT |Conditional|The copayment amount paid by an enrollee for the service, which does not include the amount paid by the insurance company. |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION
CRX123|BENEFICIARY-COPAYMENT-PAID-AMOUNT|Optional|The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element. |
|
06/24/2022
|
3.0.0 |
CRX141
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION
CRX141|DISPENSE-FEE||The charge to cover the cost of dispensing the prescription. Dispensing costs include overhead, supplies, and labor, etc. to fill the prescription. |
|DE NO| DATA ELEMENT NAME|NECESSITY|DEFINITION
CRX141|DISPENSE-FEE-SUBMITTED ||The charge to cover the cost of the professional dispensing fee for the prescription. |
|
06/24/2022
|
3.0.0 |
CRX131
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CRX131|OT-RX-CLAIM-QUANITY-ALLOWED|The value in OT-RX-CLAIM-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. |
|DE NO| DATA ELEMENT NAME|CODING REQUIREMENT
CRX131|PRESCRIPTION-QUANTITY-ALLOWED|The value in PRESCRIPTION-QUANTITY-ALLOWED must correspond with the value in UNIT-OF-MEASURE. |
|
06/24/2022
|
3.0.0 |
CIP213
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP213|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CIP213|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
|
06/24/2022
|
3.0.0 |
CLT160
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT160|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CLT160|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
|
06/24/2022
|
3.0.0 |
COT137
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT137|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. |
|DE NO| DATA ELEMENT NAME|DEFINITION
COT137|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
|
06/24/2022
|
3.0.0 |
CRX095
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX095|COPAY-WAIVED-IND|An indicator signifying that the copay was waived by the provider. |
|DE NO| DATA ELEMENT NAME|DEFINITION
CRX095|COPAY-WAIVED-IND|An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions. |
|
03/11/2022
|
3.0.0 |
CIP228
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME| DEFINITION|
CIP228 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| |
DE NO| DATA ELEMENT NAME| DEFINITION|
CIP228 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header.| |
|
03/11/2022
|
3.0.0 |
CLT179
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME| DEFINITION|
CLT179 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| |
DE NO| DATA ELEMENT NAME| DEFINITION|
CLT179 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the line level, report the sum of all the line level Medicare payment amounts at the header.| |
|
03/11/2022
|
3.0.0 |
COT182
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME| DEFINITION|
COT182 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| |
DE NO| DATA ELEMENT NAME| DEFINITION|
COT182 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines.| |
|
03/11/2022
|
3.0.0 |
CRX129
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME| DEFINITION|
CRX129 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim or adjustment.| |
DE NO| DATA ELEMENT NAME| DEFINITION|
CRX129 | MEDICARE-PAID-AMT |The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines.| |
|
02/18/2022
|
3.0.0 |
COT191
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT191|SERVICING-PROV-TAXONOMY|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]| Conditional| Not Applicable| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |CODING REQUIREMENT|
|COT191| SERVICING-PROV-TAXONOMY| The taxonomy code for the provider who treated the recipient.| Conditional | Value must be equal to a valid value.|
COT191|SERVICING-PROV-TAXONOMY|Not Applicable |Not Applicable | Leave blank or space-fill field for capitation or premium payments (TYPE-OF-SERVICE = 119, 120, 121, 122)|
COT191|SERVICING-PROV-TAXONOMY|Not Applicable| Not Applicable| Generally, the provider taxonomy requires 10 bytes. However, two additional bytes have been provided for future expansion.| |
|
02/18/2022
|
3.0.0 |
ELG224
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |
|ELG224|DISABILITY-TYPE-CODE|[No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).]|Conditional| |
|DE NO| DATA ELEMENT NAME| DEFINITION| NECESSITY |
|ELG224|DISABILITY-TYPE-CODE|A code to identify disability status in accordance with requirements of Section 4302 of the Affordable Care Act.| Mandatory| |
