Transformed - Medicaid Statistical Information System (T-MSIS)

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Overview

PRA Disclosure Statement
Record Layouts

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Sheet 1: PRA Disclosure Statement

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Sheet 2: Record Layouts

T-MSIS Record Layouts
DE_NO	DATA_ELEMENT_NAME	SIZE	START POSITION	STOP POSITION	FILE NAME	FILE SEGMENT (with RECORD-ID)
CIP001	RECORD-ID	X(8)	1	8	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP002	DATA-DICTIONARY-VERSION	X(10)	9	18	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP006	FILE-NAME	X(8)	32	39	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP007	SUBMITTING-STATE	X(2)	40	41	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP008	DATE-FILE-CREATED	9(8)	42	49	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP009	START-OF-TIME-PERIOD	9(8)	50	57	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP010	END-OF-TIME-PERIOD	9(8)	58	65	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP011	FILE-STATUS-INDICATOR	X(1)	66	66	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP012	SSN-INDICATOR	X(1)	67	67	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP013	TOT-REC-CNT	9(11)	68	78	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP275	SEQUENCE-NUMBER	X(4)	79	82	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP014	STATE-NOTATION	X(500)	83	582	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP015	FILLER	X(1518)	583	2100	CLAIMIP	FILE-HEADER-RECORD-IP-CIP00001
CIP016	RECORD-ID	X(8)	1	8	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP017	SUBMITTING-STATE	X(2)	9	10	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP018	RECORD-NUMBER	9(11)	11	21	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP019	ICN-ORIG	X(50)	22	71	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP020	ICN-ADJ	X(50)	72	121	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP021	SUBMITTER-ID	X(12)	122	133	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP022	MSIS-IDENTIFICATION-NUM	X(20)	134	153	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP023	CROSSOVER-INDICATOR	X(1)	154	154	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP024	TYPE-OF-HOSPITAL	X(2)	155	156	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP025	1115A-DEMONSTRATION-IND	X(1)	157	157	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP026	ADJUSTMENT-IND	X(1)	158	158	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP027	ADJUSTMENT-REASON-CODE	X(3)	159	161	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP028	ADMISSION-TYPE	X(1)	162	162	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP029	DRG-DESCRIPTION	X(20)	163	182	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP030	ADMITTING-DIAGNOSIS-CODE	X(7)	183	189	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP031	ADMITTING-DIAGNOSIS-CODE-FLAG	X(1)	190	190	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP032	DIAGNOSIS-CODE-1	X(7)	191	197	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP033	DIAGNOSIS-CODE-FLAG-1	X(1)	198	198	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP034	DIAGNOSIS-POA-FLAG-1	X(1)	199	199	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP035	DIAGNOSIS-CODE-2	X(7)	200	206	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP036	DIAGNOSIS-CODE-FLAG-2	X(1)	207	207	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP037	DIAGNOSIS-POA-FLAG-2	X(1)	208	208	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP038	DIAGNOSIS-CODE-3	X(7)	209	215	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP039	DIAGNOSIS-CODE-FLAG-3	X(1)	216	216	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP040	DIAGNOSIS-POA-FLAG-3	X(1)	217	217	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP041	DIAGNOSIS-CODE-4	X(7)	218	224	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP042	DIAGNOSIS-CODE-FLAG-4	X(1)	225	225	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP043	DIAGNOSIS-POA-FLAG-4	X(1)	226	226	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP044	DIAGNOSIS-CODE-5	X(7)	227	233	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP045	DIAGNOSIS-CODE-FLAG-5	X(1)	234	234	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP046	DIAGNOSIS-POA-FLAG-5	X(1)	235	235	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP047	DIAGNOSIS-CODE-6	X(7)	236	242	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP048	DIAGNOSIS-CODE-FLAG-6	X(1)	243	243	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP049	DIAGNOSIS-POA-FLAG-6	X(1)	244	244	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP050	DIAGNOSIS-CODE-7	X(7)	245	251	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP051	DIAGNOSIS-CODE-FLAG-7	X(1)	252	252	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP052	DIAGNOSIS-POA-FLAG-7	X(1)	253	253	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP053	DIAGNOSIS-CODE-8	X(7)	254	260	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP054	DIAGNOSIS-CODE-FLAG-8	X(1)	261	261	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP055	DIAGNOSIS-POA-FLAG-8	X(1)	262	262	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP056	DIAGNOSIS-CODE-9	X(7)	263	269	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP057	DIAGNOSIS-CODE-FLAG-9	X(1)	270	270	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP058	DIAGNOSIS-POA-FLAG-9	X(1)	271	271	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP059	DIAGNOSIS-CODE-10	X(7)	272	278	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP060	DIAGNOSIS-CODE-FLAG-10	X(1)	279	279	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP061	DIAGNOSIS-POA-FLAG-10	X(1)	280	280	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP062	DIAGNOSIS-CODE-11	X(7)	281	287	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP063	DIAGNOSIS-CODE-FLAG-11	X(1)	288	288	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP064	DIAGNOSIS-POA-FLAG-11	X(1)	289	289	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP065	DIAGNOSIS-CODE-12	X(7)	290	296	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP066	DIAGNOSIS-CODE-FLAG-12	X(1)	297	297	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP067	DIAGNOSIS-POA-FLAG-12	X(1)	298	298	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP068	DIAGNOSIS-RELATED-GROUP	X(4)	299	302	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP069	DIAGNOSIS-RELATED-GROUP-IND	X(4)	303	306	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP070	PROCEDURE-CODE-1	X(8)	307	314	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP071	PROCEDURE-CODE-MOD-1	X(2)	315	316	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP072	PROCEDURE-CODE-FLAG-1	X(2)	317	318	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP073	PROCEDURE-CODE-DATE-1	9(8)	319	326	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP074	PROCEDURE-CODE-2	X(8)	327	334	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP075	PROCEDURE-CODE-MOD-2	X(2)	335	336	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP076	PROCEDURE-CODE-FLAG-2	X(2)	337	338	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP077	PROCEDURE-CODE-DATE-2	9(8)	339	346	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP078	PROCEDURE-CODE-3	X(8)	347	354	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP079	PROCEDURE-CODE-MOD-3	X(2)	355	356	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP080	PROCEDURE-CODE-FLAG-3	X(2)	357	358	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP081	PROCEDURE-CODE-DATE-3	9(8)	359	366	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP082	PROCEDURE-CODE-4	X(8)	367	374	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP083	PROCEDURE-CODE-MOD-4	X(2)	375	376	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP084	PROCEDURE-CODE-FLAG-4	X(2)	377	378	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP085	PROCEDURE-CODE-DATE-4	9(8)	379	386	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP086	PROCEDURE-CODE-5	X(8)	387	394	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP087	PROCEDURE-CODE-MOD-5	X(2)	395	396	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP088	PROCEDURE-CODE-FLAG-5	X(2)	397	398	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP089	PROCEDURE-CODE-DATE-5	9(8)	399	406	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP090	PROCEDURE-CODE-6	X(8)	407	414	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP091	PROCEDURE-CODE-MOD-6	X(2)	415	416	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP092	PROCEDURE-CODE-FLAG-6	X(2)	417	418	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP093	PROCEDURE-CODE-DATE-6	9(8)	419	426	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP094	ADMISSION-DATE	9(8)	427	434	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP095	ADMISSION-HOUR	X(2)	435	436	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP096	DISCHARGE-DATE	9(8)	437	444	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP097	DISCHARGE-HOUR	X(2)	445	446	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP098	ADJUDICATION-DATE	9(8)	447	454	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP099	MEDICAID-PAID-DATE	9(8)	455	462	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP100	TYPE-OF-CLAIM	X(1)	463	463	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP101	TYPE-OF-BILL	X(4)	464	467	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP102	CLAIM-STATUS	X(3)	468	470	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP103	CLAIM-STATUS-CATEGORY	X(3)	471	473	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP104	SOURCE-LOCATION	X(2)	474	475	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP105	CHECK-NUM	X(15)	476	490	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP106	CHECK-EFF-DATE	9(8)	491	498	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP107	ALLOWED-CHARGE-SRC	X(1)	499	499	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP108	CLAIM-PYMT-REM-CODE-1	X(5)	500	504	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP109	CLAIM-PYMT-REM-CODE-2	X(5)	505	509	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP110	CLAIM-PYMT-REM-CODE-3	X(5)	510	514	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP111	CLAIM-PYMT-REM-CODE-4	X(5)	515	519	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP112	TOT-BILLED-AMT	S9(11)V99	520	532	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP113	TOT-ALLOWED-AMT	S9(11)V99	533	545	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP114	TOT-MEDICAID-PAID-AMT	S9(11)V99	546	558	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP115	TOT-COPAY-AMT	S9(11)V99	559	571	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP116	TOT-MEDICARE-DEDUCTIBLE-AMT	S9(11)V99	572	584	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP117	TOT-MEDICARE-COINS-AMT	S9(11)V99	585	597	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP118	TOT-TPL-AMT	S9(11)V99	598	610	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP119	TOT-OTHER-INSURANCE-AMT	S9(11)V99	611	623	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP121	OTHER-INSURANCE-IND	X(1)	624	624	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP122	OTHER-TPL-COLLECTION	X(3)	625	627	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP123	SERVICE-TRACKING-TYPE	X(2)	628	629	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP124	SERVICE-TRACKING-PAYMENT-AMT	S9(11)V99	630	642	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP125	FIXED-PAYMENT-IND	X(1)	643	643	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP126	FUNDING-CODE	X(2)	644	645	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP127	FUNDING-SOURCE-NONFEDERAL-SHARE	X(2)	646	647	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP128	MEDICARE-COMB-DED-IND	X(1)	648	648	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP129	PROGRAM-TYPE	X(2)	649	650	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP130	PLAN-ID-NUMBER	X(12)	651	662	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP131	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	663	672	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP132	PAYMENT-LEVEL-IND	X(1)	673	673	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP133	MEDICARE-REIM-TYPE	X(2)	674	675	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP134	NON-COV-DAYS	S9(5)	676	680	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP135	