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TMSIS Dataguide Medicaid.gov
Version 3.27.0

CLAIM-LINE-RECORD-LT

File Segment

File Segment Number

CLT00003

File Name

CLT - CLAIM LONG-TERM CARE

Last updated

No Updates

Data Elements Reference
DE Number System DE Number Data Element Definition Valid Values
CLT184 CLT.003.184 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.). CLT184 Values
CLT185 CLT.003.185 SUBMITTING-STATE A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received. CLT185 Values
CLT186 CLT.003.186 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
CLT187 CLT.003.187 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
CLT188 CLT.003.188 ICN-ORIG A unique number assigned by the state's payment system that identifies an original or adjustment claim. N/A
CLT189 CLT.003.189 ICN-ADJ

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

 N/A
CLT190 CLT.003.190 LINE-NUM-ORIG A unique number to identify the transaction line number that is being reported on the original claim. N/A
CLT191 CLT.003.191 LINE-NUM-ADJ A unique number to identify the transaction line number that identifies the line number on the adjustment claim. N/A
CLT192 CLT.003.192 LINE-ADJUSTMENT-IND

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

 CLT192 Values
CLT193 CLT.003.193 LINE-ADJUSTMENT-REASON-CODE Claim adjustment reason codes communicate why a service line was paid differently than it was billed. CLT193 Values
CLT194 CLT.003.194 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
CLT195 CLT.003.195 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. CLT195 Values
CLT196 CLT.003.196 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
CLT197 CLT.003.197 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
CLT198 CLT.003.198 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.

 CLT198 Values
CLT201 CLT.003.201 IMMUNIZATION-TYPE [No longer essential - Both data element and associated requirement(s); preserved for file submission integrity. See Data Dictionary v2.3 for specific definition and coding requirement description(s).] CLT201 Values
CLT202 CLT.003.202 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
CLT203 CLT.003.203 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
CLT204 CLT.003.204 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
CLT205 CLT.003.205 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
CLT206 CLT.003.206 TPL-AMT Third-party liability refers to the legal obligation of third parties, i.e., certain individuals, entities, or programs, to pay all or part of the expenditures for medical assistance furnished under a state plan. This is the total amount denoted at the claim detail level paid by the third party. N/A
CLT207 CLT.003.207 OTHER-INSURANCE-AMT The amount paid by insurance other than Medicare or Medicaid on this claim. N/A
CLT208 CLT.003.208 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
CLT209 CLT.003.209 MEDICAID-FFS-EQUIVALENT-AMT

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

 N/A
CLT210 CLT.003.210 BILLING-UNIT Unit of billing that is used for billing services by the facility. CLT210 Values
CLT211 CLT.003.211 TYPE-OF-SERVICE

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

 CLT211 Values
CLT212 CLT.003.212 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
CLT213 CLT.003.213 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
CLT215 CLT.003.215 SERVICING-PROV-TYPE

A code to describe the type of provider being reported.

 CLT215 Values
CLT216 CLT.003.216 SERVICING-PROV-SPECIALTY

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

 CLT216 Values
CLT217 CLT.003.217 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. CLT217 Values
CLT218 CLT.003.218 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 CLT218 Values
CLT219 CLT.003.219 CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT A code to indicate the Federal funding source for the payment. CLT219 Values
CLT221 CLT.003.221 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. CLT221 Values
CLT224 CLT.003.224 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.

 CLT224 Values
CLT225 CLT.003.225 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.

 CLT225 Values
CLT226 CLT.003.226 STATE-NOTATION

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

 N/A
CLT228 CLT.003.228 NATIONAL-DRUG-CODE A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim. N/A
CLT229 CLT.003.229 NDC-UNIT-OF-MEASURE A code to indicate the basis by which the quantity of the National Drug Code is expressed. CLT229 Values
CLT230 CLT.003.230 NDC-QUANTITY This field is to capture the actual quantity of the National Drug Code being prescribed on the claim. N/A
CLT231 CLT.003.231 HCPCS-RATE This data element is expected to capture data from the HIPAA 837I claim loop 2400 SV206 or UB-04 FL 44. CLT231 Values
CLT233 CLT.003.233 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
CLT234 CLT.003.234 SELF-DIRECTION-TYPE This data element is not applicable to this file type. CLT234 Values
CLT235 CLT.003.235 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
CLT243 CLT.003.243 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.

 CLT243 Values
Definition
A record to capture data about specific goods or services rendered to a Medicaid/CHIP enrollee during a long-term care stay.

File Segment Length
1900