|
04/01/2022
|
3.0.0 |
ELG073
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME| NECESSITY|CODING REQUIREMENT|
ELG073|ELIGIBLE-PHONE-NUM|Optional|| |
DE NO| DATA ELEMENT NAME| NECESSITY|CODING REQUIREMENT|
ELG073|ELIGIBLE-PHONE-NUM|Conditional|Value is mandatory and must be provided when the ELIGIBLE-ADDR-TYPE (ELG.004.065) = ‘01’| |
|
04/01/2022
|
3.0.0 |
ELG215
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|END_DATE|VALUE|NAME|DESCRIPTION
AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR|20200214|2|Yes, Individual does have CDIB |
VALUE_SET_ID|END_DATE|VALUE|NAME|DESCRIPTION
AMERICAN-INDIAN-ALASKA-NATIVE-INDICATOR|20171201|2|Yes, Individual does have CDIB |
|
06/24/2022
|
3.0.0 |
CIP195
|
UPDATE |
Data Dictionary |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE SEGMENT (with RECORD-ID)
CIP195|DRG-REL-WEIGHT|X(8)|CLAIM-HEADER-RECORD-IP-CIP00002 |
DE_NO|DATA_ELEMENT_NAME|SIZE|FILE SEGMENT (with RECORD-ID)
CIP195|DRG-REL-WEIGHT|S9(3)V99999)|CLAIM-HEADER-RECORD-IP-CIP00002 |
|
06/24/2022
|
3.0.0 |
CIP195/ DRG-REL-WEIGHT
|
Modify Data Type |
Data Dictionary - Record Layout |
DE_NO|DATA_ELEMENT_NAME|SIZE|
CIP195|DRG-REL-WEIGHT|X(8)| |
DE_NO|DATA_ELEMENT_NAME|SIZE|
CIP195|DRG-REL-WEIGHT|S9(3)V99999 |
|
09/26/2022
|
3.0.3 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|
PROV-SPECIALTY|00010101|99991231|C0|Sleep Medicine|
PROV-SPECIALTY|00010101|99991231|C1|Centralized Flu|
PROV-SPECIALTY|00010101|99991231|C2|Indirect Payment Procedure|
PROV-SPECIALTY|00010101|99991231|C3|Interventional Cardiology|
PROV-SPECIALTY|00010101|99991231|C4|Restricted Use|
PROV-SPECIALTY|00010101|99991231|C5|Dentist|
PROV-SPECIALTY|00010101|99991231|C6|Hospitalist|
PROV-SPECIALTY|00010101|99991231|C7|Advanced Heart Failure and Transplant Cardiology|
PROV-SPECIALTY|00010101|99991231|C8|Medical Toxicology|
PROV-SPECIALTY|00010101|99991231|C9|Hematopoietic Cell Transplantation and Cellular Therapy|
PROV-SPECIALTY|00010101|99991231|D1|Medicare Diabetes Preventive Program|
PROV-SPECIALTY|00010101|99991231|D2|Restricted Use|
PROV-SPECIALTY|00010101|99991231|D3|Medical Genetics and Genomics|
PROV-SPECIALTY|00010101|99991231|D4|Undersea and Hyperbaric Medicine|
PROV-SPECIALTY|00010101|99991231|D5|Opioid Treatment Program|
PROV-SPECIALTY|00010101|99991231|D6|Home Infusion Therapy Services|
PROV-SPECIALTY|00010101|99991231|D7|Micrographic Dermatologic Surgery|
PROV-SPECIALTY|00010101|99991231|D8|Adult Congenital Heart Disease| |
|
04/01/2022
|
3.0.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILTY-GROUP|20220401|20270330|77|Medicaid - Women who are pregnant or postpartum, 12-month extended postpartum coverage
ELIGIBILTY-GROUP|20220401|20270330|78|CHIP - Women who are pregnant or postpartum, 12-month extended postpartum coverage |
|
06/24/2022
|
3.0.0 |
COT183
|
UPDATE |
Data Dictionary |
|DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT
COT183|OT-RX-CLAIM-QUANTITY-ACTUAL|The quantity of a drug, service, or product that is rendered/dispensed for a prescription, specific date of service, or billing time span.|For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the IP-LT-QUANTITY-OF-SERVICE field. The value in OT-RX-CLAIM-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units |
|DE NO| DATA ELEMENT NAME|DEFINITION|CODING REQUIREMENT
COT183|SERVICE-QUANTITY-ACTUAL|The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line.| For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the SERVICE-QUANTITY-ACTUAL field.The value in SERVICE-QUANTITY-ACTUAL must correspond with the value in UNIT-OF-MEASURE.This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. |
|
07/15/2022
|
3.0.1 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
add new valid value file DATA-DICTIONARY-VERSION.psv |
|
05/13/2022
|
3.0.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|10|Clinic Services|10. Clinic Services (See 42 CFR 440.90.).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that:
Are provided to outpatients;
• Are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. For reporting purposes, consider a group of physicians who share, only for mutual convenience, space, services of supporting staff, etc., as physicians, rather than a clinic, even though they practice under the name of a clinic; and
• Except in the case of nurse-midwife services (see 42 CFR 440.165), are furnished by, or under, the direction of a physician.
