CLT.003.189

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TMSIS Dataguide

Medicaid.gov

Version 3.27.0

ICN-ADJ

Data Element

DE Number

CLT189

System DE Number

CLT.003.189

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

File Segment Name

CLAIM-LINE-RECORD-LT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.
Size	X(50)
FLF Start Position	92
FLF Stop Position	141
Segment Key Field Identifier	3
Coding Requirements	Value must be 50 characters or less 2. Value must not contain a pipe or asterisk symbols 3. If associated Adjustment Indicator value is 0, then value must not be populated 4. Conditional 5. If associated Adjustment Indicator value is in [‘4’, ‘1’] then value must be populated

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

RULE ID	RULE Definition
RULE-1204	All non-denied LT claim line records must have a corresponding parent record.
RULE-1206	If the icn adj is populated on a non-denied claim line from an LT file, then the icn adj reported must not contain any pipe or asterisk characters.
RULE-6405	If an LT claim line, the icn adj value must be specified in the T-MSIS picture format: X(50).
RULE-7188	If a claim line is from an LT file, then submitting state, original ICN, adjustment ICN, adjudication date, line adjustment indicator, original line ICN, and adjustment line ICN values reported must be unique across all LT claim lines.
RULE-7575	All denied LT claim line records must have a corresponding claim header record.

Measure ID	Measure Name
MIS-5-005-5	% missing: ICN-ADJ (CLT00003)
MIS-24-005-5	% missing: ICN-ADJ (CLT00003)
MIS-82-004-4	% missing: ICN-ADJ (CLT00003)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP020	CIP.002.020	ICN-ADJ	CIP00002	CLAIM-HEADER-RECORD-IP
CIP236	CIP.003.236	ICN-ADJ	CIP00003	CLAIM-LINE-RECORD-IP
CLT020	CLT.002.020	ICN-ADJ	CLT00002	CLAIM-HEADER-RECORD-LT
COT020	COT.002.020	ICN-ADJ	COT00002	CLAIM-HEADER-RECORD-OT
COT159	COT.003.159	ICN-ADJ	COT00003	CLAIM-LINE-RECORD-OT
CRX020	CRX.002.020	ICN-ADJ	CRX00002	CLAIM-HEADER-RECORD-RX
CRX113	CRX.003.113	ICN-ADJ	CRX00003	CLAIM-LINE-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
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