CLT.002.130

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TMSIS Dataguide

Medicaid.gov

Version 3.36.0

BILLING-PROV-NUM

Data Element

DE Number

CLT130

System DE Number

CLT.002.130

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-LT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

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.
Size	X(30)
FLF Start Position	775
FLF Stop Position	804
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 30 characters or less 2. Conditional 3. 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 4. 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) or 6. 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) or 8. 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)

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

RULE ID	RULE Definition
RULE-1126	If the billing provider number is populated on a non-denied claim from the LT file, then either the billing provider number value reported must be equal to a provider identifier value reported with a provider identifier type value for state-assigned Medicaid provider identifiers on a provider identifiers segment from a PRV file where the effective and end dates of the provider identifiers segment overlap with the beginning date of service and (if populated) ending date of service on the claim OR the billing provider number value reported must be equal to a submitting state provider ID on a provider main attributes segment from a PRV file where the effective and end dates of the provider main attributes segment overlap with the beginning date of service and (if populated) ending date of service on the claim.
RULE-7050	If a claim is a non-denied claim from an LT file, then the billing provider number value reported must be compatible with specified T-MSIS picture format: X(30).
RULE-7306	If a claim is a non-denied claim from an LT file, and is a Medicaid or Medicaid-expansion FFS, Medicaid or Medicaid-expansion CHIP Encounter, Separate CHIP FFS or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then the billing provider number must be populated.
RULE-7440	If the billing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid and S-CHIP FFS and encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7757	If a claim is a non-denied claim from an LT file, and is a Medicaid or Medicaid-expansion CHIP Encounter or Separate CHIP Encounter claim and is an original claim or a replacement/resubmission claim payment then the billing provider number must be populated.
RULE-7822	If a claim is a non-denied claim from an LT file, and is a Medicaid or Medicaid-expansion CHIP Fee-for-service or Separate CHIP Fee-for-service claim and is an original claim or a replacement/resubmission claim payment then the billing provider number must be populated.
RULE-7922	If the billing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid or M-CHIP Encounter or Separate CHIP Encounter original or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.
RULE-7930	If the billing provider number is populated on a non-denied claim from an LT file and the claim is a Medicaid or M-CHIP FFS or Separate CHIP FFS or adjustment paid claim, the billing provider number is equal to the submitting state provider identifier on the provider medicaid enrollment segment with an active provider enrollment status on the beginning date of service.

Measure ID	Measure Name
ALL-21-002-2	% of BILLING-PROV-NUM on claim headers that do not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
ALL-4-002-2	% of billing and servicing provider numbers on claims that are not found in the provider file
MIS-4-008-8	% missing: BILLING-PROV-NUM (CLT00002)
RULE-1126	% of claim headers with a Billing Provider Number that is not found on the provider file during the dates of service
MIS-23-009-9	% missing: BILLING-PROV-NUM (CLT00002)
MIS-81-009-9	% missing: BILLING-PROV-NUM (CLT00002)
RULE-7440	% of claim headers with a BILLING-PROV-NUM that does not have a match in PRV00007 with active provider enrollment status (PROV-MEDICAID-ENROLLMENT-STATUS-CODE in (1, 2, 3, 4, 5, 6) on Beginning Date of Service
PRV-1-010-9	LT - % of billing providers with all PROV-LOCATION-IDs represented in the practice and service locations in the Provider file
PRV-1-014-5	LT - % of unique combinations of billing providers and PROV-LOCATION-IDs that are found in the provider record's practice and service locations
RULE-7757	% missing: BILLING-PROV-NUM (CLT00002)
RULE-7822	% missing: BILLING-PROV-NUM (CLT00002)
RULE-7921	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Admission Date
RULE-7929	% of claim headers with a Billing Provider Number that does not have a match in PRV00007 with an active provider enrollment status on Admission Date

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP179	CIP.002.179	BILLING-PROV-NUM	CIP00002	CLAIM-HEADER-RECORD-IP
COT112	COT.002.112	BILLING-PROV-NUM	COT00002	CLAIM-HEADER-RECORD-OT
CRX070	CRX.002.070	BILLING-PROV-NUM	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
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)
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)
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