NOTE: Place dental clinics under Dental Services. Report any services not included above under Other Care Services. A clinic staff may include practitioners with different specialties.|
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|49|Other Care Services|49 -- Other Care Services --These are any medical or remedial care services recognized under State law and authorized by the approved Medicaid State Plan. Such services do not meet the definition of, and are not classified under, any category of service included on Lines 1 through 41. |
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|50|Total|Total| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|20210930|10|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20211001|99991231|10A|Clinic Services - Reg. Payments|10A. Clinic Services - Reg. Payments (See 42 CFR 440.90.).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that: o Are provided to outpatients; o Are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. For reporting purposes, consider a group of physicians who share, only for mutual convenience, space, services of supporting staff, etc., as physicians, rather than a clinic, even though they practice under the name of a clinic; and o Except in the case of nurse-midwife services (see 42 CFR 440.165), are furnished by, or under, the direction of a physician. NOTE: Place dental clinics under Dental Services. Report any services not included above under Other Care Services. A clinic staff may include practitioners with different specialties.|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20211001|99991231|10B|Clinic Services - Sup. Payments|10B. Clinic Services - Sup. Payments (See 42 CFR 440.90.).--These are preventive, diagnostic, therapeutic, rehabilitative, or palliative items or services that: o Are provided to outpatients; o Are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients. For reporting purposes, consider a group of physicians who share, only for mutual convenience, space, services of supporting staff, etc., as physicians, rather than a clinic, even though they practice under the name of a clinic; and o Except in the case of nurse-midwife services (see 42 CFR 440.165), are furnished by, or under, the direction of a physician. NOTE: Place dental clinics under Dental Services. Report any services not included above under Other Care Services. A clinic staff may include practitioners with different specialties.|
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|20211231|49|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|99991231|69|Other Care Services|69 - Other Care Services --These are any medical or remedial care services recognized under State law and authorized by the approved Medicaid State Plan. Such services do not meet the definition of, and are not classified under, any category of service included on Lines 1 through 41.|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|99991231|70|Total|Line 70 - TOTAL.--The MBES automatically enters the total of Columns (a)- (e).|
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|20211231|50| |
|
06/24/2022
|
3.0.0 |
CRX162
|
ADD |
Data Dictionary |
N/A |
|DE NO| DATA ELEMENT NAME|NECESSITY |DEFINITION|CODING REQUIREMENT|FILENAME| FILE SEGMENT NAME
CRX162|PRESCRIPTION-ORIGIN-CODE|Conditional|How the prescription was sent to the pharmacy.|Value must be one digit
Value must be 1:4|CLAIMRX|CLAIM-HEADER-RECORD-RX-CRX00002 |
|
06/24/2022
|
3.0.0 |
CRX162
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|DESCRIPTION|
PRESCRIPTION-ORIGIN-CODE|20220624|99991231|1|Written
PRESCRIPTION-ORIGIN-CODE|20220624|99991231|2|Telephone
PRESCRIPTION-ORIGIN-CODE|20220624|99991231|3|Electronic
PRESCRIPTION-ORIGIN-CODE|20220624|99991231|4|Fax |
|
05/13/2022
|
3.0.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|29|Non-Emergency Medical Transportation
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|99991231|37|Critical Access Hospitals |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|20211231|29|Non-Emergency Medical Transportation
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|20211231|37|Critical Access Hospitals
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|99991231|29A|Non-Emergency Medical Transportation - Reg. Payments|29A. -Non-Emergency Medical Transportation - Reg. Payments|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|99991231|29B|Non-Emergency Medical Transportation - Sup. Payments|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|99991231|37A|Critical Access Hospitals - Reg. Payments|37A. -Critical Access Hospitals - Reg. Payments|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|9991231|37B|Critical Access Hospitals - Sup. Payments|37B. -Critical Access Hospitals Inpatient - Sup. Payments|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20220101|9991231|37C|Critical Access Hospitals Outpatient - Sup. Payments|37C. -Critical Access Hospitals Outpatient - Sup. Payments| |
|
04/22/2022
|
3.0.0 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
ELIGIBILTY-GROUP|20220401|20270330|77|Medicaid - Women who are pregnant or postpartum, 12-month extended postpartum coverage
ELIGIBILTY-GROUP|20220401|20270330|78|CHIP - Women who are pregnant or postpartum, 12-month extended postpartum coverage |
N/A |
|
07/15/2022
|
3.0.1 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
BED-TYPE-CODE|00010101|99991231|1|Intermediate Care Facility for the Intellectually Disabled|
BED-TYPE-CODE|00010101|99991231|2|Inpatient|
BED-TYPE-CODE|00010101|99991231|3|Nursing Facility|
BED-TYPE-CODE|00010101|99991231|4|Title 18 Skilled Nursing Facility (T18 SNF)| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
BED-TYPE-CODE|00010101|99991231|1|Intermediate Care Facility for the Intellectually Disabled bed not in an Institution for Mental Disease|
BED-TYPE-CODE|00010101|99991231|2|Inpatient bed not in an Institution for Mental Disease|
BED-TYPE-CODE|00010101|99991231|3|Nursing Facility bed not in an Institution for Mental Disease|
BED-TYPE-CODE|00010101|99991231|4|Title 18 Skilled Nursing Facility (T18 SNF) bed not in an Institution for Mental Disease| |
|
07/15/2022
|
3.0.1 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
BED-TYPE-CODE|00010101|99991231|5|Intermediate Care Facility for the Intellectually Disabled bed in an Institution for Mental Disease|
BED-TYPE-CODE|00010101|99991231|6|Inpatient bed in an Institution for Mental Disease|
BED-TYPE-CODE|00010101|99991231|7|Nursing Facility bed in an Institution for Mental Disease| |
|
06/24/2022
|
3.0.0 |
ELG095
|
UPDATE |
Data Dictionary |
DE No|Segment Name|DE Name|Definition
ELG095|ELIGIBILITY-DETERMINANTS-ELG00005|ELIGIBILITY-CHANGE-REASON|The reason for a change in an individual's eligibility status. Report this reason when there is a change in the individual's eligibility status. |
DE No|Segment Name|DE Name|Definition
ELG095|ELIGIBILITY-DETERMINANTS-ELG00005|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. |
|
07/15/2022
|
3.0.1 |
CIP252
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP252|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP252|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CLT205
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT205|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT205|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
COT175
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT175|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT175|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CRX122
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX122|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). On managed care encounters the Allowed Amount is determined by the managed care organization. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX122|ALLOWED-AMT|The maximum amount displayed at the claim line level as determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On Fee for Service claims the Allowed Amount is determined by the state's MMIS (or PBM). 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 amount that the sub-capitated entity allowed at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