NON-COV-CHARGES	S9(11)V99	681	693	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP136	MEDICAID-COV-INPATIENT-DAYS	S9(7)	694	700	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP137	CLAIM-LINE-COUNT	9(4)	701	704	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP138	FORCED-CLAIM-IND	X(1)	705	705	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP139	HEALTH-CARE-ACQUIRED-CONDITION-IND	X(1)	706	706	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP140	OCCURRENCE-CODE-01	X(2)	707	708	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP141	OCCURRENCE-CODE-02	X(2)	709	710	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP142	OCCURRENCE-CODE-03	X(2)	711	712	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP143	OCCURRENCE-CODE-04	X(2)	713	714	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP144	OCCURRENCE-CODE-05	X(2)	715	716	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP145	OCCURRENCE-CODE-06	X(2)	717	718	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP146	OCCURRENCE-CODE-07	X(2)	719	720	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP147	OCCURRENCE-CODE-08	X(2)	721	722	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP148	OCCURRENCE-CODE-09	X(2)	723	724	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP149	OCCURRENCE-CODE-10	X(2)	725	726	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP150	OCCURRENCE-CODE-EFF-DATE-01	9(8)	727	734	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP151	OCCURRENCE-CODE-EFF-DATE-02	9(8)	735	742	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP152	OCCURRENCE-CODE-EFF-DATE-03	9(8)	743	750	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP153	OCCURRENCE-CODE-EFF-DATE-04	9(8)	751	758	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP154	OCCURRENCE-CODE-EFF-DATE-05	9(8)	759	766	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP155	OCCURRENCE-CODE-EFF-DATE-06	9(8)	767	774	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP156	OCCURRENCE-CODE-EFF-DATE-07	9(8)	775	782	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP157	OCCURRENCE-CODE-EFF-DATE-08	9(8)	783	790	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP158	OCCURRENCE-CODE-EFF-DATE-09	9(8)	791	798	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP159	OCCURRENCE-CODE-EFF-DATE-10	9(8)	799	806	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP160	OCCURRENCE-CODE-END-DATE-01	9(8)	807	814	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP161	OCCURRENCE-CODE-END-DATE-02	9(8)	815	822	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP162	OCCURRENCE-CODE-END-DATE-03	9(8)	823	830	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP163	OCCURRENCE-CODE-END-DATE-04	9(8)	831	838	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP164	OCCURRENCE-CODE-END-DATE-05	9(8)	839	846	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP165	OCCURRENCE-CODE-END-DATE-06	9(8)	847	854	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP166	OCCURRENCE-CODE-END-DATE-07	9(8)	855	862	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP167	OCCURRENCE-CODE-END-DATE-08	9(8)	863	870	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP168	OCCURRENCE-CODE-END-DATE-09	9(8)	871	878	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP169	OCCURRENCE-CODE-END-DATE-10	9(8)	879	886	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP170	BIRTH-WEIGHT-GRAMS	S9(6)V999	887	895	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP171	PATIENT-CONTROL-NUM	X(20)	896	915	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP172	ELIGIBLE-LAST-NAME	X(30)	916	945	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP173	ELIGIBLE-FIRST-NAME	X(30)	946	975	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP174	ELIGIBLE-MIDDLE-INIT	X(1)	976	976	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP175	DATE-OF-BIRTH	9(8)	977	984	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP176	HEALTH-HOME-PROV-IND	X(1)	985	985	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP177	WAIVER-TYPE	X(2)	986	987	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP178	WAIVER-ID	X(20)	988	1007	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP179	BILLING-PROV-NUM	X(30)	1008	1037	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP180	BILLING-PROV-NPI-NUM	X(10)	1038	1047	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP181	BILLING-PROV-TAXONOMY	X(12)	1048	1059	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP182	BILLING-PROV-TYPE	X(2)	1060	1061	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP183	BILLING-PROV-SPECIALTY	X(2)	1062	1063	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP184	ADMITTING-PROV-NPI-NUM	X(10)	1064	1073	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP185	ADMITTING-PROV-NUM	X(30)	1074	1103	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP186	ADMITTING-PROV-SPECIALTY	X(2)	1104	1105	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP187	ADMITTING-PROV-TAXONOMY	X(12)	1106	1117	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP188	ADMITTING-PROV-TYPE	X(2)	1118	1119	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP189	REFERRING-PROV-NUM	X(30)	1120	1149	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP190	REFERRING-PROV-NPI-NUM	X(10)	1150	1159	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP191	REFERRING-PROV-TAXONOMY	X(12)	1160	1171	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP192	REFERRING-PROV-TYPE	X(2)	1172	1173	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP193	REFERRING-PROV-SPECIALTY	X(2)	1174	1175	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP194	DRG-OUTLIER-AMT	S9(11)V99	1176	1188	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP195	DRG-REL-WEIGHT	X(8)	1189	1196	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP196	MEDICARE-HIC-NUM	X(12)	1197	1208	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP197	OUTLIER-CODE	X(2)	1209	1210	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP198	OUTLIER-DAYS	S9(5)	1211	1215	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP199	PATIENT-STATUS	X(2)	1216	1217	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP201	BMI	S9(5)V9	1218	1223	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP202	REMITTANCE-NUM	X(30)	1224	1253	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP203	SPLIT-CLAIM-IND	X(1)	1254	1254	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP204	BORDER-STATE-IND	X(1)	1255	1255	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP206	BENEFICIARY-COINSURANCE-AMOUNT	S9(11)V99	1256	1268	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP207	BENEFICIARY-COINSURANCE-DATE-PAID	9(8)	1269	1276	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP208	BENEFICIARY-COPAYMENT-AMOUNT	S9(11)V99	1277	1289	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP209	BENEFICIARY-COPAYMENT-DATE-PAID	9(8)	1290	1297	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP210	BENEFICIARY-DEDUCTIBLE-AMOUNT	S9(11)V99	1298	1310	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP211	BENEFICIARY-DEDUCTIBLE-DATE-PAID	9(8)	1311	1318	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP212	CLAIM-DENIED-INDICATOR	X(1)	1319	1319	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP213	COPAY-WAIVED-IND	X(1)	1320	1320	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP214	HEALTH-HOME-ENTITY-NAME	X(50)	1321	1370	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP216	THIRD-PARTY-COINSURANCE-AMOUNT-PAID	S9(11)V99	1371	1383	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP217	THIRD-PARTY-COINSURANCE-DATE-PAID	9(8)	1384	1391	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP218	THIRD-PARTY-COPAYMENT-AMOUNT-PAID	S9(11)V99	1392	1404	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP219	THIRD-PARTY-COPAYMENT-DATE-PAID	9(8)	1405	1412	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP220	MEDICAID-AMOUNT-PAID-DSH	S9(11)V99	1413	1425	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP221	HEALTH-HOME-PROVIDER-NPI	X(10)	1426	1435	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP222	MEDICARE-BENEFICIARY-IDENTIFIER	X(12)	1436	1447	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP223	OPERATING-PROV-TAXONOMY	X(12)	1448	1459	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP224	UNDER-DIRECTION-OF-PROV-NPI	X(10)	1460	1469	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP225	UNDER-DIRECTION-OF-PROV-TAXONOMY	X(12)	1470	1481	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP226	UNDER-SUPERVISION-OF-PROV-NPI	X(10)	1482	1491	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP227	UNDER-SUPERVISION-OF-PROV-TAXONOMY	X(12)	1492	1503	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP228	MEDICARE-PAID-AMT	S9(11)V99	1504	1516	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP229	STATE-NOTATION	X(500)	1517	2016	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP289	PROV-LOCATION-ID	X(5)	2017	2021	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP230	FILLER	X(79)	2022	2100	CLAIMIP	CLAIM-HEADER-RECORD-IP-CIP00002
CIP231	RECORD-ID	X(8)	1	8	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP232	SUBMITTING-STATE	X(2)	9	10	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP233	RECORD-NUMBER	9(11)	11	21	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP234	MSIS-IDENTIFICATION-NUM	X(20)	22	41	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP235	ICN-ORIG	X(50)	42	91	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP236	ICN-ADJ	X(50)	92	141	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP237	LINE-NUM-ORIG	X(3)	142	144	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP238	LINE-NUM-ADJ	X(3)	145	147	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP239	LINE-ADJUSTMENT-IND	X(1)	148	148	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP240	LINE-ADJUSTMENT-REASON-CODE	X(3)	149	151	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP241	SUBMITTER-ID	X(12)	152	163	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP242	CLAIM-LINE-STATUS	X(3)	164	166	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP243	BEGINNING-DATE-OF-SERVICE	9(8)	167	174	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP244	ENDING-DATE-OF-SERVICE	9(8)	175	182	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP245	REVENUE-CODE	X(4)	183	186	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP248	IMMUNIZATION-TYPE	X(2)	187	188	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP249	IP-LT-QUANTITY-OF-SERVICE-ACTUAL	S9(6)V999	189	197	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP250	IP-LT-QUANTITY-OF-SERVICE-ALLOWED	S9(6)V999	198	206	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP251	REVENUE-CHARGE	S9(11)V99	207	219	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP252	ALLOWED-AMT	S9(11)V99	220	232	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP253	TPL-AMT	S9(11)V99	233	245	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP254	MEDICAID-PAID-AMT	S9(11)V99	246	258	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP255	MEDICAID-FFS-EQUIVALENT-AMT	S9(11)V99	259	271	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP256	BILLING-UNIT	X(2)	272	273	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP257	TYPE-OF-SERVICE	X(3)	274	276	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP260	SERVICING-PROV-NUM	X(30)	277	306	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP261	SERVICING-PROV-NPI-NUM	X(10)	307	316	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP262	SERVICING-PROV-TAXONOMY	X(12)	317	328	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP263	SERVICING-PROV-TYPE	X(2)	329	330	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP264	SERVICING-PROV-SPECIALTY	X(2)	331	332	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP265	OPERATING-PROV-NPI-NUM	X(10)	333	342	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP266	OTHER-TPL-COLLECTION	X(3)	343	345	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP267	PROV-FACILITY-TYPE	X(9)	346	354	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP268	BENEFIT-TYPE	X(3)	355	357	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP269	CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT	X(2)	358	359	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP270	XIX-MBESCBES-CATEGORY-OF-SERVICE	X(4)	360	363	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP271	XXI-MBESCBES-CATEGORY-OF-SERVICE	X(3)	364	366	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP272	OTHER-INSURANCE-AMT	S9(11)V99	367	379	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP273	STATE-NOTATION	X(500)	380	879	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP279	HCPCS-RATE	X(14)	880	893	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP284	NATIONAL-DRUG-CODE	X(12)	894	905	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP285	NDC-UNIT-OF-MEASURE	X(2)	906	907	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP278	NDC-QUANTITY	S9(6)V999	908	916	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP286	ADJUDICATION-DATE	9(8)	917	924	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP287	SELF-DIRECTION-TYPE	X(3)	925	927	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP288	PRE-AUTHORIZATION-NUM	X(18)	928	945	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CIP274	FILLER	X(1155)	946	2100	CLAIMIP	CLAIM-LINE-RECORD-IP-CIP00003
