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TMSIS Dataguide Medicaid.gov
Version 3.36.0

CLAIM-LINE-RECORD-IP

File Segment

File Segment Number

CIP00003

File Name

CIP - CLAIM INPATIENT

Last updated

No Updates

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
CIP231 CIP.003.231 RECORD-ID The Record ID represents the type of segment being reported. The Record ID communicates how the contents of a given row of data should be interpreted depending on which segment type the Record ID represents. Each type of segment collects different data elements so each segment type has a distinct layout. The first 3 characters identify the relevant file (e.g., ELG, PRV, CIP, etc.). The last 5 digits are the segment identifier padded with leading zeros (e.g., 00001, 00002, 00003, etc.). CIP231 Values
CIP232 CIP.003.232 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CIP232 Values
CIP233 CIP.003.233 RECORD-NUMBER 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. N/A
CIP234 CIP.003.234 MSIS-IDENTIFICATION-NUM 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 N/A
CIP235 CIP.003.235 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A
CIP236 CIP.003.236 ICN-ADJ A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction. N/A
CIP237 CIP.003.237 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A
CIP238 CIP.003.238 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A
CIP239 CIP.003.239 LINE-ADJUSTMENT-IND A code to indicate the type of adjustment record claim/encounter represents at claim detail level. CIP239 Values
CIP240 CIP.003.240 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. CIP240 Values
CIP241 CIP.003.241 SUBMITTER-ID The Submitter Identification number is the value that identifies the provider/trading partner/clearing house organization to the state's claim adjudication system. N/A
CIP242 CIP.003.242 CLAIM-LINE-STATUS The claim line status codes from the 277 transaction set identify the status of a specific detail claim line rather than the entire claim. Only report the claim line for the final, adjudicated claim. CIP242 Values
CIP243 CIP.003.243 BEGINNING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, this would be the date on which the service covered by this claim began. For capitation premium payments, the date on which the period of coverage related to this payment began. For financial transactions reported to the OT file, populate with the first day of the time period covered by this financial transaction. N/A
CIP244 CIP.003.244 ENDING-DATE-OF-SERVICE For services received during a single encounter with a provider, the date the service covered by this claim was received. For services involving multiple encounters on different days, or periods of care extending over two or more days, the date on which the service covered by this claim ended. For capitation premium payments, the date on which the period of coverage related to this payment ends/ended. For financial transactions reported to the OT file, populate with the last day of the time period covered by this financial transaction. N/A
CIP245 CIP.003.245 REVENUE-CODE 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. CIP245 Values
CIP248 CIP.003.248 IMMUNIZATION-TYPE This field identifies the type of immunization provided in order to track additional detail not currently contained in Current Procedural Terminology (CPT) codes. CIP248 Values
CIP249 CIP.003.249 REVENUE-CENTER-QUANTITY-ACTUAL On facility claim entries, this field is to capture the actual service quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field N/A
CIP250 CIP.003.250 REVENUE-CENTER-QUANTITY-ALLOWED On facility claim entries, this field is to capture maximum allowable quantity by revenue code category, e.g., number of days in a particular type of accommodation, pints of blood, etc. However, when HCPCS codes are required for services, the units are equal to the number of times the procedure/service being reported was performed. This field is only applicable when the service being billed can be quantified in discrete units, e.g., a number of visits or the number of units of a prescription/refill that were filled. For CLAIMOT claims/encounter records use Service Quantity Actual and CLAIMRX claims/encounter records use the Prescription Quantity Actual field N/A
CIP251 CIP.003.251 REVENUE-CHARGE 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. N/A
CIP252 CIP.003.252 ALLOWED-AMT 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. N/A
CIP254 CIP.003.254 MEDICAID-PAID-AMT 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. N/A
CIP255 CIP.003.255 MEDICAID-FFS-EQUIVALENT-AMT The amount that would have been paid had the services been provided on a Fee for Service basis. N/A
CIP256 CIP.003.256 BILLING-UNIT Unit of billing that is used for billing services by the facility. CIP256 Values
CIP257 CIP.003.257 TYPE-OF-SERVICE A code to categorize the services provided to a Medicaid or CHIP enrollee. CIP257 Values
CIP260 CIP.003.260 SERVICING-PROV-NUM 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. N/A
CIP261 CIP.003.261 SERVICING-PROV-NPI-NUM 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. N/A
CIP263 CIP.003.263 SERVICING-PROV-TYPE A code to describe the type of provider being reported. CIP263 Values
CIP264 CIP.003.264 SERVICING-PROV-SPECIALTY This code describes the area of specialty for the provider being reported. CIP264 Values
CIP265 CIP.003.265 OPERATING-PROV-NPI-NUM The National Provider ID (NPI) of the provider who performed the surgical procedures on the beneficiary. N/A
CIP266 CIP.003.266 OTHER-TPL-COLLECTION This data element indicates that the claim is for a beneficiary for whom other third party resource development and collection activities are in progress, when the liability is not another health insurance plan for which the eligible is a beneficiary. CIP266 Values
CIP267 CIP.003.267 PROV-FACILITY-TYPE The type of facility in which services on the claim were rendered. The Provider Facility Type code set is based on corresponding groups of HIPAA provider taxonomy codes. CIP267 Values
CIP268 CIP.003.268 BENEFIT-TYPE The benefit category corresponding to the service reported on the claim or encounter record. Note: The code definitions in the valid value list originate from the Medicaid and CHIP Program Data System (MACPro) benefit type list. See Appendix H: Benefit Types CIP268 Values
CIP269 CIP.003.269 CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. CIP269 Values
CIP270 CIP.003.270 XIX-MBESCBES-CATEGORY-OF-SERVICE 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. CIP270 Values
CIP271 CIP.003.271 XXI-MBESCBES-CATEGORY-OF-SERVICE 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. CIP271 Values
CIP272 CIP.003.272 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A
CIP273 CIP.003.273 STATE-NOTATION A free text field for the submitting state to enter whatever information it chooses. N/A
CIP278 CIP.003.278 NDC-QUANTITY This field is to capture the actual quantity of the National Drug Code being prescribed on the claim. N/A
CIP279 CIP.003.279 HCPCS-RATE This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44. CIP279 Values
CIP284 CIP.003.284 NATIONAL-DRUG-CODE A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. N/A
CIP285 CIP.003.285 NDC-UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the National Drug Code is expressed. CIP285 Values
CIP286 CIP.003.286 ADJUDICATION-DATE The date on which the payment status of the claim was finally adjudicated by the state. For Encounter Records (Type of Claim = 3, C, W), use date the encounter was processed by the state. N/A
CIP287 CIP.003.287 SELF-DIRECTION-TYPE This data element is not applicable to this file type. CIP287 Values
CIP288 CIP.003.288 PRE-AUTHORIZATION-NUM A number, code or other value that indicates the services provided on this claim have been authorized by the payee or other service organization, or that a referral for services has been approved. (Also referred to as a Prior Authorization or Referral Number). N/A
CIP296 CIP.003.296 IHS-SERVICE-IND 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. CIP296 Values
Definition
A record to capture data about specific goods or services rendered to a Medicaid/CHIP enrollee during the hospital stay.

File Segment Length
2100