COT.002.039

CLAIM-STATUS

Data Element

DE Number

COT039

System DE Number

COT.002.039

File Name

COT - CLAIM OTHER

File Segment Number

COT00002

File Segment Name

CLAIM-HEADER-RECORD-OT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The health care claim status codes convey the status of an entire claim status codes from the 277 transaction set. Only report the claim status for the final, adjudicated claim.
Size	X(3)
FLF Start Position	215
FLF Stop Position	217
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be in Claim Status List (VVL) 2. Value must be 3 characters or less 3. Conditional 4. If value in [ 542, 585, 654 ], Claim Denied Indicator must be '0' and Claim Status Category must be 'F2'

This data element's valid value code set is maintained by a Code Set Maintenance Organization (CSMO), the official licensing organization for specific valid value code sets. The CSMO is the system of record for those specific valid value code sets. While T-MSIS endeavors to be in-sync with CMSO's updates, minor delays may occur but that shouldn't block T-MSIS data submissions using the CSMO's latest version.

Link to Claim Status List

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

RULE ID	RULE Definition
RULE-1372	If a claim is a non-denied, non-void claim from an OT file, and the claim status is populated, then the claim status value reported must be in the list of valid values for claim status.
RULE-6396	If a claim is a non-denied claim from an OT file, then the claim status value reported must be compatible with specified T-MSIS picture format: X(3).
RULE-7424	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service 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-7552	If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an OT file, and the beginning date of service 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-7635	All non-denied, paid OT claim header records must have a corresponding non-denied claim line record.
RULE-7772	If a claim is a non-denied claim from an OT file, and the waiver type is populated, and the claim beginning date of service is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
RULE-7741	If a claim in a non-denied, original or adjustment Encounter crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service 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-7983	If a claim in a non-denied, original or adjustment FFS crossover claim from an OT file, and the MSIS ID is populated and the beginning date of service 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
CIP102	CIP.002.102	CLAIM-STATUS	CIP00002	CLAIM-HEADER-RECORD-IP
CLT054	CLT.002.054	CLAIM-STATUS	CLT00002	CLAIM-HEADER-RECORD-LT
CRX030	CRX.002.030	CLAIM-STATUS	CRX00002	CLAIM-HEADER-RECORD-RX