CLT001	RECORD-ID	X(8)	1	8	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT002	DATA-DICTIONARY-VERSION	X(10)	9	18	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT006	FILE-NAME	X(8)	32	39	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT007	SUBMITTING-STATE	X(2)	40	41	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT008	DATE-FILE-CREATED	9(8)	42	49	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT009	START-OF-TIME-PERIOD	9(8)	50	57	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT010	END-OF-TIME-PERIOD	9(8)	58	65	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT011	FILE-STATUS-INDICATOR	X(1)	66	66	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT012	SSN-INDICATOR	X(1)	67	67	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT013	TOT-REC-CNT	9(11)	68	78	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT227	SEQUENCE-NUMBER	X(4)	79	82	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT014	STATE-NOTATION	X(500)	83	582	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT015	FILLER	X(1318)	583	1900	CLAIMLT	FILE-HEADER-RECORD-LT-CLT00001
CLT016	RECORD-ID	X(8)	1	8	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT017	SUBMITTING-STATE	X(2)	9	10	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT018	RECORD-NUMBER	9(11)	11	21	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT019	ICN-ORIG	X(50)	22	71	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT020	ICN-ADJ	X(50)	72	121	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT021	SUBMITTER-ID	X(12)	122	133	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT022	MSIS-IDENTIFICATION-NUM	X(20)	134	153	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT023	CROSSOVER-INDICATOR	X(1)	154	154	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT024	1115A-DEMONSTRATION-IND	X(1)	155	155	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT025	ADJUSTMENT-IND	X(1)	156	156	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT026	ADJUSTMENT-REASON-CODE	X(3)	157	159	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT027	ADMITTING-DIAGNOSIS-CODE	X(7)	160	166	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT028	ADMITTING-DIAGNOSIS-CODE-FLAG	X(1)	167	167	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT029	DIAGNOSIS-CODE-1	X(7)	168	174	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT030	DIAGNOSIS-CODE-FLAG-1	X(1)	175	175	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT031	DIAGNOSIS-POA-FLAG-1	X(1)	176	176	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT032	DIAGNOSIS-CODE-2	X(7)	177	183	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT033	DIAGNOSIS-CODE-FLAG-2	X(1)	184	184	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT034	DIAGNOSIS-POA-FLAG-2	X(1)	185	185	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT035	DIAGNOSIS-CODE-3	X(7)	186	192	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT036	DIAGNOSIS-CODE-FLAG-3	X(1)	193	193	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT037	DIAGNOSIS-POA-FLAG-3	X(1)	194	194	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT038	DIAGNOSIS-CODE-4	X(7)	195	201	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT039	DIAGNOSIS-CODE-FLAG-4	X(1)	202	202	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT040	DIAGNOSIS-POA-FLAG-4	X(1)	203	203	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT041	DIAGNOSIS-CODE-5	X(7)	204	210	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT042	DIAGNOSIS-CODE-FLAG-5	X(1)	211	211	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT043	DIAGNOSIS-POA-FLAG-5	X(1)	212	212	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT044	ADMISSION-DATE	9(8)	213	220	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT045	ADMISSION-HOUR	X(2)	221	222	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT046	DISCHARGE-DATE	9(8)	223	230	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT047	DISCHARGE-HOUR	X(2)	231	232	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT048	BEGINNING-DATE-OF-SERVICE	9(8)	233	240	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT049	ENDING-DATE-OF-SERVICE	9(8)	241	248	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT050	ADJUDICATION-DATE	9(8)	249	256	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT051	MEDICAID-PAID-DATE	9(8)	257	264	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT052	TYPE-OF-CLAIM	X(1)	265	265	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT053	TYPE-OF-BILL	X(4)	266	269	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT054	CLAIM-STATUS	X(3)	270	272	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT055	CLAIM-STATUS-CATEGORY	X(3)	273	275	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT056	SOURCE-LOCATION	X(2)	276	277	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT057	CHECK-NUM	X(15)	278	292	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT058	CHECK-EFF-DATE	9(8)	293	300	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT059	CLAIM-PYMT-REM-CODE-1	X(5)	301	305	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT060	CLAIM-PYMT-REM-CODE-2	X(5)	306	310	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT061	CLAIM-PYMT-REM-CODE-3	X(5)	311	315	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT062	CLAIM-PYMT-REM-CODE-4	X(5)	316	320	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT063	TOT-BILLED-AMT	S9(11)V99	321	333	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT064	TOT-ALLOWED-AMT	S9(11)V99	334	346	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT065	TOT-MEDICAID-PAID-AMT	S9(11)V99	347	359	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT066	TOT-COPAY-AMT	S9(11)V99	360	372	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT067	TOT-MEDICARE-DEDUCTIBLE-AMT	S9(11)V99	373	385	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT068	TOT-MEDICARE-COINS-AMT	S9(11)V99	386	398	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT069	TOT-TPL-AMT	S9(11)V99	399	411	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT070	TOT-OTHER-INSURANCE-AMT	S9(11)V99	412	424	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT071	OTHER-INSURANCE-IND	X(1)	425	425	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT072	OTHER-TPL-COLLECTION	X(3)	426	428	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT073	SERVICE-TRACKING-TYPE	X(2)	429	430	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT074	SERVICE-TRACKING-PAYMENT-AMT	S9(11)V99	431	443	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT075	FIXED-PAYMENT-IND	X(1)	444	444	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT076	FUNDING-CODE	X(2)	445	446	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT077	FUNDING-SOURCE-NONFEDERAL-SHARE	X(2)	447	448	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT078	MEDICARE-COMB-DED-IND	X(1)	449	449	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT079	PROGRAM-TYPE	X(2)	450	451	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT080	PLAN-ID-NUMBER	X(12)	452	463	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT081	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	464	473	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT082	PAYMENT-LEVEL-IND	X(1)	474	474	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT083	MEDICARE-REIM-TYPE	X(2)	475	476	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT084	NON-COV-DAYS	S9(5)	477	481	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT085	NON-COV-CHARGES	S9(11)V99	482	494	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT086	MEDICAID-COV-INPATIENT-DAYS	S9(5)	495	499	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT087	CLAIM-LINE-COUNT	9(4)	500	503	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT090	FORCED-CLAIM-IND	X(1)	504	504	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT091	HEALTH-CARE-ACQUIRED-CONDITION-IND	X(1)	505	505	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT092	OCCURRENCE-CODE-01	X(2)	506	507	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT093	OCCURRENCE-CODE-02	X(2)	508	509	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT094	OCCURRENCE-CODE-03	X(2)	510	511	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT095	OCCURRENCE-CODE-04	X(2)	512	513	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT096	OCCURRENCE-CODE-05	X(2)	514	515	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT097	OCCURRENCE-CODE-06	X(2)	516	517	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT098	OCCURRENCE-CODE-07	X(2)	518	519	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT099	OCCURRENCE-CODE-08	X(2)	520	521	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT100	OCCURRENCE-CODE-09	X(2)	522	523	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT101	OCCURRENCE-CODE-10	X(2)	524	525	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT102	OCCURRENCE-CODE-EFF-DATE-01	9(8)	526	533	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT103	OCCURRENCE-CODE-EFF-DATE-02	9(8)	534	541	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT104	OCCURRENCE-CODE-EFF-DATE-03	9(8)	542	549	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT105	OCCURRENCE-CODE-EFF-DATE-04	9(8)	550	557	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT106	OCCURRENCE-CODE-EFF-DATE-05	9(8)	558	565	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT107	OCCURRENCE-CODE-EFF-DATE-06	9(8)	566	573	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT108	OCCURRENCE-CODE-EFF-DATE-07	9(8)	574	581	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT109	OCCURRENCE-CODE-EFF-DATE-08	9(8)	582	589	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT110	OCCURRENCE-CODE-EFF-DATE-09	9(8)	590	597	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT111	OCCURRENCE-CODE-EFF-DATE-10	9(8)	598	605	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT112	OCCURRENCE-CODE-END-DATE-01	9(8)	606	613	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT113	OCCURRENCE-CODE-END-DATE-02	9(8)	614	621	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT114	OCCURRENCE-CODE-END-DATE-03	9(8)	622	629	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT115	OCCURRENCE-CODE-END-DATE-04	9(8)	630	637	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT116	OCCURRENCE-CODE-END-DATE-05	9(8)	638	645	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT117	OCCURRENCE-CODE-END-DATE-06	9(8)	646	653	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT118	OCCURRENCE-CODE-END-DATE-07	9(8)	654	661	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT119	OCCURRENCE-CODE-END-DATE-08	9(8)	662	669	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT120	OCCURRENCE-CODE-END-DATE-09	9(8)	670	677	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT121	OCCURRENCE-CODE-END-DATE-10	9(8)	678	685	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT122	PATIENT-CONTROL-NUM	X(20)	686	705	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT123	ELIGIBLE-LAST-NAME	X(30)	706	735	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT124	ELIGIBLE-FIRST-NAME	X(30)	736	765	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT125	ELIGIBLE-MIDDLE-INIT	X(1)	766	766	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT126	DATE-OF-BIRTH	9(8)	767	774	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT127	HEALTH-HOME-PROV-IND	X(1)	775	775	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT128	