COT033
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT033|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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT033|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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
|
07/15/2022
|
3.0.1 |
COT166
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT166|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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT166|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. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers. |
|
07/15/2022
|
3.0.1 |
COT174
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT174|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT174|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CRX121
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX121|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX121|BILLED-AMT|The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed the managed care plan.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
COT113
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT113|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT113|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. |
|
07/15/2022
|
3.0.1 |
COT112
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT112|BILLING-PROV-NUM|A unique identification number assigned by the state to a provider or capitation 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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT112|BILLING-PROV-NUM|A unique identification number assigned by the state to a provider or capitation 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.
For sub-capitation payments, report the state-assigned provider identifier for the sub-capitated entity, when available or required. |
|
07/15/2022
|
3.0.1 |
COT034
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT034|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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT034|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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
|
07/15/2022
|
3.0.1 |
COT167
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT167|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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT167|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. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction.
For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers. |
|
07/15/2022
|
3.0.1 |
CIP254
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP254|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP254|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CLT208
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT208|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT208|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
COT178
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT178|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT178|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CRX125
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX125|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX125|MEDICAID-PAID-AMT|The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level.
For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
COT066
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT066|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT066|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-capitation payments, report the PLAN-ID-NUMBER for the managed care plan making the payment to the sub-capitated entity. |
|
07/15/2022
|
3.0.1 |
CIP251
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP251|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP251|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CLT204
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT204|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed to the managed care plan. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT204|REVENUE-CHARGE|The total amount billed for the related Revenue Code. Total amount billed includes both covered and non-covered charges (as defined by UB-04 Billing Manual). For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that 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 amount that the provider billed the sub-capitated entity at the claim line detail level. 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. |
|
07/15/2022
|
3.0.1 |
CIP104
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP104|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP104|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. |
|
07/15/2022
|
3.0.1 |
CLT056
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT056|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT056|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. |
|
07/15/2022
|
3.0.1 |
COT041
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT041|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT041|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.
For sub-capitation payments, report a SOURCE-LOCATION of '20', indicating the managed care plan is the source of payment. |
|
07/15/2022
|
3.0.1 |
CRX032
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX032|SOURCE-LOCATION|The field denotes the claims payment system from which the claim was extracted. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX032|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. |
|
07/15/2022
|
3.0.1 |
CIP113
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP113|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP113|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. |
|
07/15/2022
|
3.0.1 |
CLT064
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT064|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT064|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. |
|
07/15/2022
|
3.0.1 |
COT049
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT049|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT049|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. |
|
07/15/2022
|
3.0.1 |
CRX040
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX040|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX040|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. |
|
07/15/2022
|
3.0.1 |
CIP112
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP112|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP112|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
|
07/15/2022
|
3.0.1 |
CLT063
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT063|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT063|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
|
07/15/2022
|
3.0.1 |
COT048
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT048|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT048|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
|
07/15/2022
|
3.0.1 |
CRX039
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX039|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX039|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 [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.
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. |
|
07/15/2022
|
3.0.1 |
CIP114
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP114|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP114|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. |
|
07/15/2022
|
3.0.1 |
CLT065
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT065|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT065|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. |
|
07/15/2022
|
3.0.1 |
COT050
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT050|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT050|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.
