CLAIM-LINE-RECORD-OT

File Segment

File Segment Number

COT00003

File Name

COT - CLAIM OTHER

Last updated

No Updates

Data Elements Reference

DE Number	System DE Number	Data Element	Definition	Valid Values
COT154	COT.003.154	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.).	COT154 Values
COT155	COT.003.155	SUBMITTING-STATE	A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.	COT155 Values
COT156	COT.003.156	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
COT157	COT.003.157	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
COT158	COT.003.158	ICN-ORIG	A unique number assigned by the state's payment system that identifies an original or adjustment claim.	N/A
COT159	COT.003.159	ICN-ADJ	A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.	N/A
COT160	COT.003.160	LINE-NUM-ORIG	A unique number to identify the transaction line number that is being reported on the original claim.	N/A
COT161	COT.003.161	LINE-NUM-ADJ	A unique number to identify the transaction line number that identifies the line number on the adjustment claim.	N/A
COT162	COT.003.162	LINE-ADJUSTMENT-IND	A code to indicate the type of adjustment record claim/encounter represents at claim detail level.	COT162 Values
COT163	COT.003.163	LINE-ADJUSTMENT-REASON-CODE	Claim adjustment reason codes communicate why a service line was paid differently than it was billed.	COT163 Values
COT164	COT.003.164	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
COT165	COT.003.165	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.	COT165 Values
COT166	COT.003.166	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. For sub-capitation payments, this represents the first date of the period the sub-capitation payment covers.	N/A
COT167	COT.003.167	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. For sub-capitation payments, this represents the last date of the period the sub-capitation payment covers.	N/A
COT168	COT.003.168	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.	COT168 Values
COT169	COT.003.169	PROCEDURE-CODE	A field to capture the CPT or HCPCS code that describes a service or good rendered by the provider to an enrollee on the specified date of service.	COT169 Values
COT170	COT.003.170	PROCEDURE-CODE-DATE	The date upon which a reported medical procedure was performed.	N/A
COT171	COT.003.171	PROCEDURE-CODE-FLAG	A flag that identifies the coding system used for an associated procedure code.	COT171 Values
COT172	COT.003.172	PROCEDURE-CODE-MOD-1	The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.	COT172 Values
COT173	COT.003.173	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).]	COT173 Values
COT174	COT.003.174	BILLED-AMT	The amount billed at the claim detail level as submitted by the provider. For encounter records, Type of Claim = 3, C, or W, this field should be populated with the amount that the provider billed 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
COT175	COT.003.175	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
COT176	COT.003.176	BENEFICIARY-COPAYMENT-PAID-AMOUNT	The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on a claim line. Do not include copayment payments made by a third party/ies on behalf of the beneficiary. This is a copayment paid for a service in the corresponding claim line for OT and RX claim files. The Beneficiary Copayment Paid Amount is an optional line level data element reported for OT and RX claim file types, only. If the beneficiary copayment paid amount is not available at the claim line level, report the total copayment paid amount in the header level copayment data element.	N/A
COT177	COT.003.177	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
COT178	COT.003.178	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
COT179	COT.003.179	MEDICAID-FFS-EQUIVALENT-AMT	The amount that would have been paid had the services been provided on a Fee for Service basis.	N/A
COT182	COT.003.182	MEDICARE-PAID-AMT	The amount paid by Medicare on this claim. For claims where Medicare payment is only available at the header level, report the entire payment amount on the T-MSIS claim line with the highest charge or the 1st non-denied line. Zero fill Medicare Paid Amount on all other claim lines.	N/A
COT183	COT.003.183	SERVICE-QUANTITY-ACTUAL	The quantity of a service or product that is rendered for a specific date of service or billing time span as reported by revenue code or procedure code on the claim line. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Service Quantity Actual field. 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.	N/A
COT184	COT.003.184	SERVICE-QUANTITY-ALLOWED	The maximum allowable quantity of a service that may be rendered per date of service or per month. For use with CLAIMOT and CLAIMRX claims. For CLAIMIP and CLAIMOT claims/encounter records, use the Revenue center -quantity Allowed field. NOTE: One prescription for 100 250 milligram tablets results in Prescription Quantity allowed=100. 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 prescriptions/refills, use the Medicaid Drug Rebate definition of a unit, which is the smallest unit by which the drug is normally measured; e.g. tablet, capsule, milliliter, etc. For drugs not identifiable or dispensed by a normal unit, e.g. powder filled vials, use 1 as the number of units. The value in Prescription Quantity allowed must correspond with the value in Unit of measure.	N/A
COT186	COT.003.186	TYPE-OF-SERVICE	A code to categorize the services provided to a Medicaid or CHIP enrollee. For sub-capitation payments, report a TYPE-OF-SERVICE value 119, 120, or 122.	COT186 Values
COT187	COT.003.187	HCBS-SERVICE-CODE	A code to indicate that the service represents a long-term care home and community based service or support for an individual with chronic medical and/or mental conditions. The codes help to delineate between acute care and long-term care provided in the home and community setting (e.g. 1915(c), 1915(i), 1915(j), and 1915(k) services).	COT187 Values
