CIP.002.212

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

CLAIM-DENIED-INDICATOR

Data Element

DE Number

CIP212

System DE Number

CIP.002.212

File Name

CIP - CLAIM INPATIENT

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-IP

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	An indicator to identify a claim that the state refused pay in its entirety.
Size	X(1)
FLF Start Position	1261
FLF Stop Position	1261
Segment Key Field Identifier	Not Applicable
Coding Requirements	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 character 4. Mandatory

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-6660	If a claim is a non-denied claim from an IP file, then the claim denied indicator value reported must be compatible with specified T-MSIS picture format: X(1).
RULE-734	If the claim denied indicator is populated on a non-denied claim from an IP file, then the claim denied indicator value reported must be in the list of valid values.
RULE-735	If the claim status category or the type of claim is for denied claims on a claim from an IP file, the claim denied indicator value reported must also indicate the claim is denied.
RULE-7412	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7550	If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an IP file, and the admission date is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
RULE-7633	All non-denied, paid IP claim header records must have a corresponding non-denied claim line record.
RULE-7770	If a claim is a non-denied claim from an IP file, and the waiver type is populated, and the claim admission date is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
RULE-7976	All denied, IP claim line records must have a corresponding claim header record with a claim denied indicator equal to '0' (Denied).
RULE-7744	If a claim in a non-denied, original or adjustment Encounter crossover claimfrom an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01','02', '04', '08'
RULE-7981	If a claim in a non-denied, original or adjustment FFS crossover claim from an IP file, and the MSIS ID is populated and the admission date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'

Measure ID	Measure Name

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CLT159	CLT.002.159	CLAIM-DENIED-INDICATOR	CLT00002	CLAIM-HEADER-RECORD-LT
COT136	COT.002.136	CLAIM-DENIED-INDICATOR	COT00002	CLAIM-HEADER-RECORD-OT
CRX094	CRX.002.094	CLAIM-DENIED-INDICATOR	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
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