For sub-capitation payments, this represents the amount paid by the managed care plan to the sub-capitated entity. |
|
07/15/2022
|
3.0.1 |
CRX041
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX041|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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX041|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. |
|
07/15/2022
|
3.0.1 |
CIP100
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP100|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CIP100|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” for an S-CHIP sub-capitated encounter record. |
|
07/15/2022
|
3.0.1 |
CLT052
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT052|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CLT052|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” for an S-CHIP sub-capitated encounter record. |
|
07/15/2022
|
3.0.1 |
COT037
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT037|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT037|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” for an S-CHIP sub-capitated encounter record.
For sub-capitation payments, report TYPE-OF-CLAIM = '6' or “F”. |
|
07/15/2022
|
3.0.1 |
CRX029
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX029|TYPE-OF-CLAIM|A code to indicate what type of payment is covered in this claim. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
CRX029|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” for an S-CHIP sub-capitated encounter record. |
|
07/15/2022
|
3.0.1 |
COT186
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT186|TYPE-OF-SERVICE|A code to categorize the services provided to a Medicaid or CHIP enrollee. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION
COT186|TYPE-OF-SERVICE|A code to categorize the services provided to a Medicaid or CHIP enrollee.
For sub-capitation payments, report a TYPE-OF-SERVICE value 119, 120, or 122. |
|
06/24/2022
|
3.0.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
add values to TYPE-OF-CLAIM.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
TYPE-OF-CLAIM|00010101|99991231|6|Medicaid or Medicaid-expansion CHIP financial transaction between an MCP and an entity other than the S-CHIP or Medicaid agency
TYPE-OF-CLAIM|00010101|99991231|F|Separate CHIP (Title XXI) financial transaction between an MCP and an entity other than the S-CHIP or Medicaid agency |
|
06/24/2022
|
3.0.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
add values to SOURCE-LOCATION.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
SOURCE-LOCATION|00010101|99991231|99991231|22|Sub-contracted entity
SOURCE-LOCATION|00010101|99991231|99991231|23|Sub-capitated network provider |
|
06/24/2022
|
3.0.0 |
N/A
|
ADD |
Data Dictionary - Valid Values |
add values to AFFILIATED-PROGRAM-TYPE.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
AFFILIATED-PROGRAM-TYPE|00010101|99991231|6||Sub-capitated Network provider – The value in the AFFILIATED-PROGRAM-ID data element contains the state-assigned health plan identifier with which the network provider has a sub-capitated contract to provide services for managed care plan enrollees. |
|
08/05/2022
|
3.0.1 |
CIP202
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
CIP202|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
CIP202|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.|| |
|
08/05/2022
|
3.0.1 |
CLT144
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
CLT144|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detaile dexplanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
CLT144|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.|| |
|
08/05/2022
|
3.0.1 |
COT126
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
COT126|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
COT126|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.|| |
|
08/05/2022
|
3.0.1 |
CRX081
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
CRX081|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 first five (5) positions are Julian date following a YYDDD format. The RA is the detailed explanation of the reason for the payment amount.|"First five (5) characters of the value must be a Julian date express in the form YYDDD (e.g. 19095, 95th day of 20(19))" |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|CODING REQUIREMENT
CRX081|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.|| |
|
07/15/2022
|
3.0.1 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
PAYMENT-LEVEL-IND|00010101|99991231|1|Claim Header - Sum of Line Item payments
PAYMENT-LEVEL-IND|00010101|99991231|2|Claim Detail - Individual Line Item payments |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
PAYMENT-LEVEL-IND|00010101|99991231|1|Payment/allowed amount is not determined at the individual line level (e.g., DRG or outpatient PPS)
PAYMENT-LEVEL-IND|00010101|99991231|2|Payment/allowed amount is determined at the individual line level (e.g., RBRVS) and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amount(s) |
|
07/15/2022
|
3.0.1 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE||DESCRIPTION
PAYMENT-LEVEL-IND|00010101|99991231|3|Payment/allowed amount is determined for each individual line (e.g., RBRVS) but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only |
|
08/26/2022
|
3.0.2 |
ELG252
|
ADD |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG252|ENROLLMENT-TYPE| |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG252|ENROLLMENT-TYPE|A person enrolled in Medicaid/CHIP must have a primary eligibility group classification for any given day of enrollment. (There may or may not be a secondary eligibility group classification for that same day.) |
|
08/05/2022
|
3.0.1 |
CIP194
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT
CIP194|DRG-OUTLIER-AMT|Value must not be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT
CIP194|DRG-OUTLIER-AMT|Value must be populated when Outlier Code (CIP.002.197) is '01' ,'02' or '10' |
