A code that uniquely identifies the U.S. State or Territory from which T-MSIS system data resources were received.

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

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

An indicator specifying whether the claim is a crossover claim where a portion is paid by Medicare.

In the claims files this data element indicates whether the claim or encounter was covered under the authority of an 1115A demonstration. In the Eligibility file, this data element indicates whether the individual participates in an 1115A demonstration.

Indicates the type of adjustment record.

The date Medicaid paid this claim or adjustment. For Encounter Records (Type of Claim = 3, C, W), the date the managed care organization paid the provider for the claim or adjustment.

A code to indicate what type of payment is covered in this claim.

For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.

The field denotes the claims payment system from which the claim was extracted.

For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report a SOURCE-LOCATION = '22' to indicate that the sub-capitated entity paid a provider for the service to the enrollee on a FFS basis.

For sub-capitated encounters from a sub-capitated network provider that were submitted to sub-capitated entity, report a SOURCE-LOCATION = '23' to indicate that the sub-capitated network provider provided the service directly to the enrollee.

For sub-capitated encounters from a sub-capitated network provider, report a SOURCE-LOCATION = “23” to indicate that the sub-capitated network provider provided the service directly to the enrollee.

The total amount billed for this claim at the claim header level as submitted by the provider. For encounter records, when Type of Claim value is [ 3, C, or W ], then value must equal amount the provider billed to the managed care plan. Total Billed Amount is not expected on financial transactions.

For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the provider billed the sub-capitated entity for the service. 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 claim header level maximum amount determined by the payer as being 'allowable' under the provisions of the contract prior to the determination of actual payment. On FFS claims the Allowed Amount is determined by the state's MMIS. 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 total amount that the sub-capitated entity allowed for the service. 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 total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim.

For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.

For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider.

The amount paid by Medicaid/CHIP, on this claim at the claim header level, toward the beneficiary's Medicare deductible. If the Medicare deductible amount can be identified separately from Medicare coinsurance payments, code that amount in this field. If the Medicare coinsurance and deductible payments cannot be separated, fill this field with the combined payment amount, code Medicare Combined Indicator a "1" and leave Total Medicare Coinsurance Amount unpopulated.

The total amount paid by the Medicaid/CHIP agency or a managed care plan towards the portion of the Medicare allowed charges that Medicare applied to coinsurance.

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 header level paid by the third party.

The field denotes whether the insured party is covered under an other insurance plan other than Medicare or Medicaid.

This indicator indicates that the reimbursement amount included on the claim is for a fixed payment. Fixed payments are made by the state to insurers or providers for premiums or eligible coverage, not for a particular service. For example, some states have Primary Care Case Management programs where the state pays providers a monthly patient management fee of $3.50 for each eligible participant under their care. This fee is considered a fixed payment. It is very important for states to correctly identify fixed payments. Fixed payments do not have a defined "medical record" associated with the payment; therefore, fixed payments are not subject to medical record request and medical record review.

A code to indicate the source of non-federal share funds.

A code to indicate the type of non-federal share used by the state to finance its expenditure to the provider. In the event of two sources, states are to report the portion which represents the largest proportion not funded by the Federal government.

A unique number assigned by the state which represents a distinct comprehensive managed care plan, prepaid health plan, primary care case management program, a program for all-inclusive care for the elderly entity, or other approved plans.

The field denotes whether the payment amount was determined at the claim header or line/detail level.

For claims where payment is NOT determined at the individual line level (PAYMENT-LEVEL-IND = 1), the claim lines’ associated allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts are left blank and the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amount is reported at the header level only.

For claims where payment/allowed amount is determined at the individual lines and when applicable, cost-sharing and/or coordination of benefits were deducted from one or more specific line-level payment/allowed amounts (PAYMENT-LEVEL-IND = 2), the allowed (ALLOWED-AMT) and paid (MEDICAID-PAID-AMT) amounts on the associated claim lines should sum to the total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts reported on the claim header.