WAIVER-TYPE	X(2)	776	777	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT129	WAIVER-ID	X(20)	778	797	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT130	BILLING-PROV-NUM	X(30)	798	827	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT131	BILLING-PROV-NPI-NUM	X(10)	828	837	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT132	BILLING-PROV-TAXONOMY	X(12)	838	849	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT133	BILLING-PROV-TYPE	X(2)	850	851	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT134	BILLING-PROV-SPECIALTY	X(2)	852	853	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT135	REFERRING-PROV-NUM	X(30)	854	883	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT136	REFERRING-PROV-NPI-NUM	X(10)	884	893	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT137	REFERRING-PROV-TAXONOMY	X(12)	894	905	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT138	REFERRING-PROV-TYPE	X(2)	906	907	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT139	REFERRING-PROV-SPECIALTY	X(2)	908	909	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT140	MEDICARE-HIC-NUM	X(12)	910	921	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT141	PATIENT-STATUS	X(2)	922	923	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT143	BMI	S9(5)V9	924	929	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT144	REMITTANCE-NUM	X(30)	930	959	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT145	LTC-RCP-LIAB-AMT	S9(11)V99	960	972	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT146	DAILY-RATE	S9(5)V99	973	979	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT147	ICF-IID-DAYS	S9(5)	980	984	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT148	LEAVE-DAYS	S9(5)	985	989	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT149	NURSING-FACILITY-DAYS	S9(5)	990	994	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT150	SPLIT-CLAIM-IND	X(1)	995	995	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT151	BORDER-STATE-IND	X(1)	996	996	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT153	BENEFICIARY-COINSURANCE-AMOUNT	S9(11)V99	997	1009	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT154	BENEFICIARY-COINSURANCE-DATE-PAID	9(8)	1010	1017	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT155	BENEFICIARY-COPAYMENT-AMOUNT	S9(11)V99	1018	1030	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT156	BENEFICIARY-COPAYMENT-DATE-PAID	9(8)	1031	1038	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT157	BENEFICIARY-DEDUCTIBLE-AMOUNT	S9(11)V99	1039	1051	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT158	BENEFICIARY-DEDUCTIBLE-DATE-PAID	9(8)	1052	1059	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT159	CLAIM-DENIED-INDICATOR	X(1)	1060	1060	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT160	COPAY-WAIVED-IND	X(1)	1061	1061	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT161	HEALTH-HOME-ENTITY-NAME	X(50)	1062	1111	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT163	THIRD-PARTY-COINSURANCE-AMOUNT-PAID	S9(11)V99	1112	1124	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT164	THIRD-PARTY-COINSURANCE-DATE-PAID	9(8)	1125	1132	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT165	THIRD-PARTY-COPAYMENT-AMOUNT-PAID	S9(11)V99	1133	1145	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT166	THIRD-PARTY-COPAYMENT-DATE-PAID	9(8)	1146	1153	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT167	HEALTH-HOME-PROVIDER-NPI	X(12)	1154	1165	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT168	MEDICARE-BENEFICIARY-IDENTIFIER	X(12)	1166	1177	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT169	UNDER-DIRECTION-OF-PROV-NPI	X(12)	1178	1189	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT170	UNDER-DIRECTION-OF-PROV-TAXONOMY	X(12)	1190	1201	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT171	UNDER-SUPERVISION-OF-PROV-NPI	X(12)	1202	1213	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT172	UNDER-SUPERVISION-OF-PROV-TAXONOMY	X(12)	1214	1225	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT174	ADMITTING-PROV-NPI-NUM	X(10)	1226	1235	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT175	ADMITTING-PROV-NUM	X(30)	1236	1265	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT176	ADMITTING-PROV-SPECIALTY	X(2)	1266	1267	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT177	ADMITTING-PROV-TAXONOMY	X(12)	1268	1279	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT178	ADMITTING-PROV-TYPE	X(2)	1280	1281	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT179	MEDICARE-PAID-AMT	S9(11)V99	1282	1294	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT173	STATE-NOTATION	X(500)	1295	1794	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT237	PROV-LOCATION-ID	X(5)	1795	1799	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT183	FILLER	X(101)	1800	1900	CLAIMLT	CLAIM-HEADER-RECORD-LT-CLT00002
CLT184	RECORD-ID	X(8)	1	8	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT185	SUBMITTING-STATE	X(2)	9	10	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT186	RECORD-NUMBER	9(11)	11	21	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT187	MSIS-IDENTIFICATION-NUM	X(20)	22	41	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT188	ICN-ORIG	X(50)	42	91	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT189	ICN-ADJ	X(50)	92	141	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT190	LINE-NUM-ORIG	X(3)	142	144	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT191	LINE-NUM-ADJ	X(3)	145	147	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT192	LINE-ADJUSTMENT-IND	X(1)	148	148	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT193	LINE-ADJUSTMENT-REASON-CODE	X(3)	149	151	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT194	SUBMITTER-ID	X(12)	152	163	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT195	CLAIM-LINE-STATUS	X(3)	164	166	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT196	BEGINNING-DATE-OF-SERVICE	9(8)	167	174	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT197	ENDING-DATE-OF-SERVICE	9(8)	175	182	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT198	REVENUE-CODE	X(4)	183	186	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT201	IMMUNIZATION-TYPE	X(2)	187	188	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT202	IP-LT-QUANTITY-OF-SERVICE-ACTUAL	S9(6)V999	189	197	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT203	IP-LT-QUANTITY-OF-SERVICE-ALLOWED	S9(6)V999	198	206	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT204	REVENUE-CHARGE	S9(11)V99	207	219	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT205	ALLOWED-AMT	S9(11)V99	220	232	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT206	TPL-AMT	S9(11)V99	233	245	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT207	OTHER-INSURANCE-AMT	S9(11)V99	246	258	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT208	MEDICAID-PAID-AMT	S9(11)V99	259	271	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT209	MEDICAID-FFS-EQUIVALENT-AMT	S9(11)V99	272	284	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT210	BILLING-UNIT	X(2)	285	286	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT211	TYPE-OF-SERVICE	X(3)	287	289	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT212	SERVICING-PROV-NUM	X(30)	290	319	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT213	SERVICING-PROV-NPI-NUM	X(10)	320	329	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT214	SERVICING-PROV-TAXONOMY	X(12)	330	341	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT215	SERVICING-PROV-TYPE	X(2)	342	343	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT216	SERVICING-PROV-SPECIALTY	X(2)	344	345	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT217	OTHER-TPL-COLLECTION	X(3)	346	348	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT218	BENEFIT-TYPE	X(3)	349	351	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT219	CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT	X(2)	352	353	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT221	PROV-FACILITY-TYPE	X(9)	354	362	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT224	XIX-MBESCBES-CATEGORY-OF-SERVICE	X(4)	363	366	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT225	XXI-MBESCBES-CATEGORY-OF-SERVICE	X(3)	367	369	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT226	STATE-NOTATION	X(500)	370	869	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT228	NATIONAL-DRUG-CODE	X(12)	870	881	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT229	NDC-UNIT-OF-MEASURE	X(2)	882	883	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT230	NDC-QUANTITY	S9(6)V999	884	892	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT231	HCPCS-RATE	X(14)	893	906	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT233	ADJUDICATION-DATE	9(8)	907	914	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT234	SELF-DIRECTION-TYPE	X(3)	915	917	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT235	PRE-AUTHORIZATION-NUM	X(18)	918	935	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
CLT238	FILLER	X(965)	936	1900	CLAIMLT	CLAIM-LINE-RECORD-LT-CLT00003
COT001	RECORD-ID	X(8)	1	8	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT002	DATA-DICTIONARY-VERSION	X(10)	9	18	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT006	FILE-NAME	X(8)	32	39	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT007	SUBMITTING-STATE	X(2)	40	41	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT008	DATE-FILE-CREATED	9(8)	42	49	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT009	START-OF-TIME-PERIOD	9(8)	50	57	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT010	END-OF-TIME-PERIOD	9(8)	58	65	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT011	FILE-STATUS-INDICATOR	X(1)	66	66	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT012	SSN-INDICATOR	X(1)	67	67	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT013	TOT-REC-CNT	9(11)	68	78	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT216	SEQUENCE-NUMBER	X(4)	79	82	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT014	STATE-NOTATION	X(500)	83	582	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT015	FILLER	X(1168)	583	1750	CLAIMOT	FILE-HEADER-RECORD-OT-COT00001
COT016	RECORD-ID	X(8)	1	8	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT017	SUBMITTING-STATE	X(2)	9	10	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT018	RECORD-NUMBER	9(11)	11	21	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT019	ICN-ORIG	X(50)	22	71	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT020	ICN-ADJ	X(50)	72	121	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT021	SUBMITTER-ID	X(12)	122	133	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT022	MSIS-IDENTIFICATION-NUM	X(20)	134	153	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT023	CROSSOVER-INDICATOR	X(1)	154	154	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT024	1115A-DEMONSTRATION-IND	X(1)	155	155	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT025	ADJUSTMENT-IND	X(1)	156	156	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT026	ADJUSTMENT-REASON-CODE	X(3)	157	159	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT027	DIAGNOSIS-CODE-1	X(7)	160	166	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT028	DIAGNOSIS-CODE-FLAG-1	X(1)	167	167	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT029	DIAGNOSIS-POA-FLAG-1	X(1)	168	168	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT030	DIAGNOSIS-CODE-2	X(7)	169	175	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT031	DIAGNOSIS-CODE-FLAG-2	X(1)	176	176	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT032	DIAGNOSIS-POA-FLAG-2	X(1)	177	177	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT033	BEGINNING-DATE-OF-SERVICE	9(8)	178	185	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT034	ENDING-DATE-OF-SERVICE	9(8)	186	193	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT035	ADJUDICATION-DATE	9(8)	194	201	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT036	MEDICAID-PAID-DATE	9(8)	202	209	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT037	TYPE-OF-CLAIM	X(1)	210	210	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT038	TYPE-OF-BILL	X(4)	211	214	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT039	CLAIM-STATUS	X(3)	215	217	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT040	