|
08/26/2022
|
3.0.2 |
CIP132
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP132|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP132|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. |
|
08/26/2022
|
3.0.2 |
CLT082
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CLT082|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CLT082|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. |
|
08/26/2022
|
3.0.2 |
COT068
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
COT068|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
COT068|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. |
|
08/26/2022
|
3.0.2 |
CRX058
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CRX058|PAYMENT-LEVEL-IND|The field denotes whether the payment amount was determined at the claim header or line/detail level. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CRX058|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. |
|
08/26/2022
|
3.0.2 |
N/A
|
ADD |
Data Dictionary - Valid Values |
PRESCRIPTION-ORIGIN-CODE.psv |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
PRESCRIPTION-ORIGIN-CODE|00010101|99991231|0|Not Known||
PRESCRIPTION-ORIGIN-CODE|00010101|99991231|1|Written|Prescription obtained via paper.|
PRESCRIPTION-ORIGIN-CODE|00010101|99991231|2|Telephone|Prescription obtained via oral instructions or interactive voice response using a phone.|
PRESCRIPTION-ORIGIN-CODE|00010101|99991231|3|Electronic|Prescription obtained via SCRIPT or HL7 Standard transactions, or electronically within closed systems.|
PRESCRIPTION-ORIGIN-CODE|00010101|99991231|4|Facsimile|Prescription obtained via transmission using a fax machine.|
PRESCRIPTION-ORIGIN-CODE|00010101|99991231|5|Pharmacy|This value is used to cover any situation where a new Rx number needs to be created from an existing valid prescription such as traditional transfers, intrachain transfers, file buys, software upgrades/migrations, and any reason necessary to give it a new number. This value is also the appropriate value for Pharmacy dispensing when applicable such as BTC (behind the counter), Plan B, established protocols, pharmacists authority to prescribe, etc.| |
|
09/26/2022
|
3.0.3 |
N/A
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|
XIX-MBESCBES-CATEGORY-OF-SERVICE|00010101|20211231|49|Other Care Services| |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20221001|99991231|49|Health Homes For Children With Medically Complex Conditions| |
|
09/26/2022
|
3.0.3 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|
XIX-MBESCBES-CATEGORY-OF-SERVICE|20221001|99991231|7A7|Drug Rebate Offset - Value Based Purchasing| |
|
09/26/2022
|
3.0.3 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|
XXI-MBESCBES-CATEGORY-OF-SERVICE|20221001|99991231|8A7|Drug Rebate Offset - Value Based Purchasing| |
|
09/26/2022
|
3.0.3 |
N/A
|
ADD |
Data Dictionary - Valid Values |
N/A |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION
IHS-SERVICE-IND|20220624|99991231|0|No
IHS-SERVICE-IND|20220624|99991231|1|Yes |
|
10/07/2022
|
3.0.3 |
ELG040
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG040|CITIZENSHIP-IND|Value must be in [0, 1] or not populated |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG040|CITIZENSHIP-IND|Value must be in [0, 1, 2] or not populated |
|
11/18/2022
|
3.0.5 |
MCR020
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
MCR020|MANAGED-CARE-CONTRACT-EFF-DATE|The first calendar day on which all of the other data elements in the same segment were effective. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
MCR020|MANAGED-CARE-CONTRACT-EFF-DATE|The start date of the managed care contract period with the state. |
|
10/28/2022
|
3.0.4 |
CIP099, CLT051, COT036, CRX028
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP099|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment.
CLT051|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment.
COT036|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment.
CRX028|MEDICAID-PAID-DATE|The date Medicaid paid this claim or adjustment. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP099|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.
CLT051|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.
COT036|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.
CRX028|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. |
|
10/07/2022
|
3.0.3 |
CIP293, CLT240, COT231, CRX164
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP293|TOT-BENEFICIARY-COINSURANCE-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.
CLT240|TOT-BENEFICIARY-COINSURANCE-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.
COT231|TOT-BENEFICIARY-COINSURANCE-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.
CRX164|TOT-BENEFICIARY-COINSURANCE-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. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP293|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.
CLT240|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.
COT231|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.
CRX164|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. |
|
10/07/2022
|
3.0.3 |
CIP294, CLT241, COT232, CRX165
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP294|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.
CLT241|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.
COT232|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 for covered services on the claim. Do not subtract out any payments made toward the deductible.
CRX165|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 for covered services on the claim. Do not subtract out any payments made toward the deductible. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP294|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.
CLT241|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.
COT232|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.