COT188	COT.003.188	HCBS-TAXONOMY	A code to classify the home and community based services listed on the claim into the HCBS taxonomy.	COT188 Values
COT189	COT.003.189	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
COT190	COT.003.190	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-PROV-NPI-NUM 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
COT191	COT.003.191	SERVICING-PROV-TAXONOMY	The taxonomy code for the provider who treated the recipient.	COT191 Values
COT192	COT.003.192	SERVICING-PROV-TYPE	A code to describe the type of provider being reported.	COT192 Values
COT193	COT.003.193	SERVICING-PROV-SPECIALTY	This code describes the area of specialty for the provider being reported.	COT193 Values
COT194	COT.003.194	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.	COT194 Values
COT195	COT.003.195	TOOTH-DESIGNATION-SYSTEM	A code to identify the tooth numbering system being used.	COT195 Values
COT196	COT.003.196	TOOTH-NUM	The tooth number serviced based on the tooth numbering system identified in the TOOTH-DESIGNATION-SYSTEM field.	COT196 Values
COT197	COT.003.197	TOOTH-QUAD-CODE	The area of the oral cavity is designated by a two-digit code.	COT197 Values
COT198	COT.003.198	TOOTH-SURFACE-CODE	A code to identify the tooth's surface on which the service was performed.	COT198 Values
COT199	COT.003.199	ORIGINATION-ADDR-LN1	The street address of the origination point from which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.	N/A
COT200	COT.003.200	ORIGINATION-ADDR-LN2	The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.	N/A
COT201	COT.003.201	ORIGINATION-CITY	The name of the origination city from which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims, this is only required if state has captured this information, otherwise it is conditional.	N/A
COT202	COT.003.202	ORIGINATION-STATE	The ANSI numeric code of the origination state in which a patient is transported either from home or a long term care facility to a health care provider to a health care provider for healthcare services or vice versa.	COT202 Values
COT203	COT.003.203	ORIGINATION-ZIP-CODE	The zip code of the origination city from which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa.	COT203 Values
COT204	COT.003.204	DESTINATION-ADDR-LN1	The street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.	N/A
COT205	COT.003.205	DESTINATION-ADDR-LN2	The second line of the street address of the destination point to which a patient is transported either from home or Long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.	N/A
COT206	COT.003.206	DESTINATION-CITY	The name of the destination city to which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.	N/A
COT207	COT.003.207	DESTINATION-STATE	The ANSI state numeric code for the U.S. state, Territory, or the District of Columbia code of the destination state in which a patient is transported either from home or a long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.	COT207 Values
COT208	COT.003.208	DESTINATION-ZIP-CODE	The zip code of the destination city to which a patient is transported either from home or long term care facility to a health care provider for healthcare services or vice versa. For transportation claims only. Required if state has captured this information, otherwise it is conditional.	COT208 Values
COT209	COT.003.209	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	COT209 Values
COT210	COT.003.210	CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT	A code to indicate the Federal funding source for the payment.	COT210 Values
COT211	COT.003.211	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.	COT211 Values
COT212	COT.003.212	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.	COT212 Values
COT213	COT.003.213	OTHER-INSURANCE-AMT	The amount paid by insurance other than Medicare or Medicaid on this claim.	N/A
COT214	COT.003.214	STATE-NOTATION	A free text field for the submitting state to enter whatever information it chooses.	N/A
COT217	COT.003.217	NATIONAL-DRUG-CODE	A code following the National Drug Code format indicating the drug, device, or medical supply covered by this claim.	N/A
COT218	COT.003.218	PROCEDURE-CODE-MOD-3	The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.	COT218 Values
COT219	COT.003.219	PROCEDURE-CODE-MOD-4	The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.	COT219 Values
COT221	COT.003.221	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
COT222	COT.003.222	SELF-DIRECTION-TYPE	A data element to identify how the beneficiary self-directed the service, i.e. hiring authority (the beneficiary has decision-making authority to recruit, hire, train and supervise the individuals who furnish his/her services), budget authority (The beneficiary has decision-making authority over how the Medicaid funds in a budget are spent), or both hiring and budget authority.	COT222 Values
COT223	COT.003.223	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
COT224	COT.003.224	NDC-UNIT-OF-MEASURE	A code to indicate the basis by which the quantity of the National Drug Code is expressed.	COT224 Values
COT225	COT.003.225	NDC-QUANTITY	This field is to capture the actual quantity of the National Drug Code being prescribed on the claim.	N/A
COT227	COT.003.227	PROCEDURE-CODE-MOD-2	The procedure code modifier used with an associated procedure code. For example, some states use modifiers to indicate assistance in surgery or anesthesia services.	COT227 Values
COT234	COT.003.234	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.	COT234 Values

Definition: A record to capture data about specific goods or services rendered to a Medicaid/CHIP enrollee during an outpatient visit.
File Segment Length: 1750