CLAIM-STATUS-CATEGORY	X(3)	218	220	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT041	SOURCE-LOCATION	X(2)	221	222	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT042	CHECK-NUM	X(15)	223	237	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT043	CHECK-EFF-DATE	9(8)	238	245	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT044	CLAIM-PYMT-REM-CODE-1	X(5)	246	250	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT045	CLAIM-PYMT-REM-CODE-2	X(5)	251	255	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT046	CLAIM-PYMT-REM-CODE-3	X(5)	256	260	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT047	CLAIM-PYMT-REM-CODE-4	X(5)	261	265	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT048	TOT-BILLED-AMT	S9(11)V99	266	278	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT049	TOT-ALLOWED-AMT	S9(11)V99	279	291	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT050	TOT-MEDICAID-PAID-AMT	S9(11)V99	292	304	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT051	TOT-COPAY-AMT	S9(11)V99	305	317	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT052	TOT-MEDICARE-DEDUCTIBLE-AMT	S9(11)V99	318	330	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT053	TOT-MEDICARE-COINS-AMT	S9(11)V99	331	343	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT054	TOT-TPL-AMT	S9(11)V99	344	356	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT056	TOT-OTHER-INSURANCE-AMT	S9(11)V99	357	369	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT057	OTHER-INSURANCE-IND	X(1)	370	370	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT058	OTHER-TPL-COLLECTION	X(3)	371	373	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT059	SERVICE-TRACKING-TYPE	X(2)	374	375	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT060	SERVICE-TRACKING-PAYMENT-AMT	S9(11)V99	376	388	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT061	FIXED-PAYMENT-IND	X(1)	389	389	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT062	FUNDING-CODE	X(2)	390	391	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT063	FUNDING-SOURCE-NONFEDERAL-SHARE	X(2)	392	393	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT064	MEDICARE-COMB-DED-IND	X(1)	394	394	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT065	PROGRAM-TYPE	X(2)	395	396	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT066	PLAN-ID-NUMBER	X(12)	397	408	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT067	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	409	418	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT068	PAYMENT-LEVEL-IND	X(1)	419	419	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT069	MEDICARE-REIM-TYPE	X(2)	420	421	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT070	CLAIM-LINE-COUNT	9(4)	422	425	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT072	FORCED-CLAIM-IND	X(1)	426	426	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT073	HEALTH-CARE-ACQUIRED-CONDITION-IND	X(1)	427	427	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT074	OCCURRENCE-CODE-01	X(2)	428	429	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT075	OCCURRENCE-CODE-02	X(2)	430	431	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT076	OCCURRENCE-CODE-03	X(2)	432	433	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT077	OCCURRENCE-CODE-04	X(2)	434	435	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT078	OCCURRENCE-CODE-05	X(2)	436	437	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT079	OCCURRENCE-CODE-06	X(2)	438	439	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT080	OCCURRENCE-CODE-07	X(2)	440	441	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT081	OCCURRENCE-CODE-08	X(2)	442	443	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT082	OCCURRENCE-CODE-09	X(2)	444	445	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT083	OCCURRENCE-CODE-10	X(2)	446	447	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT084	OCCURRENCE-CODE-EFF-DATE-01	9(8)	448	455	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT085	OCCURRENCE-CODE-EFF-DATE-02	9(8)	456	463	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT086	OCCURRENCE-CODE-EFF-DATE-03	9(8)	464	471	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT087	OCCURRENCE-CODE-EFF-DATE-04	9(8)	472	479	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT088	OCCURRENCE-CODE-EFF-DATE-05	9(8)	480	487	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT089	OCCURRENCE-CODE-EFF-DATE-06	9(8)	488	495	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT090	OCCURRENCE-CODE-EFF-DATE-07	9(8)	496	503	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT091	OCCURRENCE-CODE-EFF-DATE-08	9(8)	504	511	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT092	OCCURRENCE-CODE-EFF-DATE-09	9(8)	512	519	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT093	OCCURRENCE-CODE-EFF-DATE-10	9(8)	520	527	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT094	OCCURRENCE-CODE-END-DATE-01	9(8)	528	535	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT095	OCCURRENCE-CODE-END-DATE-02	9(8)	536	543	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT096	OCCURRENCE-CODE-END-DATE-03	9(8)	544	551	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT097	OCCURRENCE-CODE-END-DATE-04	9(8)	552	559	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT098	OCCURRENCE-CODE-END-DATE-05	9(8)	560	567	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT099	OCCURRENCE-CODE-END-DATE-06	9(8)	568	575	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT100	OCCURRENCE-CODE-END-DATE-07	9(8)	576	583	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT101	OCCURRENCE-CODE-END-DATE-08	9(8)	584	591	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT102	OCCURRENCE-CODE-END-DATE-09	9(8)	592	599	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT103	OCCURRENCE-CODE-END-DATE-10	9(8)	600	607	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT104	PATIENT-CONTROL-NUM	X(20)	608	627	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT105	ELIGIBLE-LAST-NAME	X(30)	628	657	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT106	ELIGIBLE-FIRST-NAME	X(30)	658	687	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT107	ELIGIBLE-MIDDLE-INIT	X(1)	688	688	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT108	DATE-OF-BIRTH	9(8)	689	696	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT109	HEALTH-HOME-PROV-IND	X(1)	697	697	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT110	WAIVER-TYPE	X(2)	698	699	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT111	WAIVER-ID	X(20)	700	719	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT112	BILLING-PROV-NUM	X(30)	720	749	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT113	BILLING-PROV-NPI-NUM	X(10)	750	759	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT114	BILLING-PROV-TAXONOMY	X(12)	760	771	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT115	BILLING-PROV-TYPE	X(2)	772	773	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT116	BILLING-PROV-SPECIALTY	X(2)	774	775	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT117	REFERRING-PROV-NUM	X(30)	776	805	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT118	REFERRING-PROV-NPI-NUM	X(10)	806	815	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT119	REFERRING-PROV-TAXONOMY	X(12)	816	827	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT120	REFERRING-PROV-TYPE	X(2)	828	829	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT121	REFERRING-PROV-SPECIALTY	X(2)	830	831	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT122	MEDICARE-HIC-NUM	X(12)	832	843	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT123	PLACE-OF-SERVICE	X(2)	844	845	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT125	BMI	S9(5)V9	846	851	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT126	REMITTANCE-NUM	X(30)	852	881	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT127	DAILY-RATE	S9(5)V99	882	888	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT128	BORDER-STATE-IND	X(1)	889	889	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT130	BENEFICIARY-COINSURANCE-AMOUNT	S9(11)V99	890	902	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT131	BENEFICIARY-COINSURANCE-DATE-PAID	9(8)	903	910	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT132	BENEFICIARY-COPAYMENT-AMOUNT	S9(11)V99	911	923	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT133	BENEFICIARY-COPAYMENT-DATE-PAID	9(8)	924	931	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT134	BENEFICIARY-DEDUCTIBLE-AMOUNT	S9(11)V99	932	944	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT135	BENEFICIARY-DEDUCTIBLE-DATE-PAID	9(8)	945	952	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT136	CLAIM-DENIED-INDICATOR	X(1)	953	953	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT137	COPAY-WAIVED-IND	X(1)	954	954	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT138	HEALTH-HOME-ENTITY-NAME	X(50)	955	1004	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT140	THIRD-PARTY-COINSURANCE-AMOUNT-PAID	S9(11)V99	1005	1017	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT141	THIRD-PARTY-COINSURANCE-DATE-PAID	9(8)	1018	1025	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT142	THIRD-PARTY-COPAYMENT-AMOUNT-PAID	S9(11)V99	1026	1038	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT143	THIRD-PARTY-COPAYMENT-DATE-PAID	9(8)	1039	1046	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT144	DATE-CAPITATED-AMOUNT-REQUESTED	9(8)	1047	1054	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT145	CAPITATED-PAYMENT-AMT-REQUESTED	S9(11)V99	1055	1067	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT146	HEALTH-HOME-PROVIDER-NPI	X(10)	1068	1077	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT147	MEDICARE-BENEFICIARY-IDENTIFIER	X(12)	1078	1089	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT148	UNDER-DIRECTION-OF-PROV-NPI	X(10)	1090	1099	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT149	UNDER-DIRECTION-OF-PROV-TAXONOMY	X(12)	1100	1111	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT150	UNDER-SUPERVISION-OF-PROV-NPI	X(10)	1112	1121	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT151	UNDER-SUPERVISION-OF-PROV-TAXONOMY	X(12)	1122	1133	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT152	STATE-NOTATION	X(500)	1134	1633	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT226	PROV-LOCATION-ID	X(5)	1634	1638	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT153	FILLER	X(112)	1639	1750	CLAIMOT	CLAIM-HEADER-RECORD-OT-COT00002