CRX165|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. |
|
10/07/2022
|
3.0.3 |
PRV024
|
ADD |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
PRV024|PROV-ORGANIZATION-NAME|The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
PRV024|PROV-ORGANIZATION-NAME|The name of the provider when the provider is an organization. If the provider organization name exceeds 60 characters submit only the first 60 characters of the name. Provider Organization Name should be same as provider last name when provider is an individual. |
|
10/28/2022
|
3.0.4 |
ELG095
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
ELG095|ELIGIBILITY-CHANGE-REASON|The reason for a complete loss/termination in an individual's eligibility for Medicaid and CHIP. The end date of the segment in which the value is reported must represent the date that the complete loss/termination of Medicaid and CHIP eligibility occurred. The reason for the termination represents the reason that the segment in which it was reported was closed. If for a single termination in eligibility for a single individual there are multiple distinct co-occurring values in the state's system explaining the reason for the termination, and if one of the multiple co-occurring values maps to T-MSIS ELIGIBILITY-CHANGE-REASON value '21' (Other) or '22' (Unknown), then the state should not report the co-occurring value '21' and/or '22' to T-MSIS. If there are multiple co-occurring distinct values between '01' and '19', then the state should choose whichever is first in the state's system. Of the values that could logically co-occur in the range of '01' through '19', CMS does not currently have a preference for any one value over another. |
|
11/18/2022
|
3.0.5 |
ELG097
|
ADD |
Data Dictionary |
N/A |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG097|RESTRICTED-BENEFITS-CODE|(Restricted Benefits) if value is "G", then Dual Eligible Code (ELG.005.085) must be in (‘01’, ‘03', ‘06’) |
|
11/18/2022
|
3.0.5 |
ELG270
|
ADD |
Data Dictionary |
N/A |
DE NO| DATA ELEMENT NAME COMPUTING|CODING REQUIREMENT|
ELG270|LOCKED-IN-SRVCS|Must be a 3 digit value from the Type-of-Service valid value list |
|
12/30/2022
|
3.1.0 |
IHS-SERVICE-IND (CIP296, CLT243, COT234, CRX172)
|
UPDATE |
Data Dictionary |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP296|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.
CLT243|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.
COT234|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.
CRX172|IHS-SERVICE-IND|This data element indicates services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
DE NO| DATA ELEMENT NAME COMPUTING|DEFINITION|
CIP296|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.
CLT243|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.
COT234|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes.
CRX172|IHS-SERVICE-IND|To indicate Services received by Medicaid-eligible individuals who are American Indian or Alaska Native (AI/AN) through facilities of the Indian Health Service (IHS), whether operated by IHS or by Tribes. |
|
12/09/2022
|
3.0.6 |
IHS-SERVICE-IND (CIP296, CLT243, COT234, CRX172)
|
UPDATE |
Data Dictionary - Valid Values |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
IHS-SERVICE-IND|20220624|99991231|0|No
IHS-SERVICE-IND|20220624|99991231|1|Yes |
VALUE_SET_ID|EFFECTIVE_DATE|END_DATE|VALUE|NAME|DESCRIPTION|
IHS-SERVICE-IND|00010101|99991231|0|No
IHS-SERVICE-IND|00010101|99991231|1|Yes |
|
12/04/2020
|
2.4.0 |
CITIZENSHIP-IND
|
UPDATE |
Data Dictionary - Valid Values |
|Value ID|Effective Date|End Date|Value|Description|
|CITIZENSHIP-IND|00010101|99991231|0|No|
|CITIZENSHIP-IND|00010101|99991231|1|Yes| |
|Value ID|Effective Date|End Date|Value|Description|
|CITIZENSHIP-IND|00010101|99991231|0|Non-citizen|
|CITIZENSHIP-IND|00010101|99991231|1|U.S. Citizen|
|CITIZENSHIP-IND|00010101|99991231|2|U.S. National| |
|
12/04/2020
|
2.4.0 |
IMMIGRATION-STATUS
|
UPDATE |
Data Dictionary - Valid Values |
|Value ID|Effective Date|End Date|Value|Description|
|IMMIGRATION-STATUS|00010101|99991231|1|Qualified non-citizen|
|IMMIGRATION-STATUS|00010101|99991231|2|Lawfully present under CHIPRA 214|
|IMMIGRATION-STATUS|00010101|99991231|3|Eligible only for payment for emergency services|
|IMMIGRATION-STATUS|00010101|99991231|8|Not Applicable (U.S. citizen)| |
|Value ID|Effective Date|End Date|Value|Description|
|IMMIGRATION-STATUS|00010101|99991231|1|Qualified non-citizen|
|IMMIGRATION-STATUS|00010101|99991231|2|Lawfully present under CHIPRA 214|
|IMMIGRATION-STATUS|00010101|99991231|3|Eligible only for payment for emergency services|
|IMMIGRATION-STATUS|00010101|99991231|8|Not Applicable (U.S. citizen or U.S. national)| |
|
11/23/2018
|
2.3.0 |
ADJUSTMENT-IND
|
UPDATE |
Data Dictionary - Valid Values |
N/A |
Valid values for ADJUSTMENT-IND has been updated per T-MSIS DD 2.1.
