A sequential number assigned by the submitter to identify each record segment row in the submission file. The Record Number, in conjunction with the Record Identifier, uniquely identifies a single record within the submission file.

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 unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.

A code to indicate the type of adjustment record claim/encounter represents at claim detail level.

A code which identifies a specific accommodation, ancillary service or billing calculation (as defined by UB-04 Billing Manual). Revenue Code should be passed through to T-MSIS exactly as it was billed by the provider on the provider's 837I or UB-04 claim. It is only required on Inpatient, Long-Term Care and Other Fee for Service claims and managed care encounters that have a valid Type of Bill value. It's not required on financial transactions or non-institutional claims.

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 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 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 that would have been paid had the services been provided on a Fee for Service basis.

A code to categorize the services provided to a Medicaid or CHIP enrollee.

A unique number to identify the provider who treated the recipient. The Servicing Provider Number should be for the individual doctor who rendered the service. If "Servicing" provider and the "Billing" provider such as a sole-practitioner are the same then use the same number in both fields. The value is conditional as its usage varies by state.

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.

A code to describe the type of provider being reported.

This code describes the area of specialty for the provider being reported.

The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary.

A code to indicate the Federal funding source for the payment.

A code indicating the category of service for the paid claim. The category of service is the line item from the CMS-64 form that states use to report their expenditures and request federal financial participation.

A code to indicate the category of service for the paid claim. The category of service is the line item from the CMS-21 form that states use to report their expenditures and request federal financial participation.

A free text field for the submitting state to enter whatever information it chooses.

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.