COT154	RECORD-ID	X(8)	1	8	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT155	SUBMITTING-STATE	X(2)	9	10	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT156	RECORD-NUMBER	9(11)	11	21	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT157	MSIS-IDENTIFICATION-NUM	X(20)	22	41	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT158	ICN-ORIG	X(50)	42	91	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT159	ICN-ADJ	X(50)	92	141	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT160	LINE-NUM-ORIG	X(3)	142	144	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT161	LINE-NUM-ADJ	X(3)	145	147	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT162	LINE-ADJUSTMENT-IND	X(1)	148	148	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT163	LINE-ADJUSTMENT-REASON-CODE	X(3)	149	151	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT164	SUBMITTER-ID	X(12)	152	163	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT165	CLAIM-LINE-STATUS	X(3)	164	166	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT166	BEGINNING-DATE-OF-SERVICE	9(8)	167	174	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT167	ENDING-DATE-OF-SERVICE	9(8)	175	182	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT168	REVENUE-CODE	X(4)	183	186	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT169	PROCEDURE-CODE	X(8)	187	194	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT170	PROCEDURE-CODE-DATE	9(8)	195	202	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT171	PROCEDURE-CODE-FLAG	X(2)	203	204	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT172	PROCEDURE-CODE-MOD-1	X(2)	205	206	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT173	IMMUNIZATION-TYPE	X(2)	207	208	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT174	BILLED-AMT	S9(11)V99	209	221	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT175	ALLOWED-AMT	S9(11)V99	222	234	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT176	COPAY-AMT	S9(11)V99	235	247	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT177	TPL-AMT	S9(11)V99	248	260	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT178	MEDICAID-PAID-AMT	S9(11)V99	261	273	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT179	MEDICAID-FFS-EQUIVALENT-AMT	S9(11)V99	274	286	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT182	MEDICARE-PAID-AMT	S9(11)V99	287	299	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT183	OT-RX-CLAIM-QUANTITY-ACTUAL	S9(6)V999	300	308	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT184	OT-RX-CLAIM-QUANTITY-ALLOWED	S9(6)V999	309	317	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT186	TYPE-OF-SERVICE	X(3)	318	320	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT187	HCBS-SERVICE-CODE	X(1)	321	321	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT188	HCBS-TAXONOMY	X(5)	322	326	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT189	SERVICING-PROV-NUM	X(30)	327	356	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT190	SERVICING-PROV-NPI-NUM	X(10)	357	366	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT191	SERVICING-PROV-TAXONOMY	X(12)	367	378	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT192	SERVICING-PROV-TYPE	X(2)	379	380	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT193	SERVICING-PROV-SPECIALTY	X(2)	381	382	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT194	OTHER-TPL-COLLECTION	X(3)	383	385	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT195	TOOTH-DESIGNATION-SYSTEM	X(2)	386	387	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT196	TOOTH-NUM	X(2)	388	389	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT197	TOOTH-QUAD-CODE	X(2)	390	391	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT198	TOOTH-SURFACE-CODE	X(1)	392	392	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT199	ORIGINATION-ADDR-LN1	X(60)	393	452	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT200	ORIGINATION-ADDR-LN2	X(60)	453	512	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT201	ORIGINATION-CITY	X(28)	513	540	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT202	ORIGINATION-STATE	X(2)	541	542	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT203	ORIGINATION-ZIP-CODE	X(9)	543	551	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT204	DESTINATION-ADDR-LN1	X(60)	552	611	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT205	DESTINATION-ADDR-LN2	X(60)	612	671	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT206	DESTINATION-CITY	X(28)	672	699	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT207	DESTINATION-STATE	X(2)	700	701	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT208	DESTINATION-ZIP-CODE	X(9)	702	710	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT209	BENEFIT-TYPE	X(3)	711	713	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT210	CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT	X(2)	714	715	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT211	XIX-MBESCBES-CATEGORY-OF-SERVICE	X(4)	716	719	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT212	XXI-MBESCBES-CATEGORY-OF-SERVICE	X(3)	720	722	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT213	OTHER-INSURANCE-AMT	S9(11)V99	723	735	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT214	STATE-NOTATION	X(500)	736	1235	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT217	NATIONAL-DRUG-CODE	X(12)	1236	1247	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT227	PROCEDURE-CODE-MOD-2	X(2)	1248	1249	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT218	PROCEDURE-CODE-MOD-3	X(2)	1250	1251	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT219	PROCEDURE-CODE-MOD-4	X(2)	1252	1253	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT220	HCPCS-RATE	X(14)	1254	1267	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT221	ADJUDICATION-DATE	9(8)	1268	1275	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT222	SELF-DIRECTION-TYPE	X(3)	1276	1278	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT223	PRE-AUTHORIZATION-NUM	X(18)	1279	1296	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT224	NDC-UNIT-OF-MEASURE	X(2)	1297	1298	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT225	NDC-QUANTITY	S9(6)V999	1299	1307	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
COT215	FILLER	X(443)	1308	1750	CLAIMOT	CLAIM-LINE-RECORD-OT-COT00003
CRX001	RECORD-ID	X(8)	1	8	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX002	DATA-DICTIONARY-VERSION	X(10)	9	18	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX006	FILE-NAME	X(8)	32	39	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX007	SUBMITTING-STATE	X(2)	40	41	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX008	DATE-FILE-CREATED	9(8)	42	49	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX009	START-OF-TIME-PERIOD	9(8)	50	57	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX010	END-OF-TIME-PERIOD	9(8)	58	65	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX011	FILE-STATUS-INDICATOR	X(1)	66	66	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX012	SSN-INDICATOR	X(1)	67	67	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX013	TOT-REC-CNT	9(11)	68	78	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX155	SEQUENCE-NUMBER	X(4)	79	82	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX014	STATE-NOTATION	X(500)	83	582	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX015	FILLER	X(868)	583	1450	CLAIMRX	FILE-HEADER-RECORD-RX-CRX00001
CRX016	RECORD-ID	X(8)	1	8	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX017	SUBMITTING-STATE	X(2)	9	10	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX018	RECORD-NUMBER	9(11)	11	21	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX019	ICN-ORIG	X(50)	22	71	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX020	ICN-ADJ	X(50)	72	121	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX021	SUBMITTER-ID	X(12)	122	133	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX022	MSIS-IDENTIFICATION-NUM	X(20)	134	153	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX023	CROSSOVER-INDICATOR	X(1)	154	154	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX024	1115A-DEMONSTRATION-IND	X(1)	155	155	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX025	ADJUSTMENT-IND	X(1)	156	156	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX026	ADJUSTMENT-REASON-CODE	X(3)	157	159	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX027	ADJUDICATION-DATE	9(8)	160	167	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX028	MEDICAID-PAID-DATE	9(8)	168	175	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX029	TYPE-OF-CLAIM	X(1)	176	176	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX030	CLAIM-STATUS	X(3)	177	179	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX031	CLAIM-STATUS-CATEGORY	X(3)	180	182	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX032	SOURCE-LOCATION	X(2)	183	184	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX033	CHECK-NUM	X(15)	185	199	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX034	CHECK-EFF-DATE	9(8)	200	207	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX035	CLAIM-PYMT-REM-CODE-1	X(5)	208	212	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX036	CLAIM-PYMT-REM-CODE-2	X(5)	213	217	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX037	CLAIM-PYMT-REM-CODE-3	X(5)	218	222	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX038	CLAIM-PYMT-REM-CODE-4	X(5)	223	227	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX039	TOT-BILLED-AMT	S9(11)V99	228	240	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX040	TOT-ALLOWED-AMT	S9(11)V99	241	253	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX041	TOT-MEDICAID-PAID-AMT	S9(11)V99	254	266	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX042	TOT-COPAY-AMT	S9(11)V99	267	279	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX043	TOT-MEDICARE-DEDUCTIBLE-AMT	S9(11)V99	280	292	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX044	TOT-MEDICARE-COINS-AMT	S9(11)V99	293	305	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX045	TOT-TPL-AMT	S9(11)V99	306	318	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX047	TOT-OTHER-INSURANCE-AMT	S9(11)V99	319	331	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX048	OTHER-INSURANCE-IND	X(1)	332	332	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX049	OTHER-TPL-COLLECTION	X(3)	333	335	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX050	SERVICE-TRACKING-TYPE	X(2)	336	337	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX051	SERVICE-TRACKING-PAYMENT-AMT	S9(11)V99	338	350	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX052	FIXED-PAYMENT-IND	X(1)	351	351	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX053	FUNDING-CODE	X(2)	352	353	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX054	FUNDING-SOURCE-NONFEDERAL-SHARE	X(2)	354	355	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX055	PROGRAM-TYPE	X(2)	356	357	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX056	PLAN-ID-NUMBER	X(12)	358	369	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX057	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	370	379	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX058	PAYMENT-LEVEL-IND	X(1)	380	380	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX059	MEDICARE-REIM-TYPE	X(2)	381	382	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX060	CLAIM-LINE-COUNT	9(4)	383	386	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX061	FORCED-CLAIM-IND	X(1)	387	387	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX062	PATIENT-CONTROL-NUM	X(20)	388	407	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX063	ELIGIBLE-LAST-NAME	X(30)	408	437	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX064	ELIGIBLE-FIRST-NAME	X(30)	438	467	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX065	ELIGIBLE-MIDDLE-INIT	X(1)	468	468	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX066	DATE-OF-BIRTH	9(8)	469	476	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX067	HEALTH-HOME-PROV-IND	X(1)	477	477	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX068	WAIVER-TYPE	X(2)	478	479	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX069	WAIVER-ID	X(20)	480	499	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX070	BILLING-PROV-NUM	X(30)	500	529	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX071	BILLING-PROV-NPI-NUM	X(10)	530	539	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX072	BILLING-PROV-TAXONOMY	X(12)	540	551	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX073	BILLING-PROV-SPECIALTY	X(2)	552	553	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX074	PRESCRIBING-PROV-NUM	X(30)	554	583	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX075	PRESCRIBING-PROV-NPI-NUM	X(10)	584	593	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX076	PRESCRIBING-PROV-TAXONOMY	X(12)	594	605	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX077	PRESCRIBING-PROV-TYPE	X(2)	606	607	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX078	PRESCRIBING-PROV-SPECIALTY	X(2)	608	609	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX079	MEDICARE-HIC-NUM	X(12)	610	621	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX081	REMITTANCE-NUM	X(30)	622	651	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX082	BORDER-STATE-IND	X(1)	652	652	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX084	DATE-PRESCRIBED	9(8)	653	660	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX085	PRESCRIPTION-FILL-DATE	9(8)	661	668	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX086	COMPOUND-DRUG-IND	X(1)	669	669	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX087	BENEFICIARY-COINSURANCE-AMOUNT	S9(11)V99	670	682	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX089	BENEFICIARY-COPAYMENT-AMOUNT	S9(11)V99	683	695	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX090	BENEFICIARY-COPAYMENT-DATE-PAID	9(8)	696	703	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX088	BENEFICIARY-COINSURANCE-DATE-PAID	9(8)	704	711	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX092	BENEFICIARY-DEDUCTIBLE-AMOUNT	S9(11)V99	712	724	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX093	BENEFICIARY-DEDUCTIBLE-DATE-PAID	9(8)	725	732	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX094	CLAIM-DENIED-INDICATOR	X(1)	733	733	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX095	COPAY-WAIVED-IND	X(1)	734	734	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX096	HEALTH-HOME-ENTITY-NAME	X(50)	735	784	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX098	THIRD-PARTY-COINSURANCE-AMOUNT-PAID	S9(11)V99	785	797	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX099	THIRD-PARTY-COINSURANCE-DATE-PAID	9(8)	798	805	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX100	THIRD-PARTY-COPAYMENT-AMOUNT-PAID	S9(11)V99	806	818	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX101	THIRD-PARTY-COPAYMENT-DATE-PAID	9(8)	819	826	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX102	DISPENSING-PRESCRIPTION-DRUG-PROV-NPI	X(10)	827	836	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX103	DISPENSING-PRESCRIPTION-DRUG-PROV-TAXONOMY	X(12)	837	848	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX104	HEALTH-HOME-PROVIDER-NPI	X(10)	849	858	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX105	MEDICARE-BENEFICIARY-IDENTIFIER	X(12)	859	870	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX106	STATE-NOTATION	X(500)	871	1370	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX156	DISPENSING-PRESCRIPTION-DRUG-PROV-NUM	X(30)	1371	1400	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX160	MEDICARE-COMB-DED-IND	X(1)	1401	1401	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX161	PROV-LOCATION-ID	X(5)	1402	1406	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX107	FILLER	X(44)	1407	1450	CLAIMRX	CLAIM-HEADER-RECORD-RX-CRX00002