For claims where payment/allowed amount is determined at the individual lines but then cost sharing or coordination of benefits was deducted from the total paid/allowed amount at the header only (PAYMENT-LEVEL-IND = 3), then the line-level paid amount (MEDICAID-PAID-AMT) would be blank and line-level allowed (ALLOWED-AMT) and header level total allowed (TOT-ALLOWED-AMT) and total paid (TOT-MEDICAID-PAID-AMT) amounts must all be populated but the line level allowed amounts are not expected to sum exactly to the header level total allowed.

For example, if a claim for an office visit and a procedure is assigned a separate line-level allowed amount for each line, but then at the header level a copay is deducted from the header-level total allowed and/or total paid amounts, then the sum of line-level allowed amounts may not be equal to the header-level total allowed amounts or correspond directly to the total paid amount. If the state cannot distinguish between the scenarios for value 1 and value 3, then value 1 can be used for all claims with only header-level total allowed/paid amounts.

The total number of lines on the claim.

Indicates if the claim was processed by forcing it through a manual override process.

Indicates whether the claim is submitted by a provider or provider group enrolled in the Health Home care model to provide services for the beneficiary on the claim. Health home providers provide service for patients with chronic illnesses. States that do not specify an eligible individual's health home provider number, if applicable, should not report claims that indicate the claim is submitted by a provider or provider group enrolled in the health home model.

Field specifying the waiver or demonstration which authorized payment for a claim. These IDs must be the approved, full federal waiver ID number assigned during the state submission and CMS approval process. Waiver IDs should actually only be the "core" part of the waiver IDs, without including suffixes for renewals or amendments.

A unique identification number assigned by the state to a provider or capitation plan. This data element should represent the entity billing for the service. For encounter records, if associated Type of Claim value equals 3, C, or W, then value must be the state identifier of the provider or entity (billing or reporting) to the managed care plan.

The National Provider ID (NPI) of the billing provider responsible for billing for the service on the claim. The billing provider can also be servicing, referring, or prescribing provider; can be admitting provider except for Long Term Care.

The taxonomy code for the provider billing for the service.

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

The National Provider ID (NPI) of the provider who prescribed a medication to a patient.

The Remittance Advice Number is a sequential number that identifies the current Remittance Advice (RA) produced for a provider. The number is incremented by one each time a new RA is generated. The RA is the detailed explanation of the reason for the payment amount.

A code to indicate whether an individual received services or equipment across state borders. (The provider location is out of state, but for payment purposes the provider is treated as an in-state provider.)

Date the drug, device, or supply was dispensed by the provider.

The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their coinsurance for the covered services on the claim. Do not include coinsurance payments made by a third party/ies on behalf of the beneficiary.

The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their copayment for the covered services on the claim. Do not include copayment payments made by a third party/ies on behalf of the beneficiary.

The amount the beneficiary or his or her representative (e.g., their guardian) paid towards their deductible for the covered services on the claim. Do not include deductible payments made by a third party/ies on behalf of the beneficiary.

An indicator to identify a claim that the state refused pay in its entirety.

An indicator signifying that the copay was discounted or waived by the provider (e.g., physician or hospital). Do not use to indicate administrative-level, Medicaid State Agency or Medicaid MCO copayment waived decisions.

The amount of money paid by a third party on behalf of the beneficiary towards coinsurance.

The date the third party paid the coinsurance amount

The amount of money paid by a third party on behalf of the beneficiary towards copayment.

The date the third party paid the copayment amount.

The National Provider ID (NPI) of the provider responsible for dispensing the prescription drug.

The National Provider ID (NPI) of the health home provider.

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

Code indicating that the amount paid by Medicaid/CHIP on this claim toward the recipient's Medicare deductible was combined with their coinsurance amount because the amounts could not be separated.

The total coinsurance amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary coinsurance liability for covered services on the claim. Do not subtract out any payments made toward the coinsurance.

The total deductible amount on a claim the beneficiary is obligated to pay for covered services. This amount is the total Medicaid or contract negotiated beneficiary deductible liability minus previous beneficiary payments that went toward their deductible. Do not subtract out any payments for the given claim that went toward the deductible.