As per DD 2.1 the Valid values are:
0 Original Claim/Encounter/Payment
1 Void/Reversal/Cancel of a prior submission
4 Replacement/Resubmission of a previously paid/approved claim/encounter/payment
5 Credit Gross Adjustment
6 Debit Gross Adjustment |
|
06/24/2022
|
3.0.0 |
PRV081/ PROV-IDENTIFIER
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
X(12) |
SIZE
X(30) |
|
06/24/2022
|
3.0.0 |
CIP278/ NDC-QUANTITY
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
06/24/2022
|
3.0.0 |
CLT230/ NDC-QUANTITY
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
06/24/2022
|
3.0.0 |
COT225/ NDC-QUANTITY
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
06/24/2022
|
3.0.0 |
CRX131
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
06/24/2022
|
3.0.0 |
CRX132
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
06/24/2022
|
3.0.0 |
COT183
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
06/24/2022
|
3.0.0 |
COT184
|
Modify DE Width |
Data Dictionary - Record Layout |
SIZE
S9(6)V999 |
SIZE
S9(8)V999 |
|
05/25/2018
|
2.2.0 |
ELG036
|
UPDATE |
Data Dictionary |
"For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number." |
"For SSN states, the MSIS-IDENTIFICATION-NUM and SSN fields should match and be populated with the eligible person’s social security number. States should submit a 9-digit number for the SSN." |
|
05/25/2018
|
2.2.0 |
ELG036
|
UPDATE |
Data Dictionary - Record Layout |
SIZE text
"9(9)" |
SIZE text
"X(9)" |
|
06/24/2022
|
3.0.0 |
DRG-REL-WEIGHT
|
UPDATE |
Data Dictionary |
|DE No|Data Element Name|Definition|
|CIP195|DRG Relative Weight |The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually
in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000 was half the average.| |
|DE No|Data Element Name|Definition|
|CIP195|DRG Relative Weight|The relative weight for the DRG on the claim. Each year CMS assigns a relative weight to each DRG. These weights indicate the relative costs for treating patients during the prior year. The national average charge for each DRG is compared to the overall average. This ratio is published annually in the Federal Register for each DRG. A DRG with a weight of 2.0000 means that charges were historically twice the average; a DRG with a weight of 0.5000
was half the average. This data element in T-MSIS is expected to capture the relative weight of the DRG in the state's system regardless of which DRG system the state uses.| |
|
12/04/2020
|
2.4.0 |
COT172-0001
|
UPDATE |
Data Dictionary |
diagnosis code fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files |
All UNUSED PROCEDURE-CODE-MOD or PROCEDURE-CODE-MOD-1 through PROCEDURE-CODE-MOD-4 fields should be left blank (i.e., submitted as "pipe pipe" with nothing in between (||) on PSV files and space-filled on FLF files |
|
12/04/2020
|
2.4.0 |
COT218-0004
|
UPDATE |
Data Dictionary |
If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill. |
If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-4) was performed, leave blank or space-fill. |
|
12/04/2020
|
2.4.0 |
COT219-0004
|
UPDATE |
Data Dictionary |
If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill. |
If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-4) was performed, leave blank or space-fill. |
|
12/04/2020
|
2.4.0 |
COT227-0001
|
UPDATE |
Data Dictionary |
If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-6) was performed, leave blank or space-fill. |
If no corresponding procedure (PROCDURE-CODE-2 through PROCDURE-CODE-4) was performed, leave blank or space-fill. |
|
06/19/2020
|
2.4.0 |
TYPE-OF-SERVICE (COT186)
|
ADD |
Data Dictionary - Valid Values |
N/A |
|Data Element|Code|Description|Effective Date|End Date|
|TYPE-OF-SERVICE|138|Per member per month (PMPM) payments for health home services|01/01/0001|12/31/9999|
|TYPE-OF-SERVICE|139|Per member per month (PMPM) payments for Medicare Part A premiums|01/01/0001|12/31/9999
|TYPE-OF-SERVICE|140|Per member per month (PMPM) payments for Medicare Part B premiums|01/01/0001|12/31/9999|
|TYPE-OF-SERVICE|141|Per member per month (PMPM) payments for Medicare Advantage Dual Special Needs Plans (D-SNP) – Medicare Part C.|01/01/0001|12/31/9999|
|TYPE-OF-SERVICE|142|Per member per month (PMPM) payments for Medicare Part D premiums|01/01/0001|12/31/9999|
|TYPE-OF-SERVICE|143|Per member per month (PMPM) payments for other payments|01/01/0001|12/31/9999|
|TYPE-OF-SERVICE|144|Payments to individuals for personal assistance services under 1915(j)|01/01/0001|12/31/9999| |
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