CRX108	RECORD-ID	X(8)	1	8	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX109	SUBMITTING-STATE	X(2)	9	10	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX110	RECORD-NUMBER	9(11)	11	21	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX111	MSIS-IDENTIFICATION-NUM	X(20)	22	41	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX112	ICN-ORIG	X(50)	42	91	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX113	ICN-ADJ	X(50)	92	141	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX114	LINE-NUM-ORIG	X(3)	142	144	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX115	LINE-NUM-ADJ	X(3)	145	147	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX116	LINE-ADJUSTMENT-IND	X(1)	148	148	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX117	LINE-ADJUSTMENT-REASON-CODE	X(3)	149	151	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX118	SUBMITTER-ID	X(12)	152	163	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX119	CLAIM-LINE-STATUS	X(3)	164	166	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX120	NATIONAL-DRUG-CODE	X(12)	167	178	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX121	BILLED-AMT	S9(11)V99	179	191	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX122	ALLOWED-AMT	S9(11)V99	192	204	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX123	COPAY-AMT	S9(5)V99	205	211	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX124	TPL-AMT	S9(11)V99	212	224	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX125	MEDICAID-PAID-AMT	S9(11)V99	225	237	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX126	MEDICAID-FFS-EQUIVALENT-AMT	S9(11)V99	238	250	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX127	MEDICARE-DEDUCTIBLE-AMT	S9(11)V99	251	263	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX128	MEDICARE-COINS-AMT	S9(11)V99	264	276	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX129	MEDICARE-PAID-AMT	S9(11)V99	277	289	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX131	OT-RX-CLAIM-QUANTITY-ALLOWED	S9(6)V999	290	298	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX132	OT-RX-CLAIM-QUANTITY-ACTUAL	S9(6)V999	299	307	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX133	UNIT-OF-MEASURE	X(2)	308	309	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX134	TYPE-OF-SERVICE	X(3)	310	312	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX135	HCBS-SERVICE-CODE	X(1)	313	313	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX136	HCBS-TAXONOMY	X(5)	314	318	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX137	OTHER-TPL-COLLECTION	X(3)	319	321	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX138	DAYS-SUPPLY	S9(5)	322	326	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX139	NEW-REFILL-IND	X(2)	327	328	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX140	BRAND-GENERIC-IND	X(1)	329	329	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX141	DISPENSE-FEE	S9(6)V99	330	337	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX142	PRESCRIPTION-NUM	X(12)	338	349	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX143	DRUG-UTILIZATION-CODE	X(6)	350	355	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX144	DTL-METRIC-DEC-QTY	S9(7)V999	356	365	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX145	COMPOUND-DOSAGE-FORM	X(2)	366	367	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX146	REBATE-ELIGIBLE-INDICATOR	X(1)	368	368	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX147	IMMUNIZATION-TYPE	X(2)	369	370	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX148	BENEFIT-TYPE	X(3)	371	373	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX149	CMS-64-CATEGORY-FOR-FEDERAL-REIMBURSEMENT	X(2)	374	375	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX150	XIX-MBESCBES-CATEGORY-OF-SERVICE	X(4)	376	379	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX151	XXI-MBESCBES-CATEGORY-OF-SERVICE	X(3)	380	382	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX152	OTHER-INSURANCE-AMT	S9(11)V99	383	395	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX153	STATE-NOTATION	X(500)	396	895	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX157	ADJUDICATION-DATE	9(8)	896	903	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX158	SELF-DIRECTION-TYPE	X(3)	904	906	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX159	PRE-AUTHORIZATION-NUM	X(18)	907	924	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
CRX154	FILLER	X(526)	925	1450	CLAIMRX	CLAIM-LINE-RECORD-RX-CRX00003
ELG001	RECORD-ID	X(8)	1	8	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG002	DATA-DICTIONARY-VERSION	X(10)	9	18	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG006	FILE-NAME	X(8)	32	39	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG007	SUBMITTING-STATE	X(2)	40	41	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG008	DATE-FILE-CREATED	9(8)	42	49	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG009	START-OF-TIME-PERIOD	9(8)	50	57	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG010	END-OF-TIME-PERIOD	9(8)	58	65	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG011	FILE-STATUS-INDICATOR	X(1)	66	66	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG012	SSN-INDICATOR	X(1)	67	67	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG013	TOT-REC-CNT	9(11)	68	78	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG247	SEQUENCE-NUMBER	X(4)	79	82	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG014	STATE-NOTATION	X(500)	83	582	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG015	FILLER	X(418)	583	1000	ELIGIBLE	FILE-HEADER-RECORD-ELIGIBILITY-ELG00001
ELG016	RECORD-ID	X(8)	1	8	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG017	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG018	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG019	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG020	ELIGIBLE-FIRST-NAME	X(30)	42	71	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG021	ELIGIBLE-LAST-NAME	X(30)	72	101	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG022	ELIGIBLE-MIDDLE-INIT	X(1)	102	102	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG023	SEX	X(1)	103	103	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG024	DATE-OF-BIRTH	9(8)	104	111	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG025	DATE-OF-DEATH	9(8)	112	119	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG026	PRIMARY-DEMOGRAPHIC-ELEMENT-EFF-DATE	9(8)	120	127	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG027	PRIMARY-DEMOGRAPHIC-ELEMENT-END-DATE	9(8)	128	135	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG028	STATE-NOTATION	X(500)	136	635	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG029	FILLER	X(365)	636	1000	ELIGIBLE	PRIMARY-DEMOGRAPHICS-ELIGIBILITY-ELG00002
ELG030	RECORD-ID	X(8)	1	8	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG031	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG032	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG033	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG034	MARITAL-STATUS	X(2)	42	43	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG035	MARITAL-STATUS-OTHER-EXPLANATION	X(50)	44	93	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG036	SSN	9(9)	94	102	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG037	SSN-VERIFICATION-FLAG	X(1)	103	103	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG038	INCOME-CODE	X(2)	104	105	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG039	VETERAN-IND	X(1)	106	106	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG040	CITIZENSHIP-IND	X(1)	107	107	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG041	CITIZENSHIP-VERIFICATION-FLAG	X(1)	108	108	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG042	IMMIGRATION-STATUS	X(1)	109	109	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG043	IMMIGRATION-VERIFICATION-FLAG	X(1)	110	110	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG044	IMMIGRATION-STATUS-FIVE-YEAR-BAR-END-DATE	9(8)	111	118	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG045	PRIMARY-LANGUAGE-ENGL-PROF-CODE	X(1)	119	119	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG046	PRIMARY-LANGUAGE-CODE	X(3)	120	122	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG047	HOUSEHOLD-SIZE	X(2)	123	124	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG049	PREGNANCY-IND	X(1)	125	125	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG050	MEDICARE-HIC-NUM	X(12)	126	137	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG051	MEDICARE-BENEFICIARY-IDENTIFIER	X(12)	138	149	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG054	CHIP-CODE	X(1)	150	150	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG057	VARIABLE-DEMOGRAPHIC-ELEMENT-EFF-DATE	9(8)	151	158	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG058	VARIABLE-DEMOGRAPHIC-ELEMENT-END-DATE	9(8)	159	166	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG059	STATE-NOTATION	X(500)	167	666	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG060	FILLER	X(334)	667	1000	ELIGIBLE	VARIABLE-DEMOGRAPHICS-ELIGIBILITY-ELG00003
ELG061	RECORD-ID	X(8)	1	8	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG062	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG063	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG064	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG065	ELIGIBLE-ADDR-TYPE	X(2)	42	43	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG066	ELIGIBLE-ADDR-LN1	X(60)	44	103	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG067	ELIGIBLE-ADDR-LN2	X(60)	104	163	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG068	ELIGIBLE-ADDR-LN3	X(60)	164	223	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG069	ELIGIBLE-CITY	X(28)	224	251	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG070	ELIGIBLE-STATE	X(2)	252	253	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG071	ELIGIBLE-ZIP-CODE	X(9)	254	262	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG072	ELIGIBLE-COUNTY-CODE	X(3)	263	265	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG073	ELIGIBLE-PHONE-NUM	X(10)	266	275	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG074	TYPE-OF-LIVING-ARRANGEMENT	X(100)	276	375	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG075	ELIGIBLE-ADDR-EFF-DATE	9(8)	376	383	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG076	ELIGIBLE-ADDR-END-DATE	9(8)	384	391	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG077	STATE-NOTATION	X(500)	392	891	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG078	FILLER	X(109)	892	1000	ELIGIBLE	ELIGIBLE-CONTACT-INFORMATION-ELG00004
ELG079	RECORD-ID	X(8)	1	8	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG080	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG081	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG082	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG083	MSIS-CASE-NUM	X(12)	42	53	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG084	MEDICAID-BASIS-OF-ELIGIBILITY	X(2)	54	55	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG085	DUAL-ELIGIBLE-CODE	X(2)	56	57	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG086	PRIMARY-ELIGIBILITY-GROUP-IND	X(1)	58	58	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG087	ELIGIBILITY-GROUP	X(2)	59	60	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG088	LEVEL-OF-CARE-STATUS	X(3)	61	63	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG089	SSDI-IND	X(1)	64	64	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG090	SSI-IND	X(1)	65	65	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG091	SSI-STATE-SUPPLEMENT-STATUS-CODE	X(3)	66	68	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG092	SSI-STATUS	X(3)	69	71	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG093	STATE-SPEC-ELIG-GROUP	X(6)	72	77	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG094	CONCEPTION-TO-BIRTH-IND	X(1)	78	78	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG095	ELIGIBILITY-CHANGE-REASON	X(2)	79	80	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG096	MAINTENANCE-ASSISTANCE-STATUS	X(1)	81	81	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG097	RESTRICTED-BENEFITS-CODE	X(1)	82	82	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG098	TANF-CASH-CODE	X(1)	83	83	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG099	ELIGIBILITY-DETERMINANT-EFF-DATE	9(8)	84	91	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG100	ELIGIBILITY-DETERMINANT-END-DATE	9(8)	92	99	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG101	STATE-NOTATION	X(500)	100	599	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG102	FILLER	X(401)	600	1000	ELIGIBLE	ELIGIBILITY-DETERMINANTS-ELG00005
ELG103	RECORD-ID	X(8)	1	8	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG104	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG105	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG106	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG107	HEALTH-HOME-SPA-NAME	X(100)	42	141	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG108	HEALTH-HOME-ENTITY-NAME	X(100)	142	241	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG109	HEALTH-HOME-SPA-PARTICIPATION-EFF-DATE	9(8)	242	249	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG110	HEALTH-HOME-SPA-PARTICIPATION-END-DATE	9(8)	250	257	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG111	HEALTH-HOME-ENTITY-EFF-DATE	9(8)	258	265	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG112	STATE-NOTATION	X(500)	266	765	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG113	FILLER	X(235)	766	1000	ELIGIBLE	HEALTH-HOME-SPA-PARTICIPATION-INFORMATION-ELG00006
ELG114	RECORD-ID	X(8)	1	8	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG115	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG116	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG117	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG118	HEALTH-HOME-SPA-NAME	X(100)	42	141	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG119	HEALTH-HOME-ENTITY-NAME	X(100)	142	241	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG120	HEALTH-HOME-PROV-NUM	X(30)	242	271	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG121	HEALTH-HOME-SPA-PROVIDER-EFF-DATE	9(8)	272	279	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG122	HEALTH-HOME-SPA-PROVIDER-END-DATE	9(8)	280	287	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG123	HEALTH-HOME-ENTITY-EFF-DATE	9(8)	288	295	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG124	STATE-NOTATION	X(500)	296	795	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG125	FILLER	X(205)	796	1000	ELIGIBLE	HEALTH-HOME-SPA-PROVIDERS-ELG00007
ELG126	RECORD-ID	X(8)	1	8	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG127	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG128	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG129	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG130	HEALTH-HOME-CHRONIC-CONDITION	X(1)	42	42	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG131	HEALTH-HOME-CHRONIC-CONDITION-OTHER-EXPLANATION	X(50)	43	92	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG132	HEALTH-HOME-CHRONIC-CONDITION-EFF-DATE	9(8)	93	100	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG133	HEALTH-HOME-CHRONIC-CONDITION-END-DATE	9(8)	101	108	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG134	STATE-NOTATION	X(500)	109	608	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG135	FILLER	X(392)	609	1000	ELIGIBLE	HEALTH-HOME-CHRONIC-CONDITIONS-ELG00008
ELG136	RECORD-ID	X(8)	1	8	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG137	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG138	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG139	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG140	LOCKIN-PROV-NUM	X(30)	42	71	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG141	LOCKIN-PROV-TYPE	X(2)	72	73	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG142	LOCKIN-EFF-DATE	9(8)	74	81	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG143	LOCKIN-END-DATE	9(8)	82	89	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG144	STATE-NOTATION	X(500)	90	589	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG145	FILLER	X(411)	590	1000	ELIGIBLE	LOCK-IN-INFORMATION-ELG00009
ELG146	RECORD-ID	X(8)	1	8	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG147	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG148	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG149	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG150	MFP-LIVES-WITH-FAMILY	X(1)	42	42	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG151	MFP-QUALIFIED-INSTITUTION	X(2)	43	44	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG152	MFP-QUALIFIED-RESIDENCE	X(2)	45	46	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG153	MFP-REASON-PARTICIPATION-ENDED	X(2)	47	48	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG154	MFP-REINSTITUTIONALIZED-REASON	X(2)	49	50	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG155	MFP-ENROLLMENT-EFF-DATE	9(8)	51	58	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG156	MFP-ENROLLMENT-END-DATE	9(8)	59	66	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG157	STATE-NOTATION	X(500)	67	566	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG158	FILLER	X(434)	567	1000	ELIGIBLE	MFP-INFORMATION-ELG00010
ELG159	RECORD-ID	X(8)	1	8	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG160	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG161	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG162	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG163	STATE-PLAN-OPTION-TYPE	X(2)	42	43	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG164	STATE-PLAN-OPTION-EFF-DATE	9(8)	44	51	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG165	STATE-PLAN-OPTION-END-DATE	9(8)	52	59	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG166	STATE-NOTATION	X(500)	60	559	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG167	FILLER	X(441)	560	1000	ELIGIBLE	STATE-PLAN-OPTION-PARTICIPATION-ELG00011
ELG168	RECORD-ID	X(8)	1	8	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG169	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG170	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG171	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG172	WAIVER-ID	X(20)	42	61	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG173	WAIVER-TYPE	X(2)	62	63	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG174	WAIVER-ENROLLMENT-EFF-DATE	9(8)	64	71	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG175	WAIVER-ENROLLMENT-END-DATE	9(8)	72	79	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG176	STATE-NOTATION	X(500)	80	579	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG177	FILLER	X(421)	580	1000	ELIGIBLE	WAIVER-PARTICIPATION-ELG00012
ELG178	RECORD-ID	X(8)	1	8	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG179	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG180	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG181	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG182	LTSS-LEVEL-CARE	X(1)	42	42	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG183	LTSS-PROV-NUM	X(30)	43	72	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG184	LTSS-ELIGIBILITY-EFF-DATE	9(8)	73	80	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG185	LTSS-ELIGIBILITY-END-DATE	9(8)	81	88	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG186	STATE-NOTATION	X(500)	89	588	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG187	FILLER	X(412)	589	1000	ELIGIBLE	LTSS-PARTICIPATION-ELG00013
ELG188	RECORD-ID	X(8)	1	8	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG189	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG190	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG191	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG192	MANAGED-CARE-PLAN-ID	X(12)	42	53	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG193	ENROLLED-MANAGED-CARE-PLAN-TYPE	X(2)	54	55	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG194	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	56	65	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG195	NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE	X(1)	66	66	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG196	MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE	9(8)	67	74	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG197	MANAGED-CARE-PLAN-ENROLLMENT-END-DATE	9(8)	75	82	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG198	STATE-NOTATION	X(500)	83	582	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG199	FILLER	X(418)	583	1000	ELIGIBLE	MANAGED-CARE-PARTICIPATION-ELG00014
ELG200	RECORD-ID	X(8)	1	8	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG201	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG202	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG203	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG204	ETHNICITY-CODE	X(1)	42	42	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG205	ETHNICITY-DECLARATION-EFF-DATE	9(8)	43	50	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG206	ETHNICITY-DECLARATION-END-DATE	9(8)	51	58	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG207	STATE-NOTATION	X(500)	59	558	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG208	FILLER	X(442)	559	1000	ELIGIBLE	ETHNICITY-INFORMATION-ELG00015
ELG209	RECORD-ID	X(8)	1	8	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG210	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG211	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG212	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG213	RACE	X(3)	42	44	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG214	RACE-OTHER	X(25)	45	69	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG215	CERTIFIED-AMERICAN-INDIAN-ALASKAN-NATIVE-INDICATOR	X(1)	70	70	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG216	RACE-DECLARATION-EFF-DATE	9(8)	71	78	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG217	RACE-DECLARATION-END-DATE	9(8)	79	86	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG218	STATE-NOTATION	X(500)	87	586	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG219	FILLER	X(414)	587	1000	ELIGIBLE	RACE-INFORMATION-ELG00016
ELG220	RECORD-ID	X(8)	1	8	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG221	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG222	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG223	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG224	DISABILITY-TYPE-CODE	X(2)	42	43	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG225	DISABILITY-TYPE-EFF-DATE	9(8)	44	51	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG226	DISABILITY-TYPE-END-DATE	9(8)	52	59	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG227	STATE-NOTATION	X(500)	60	559	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG228	FILLER	X(441)	560	1000	ELIGIBLE	DISABILITY-INFORMATION-ELG00017
ELG229	RECORD-ID	X(8)	1	8	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG230	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG231	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG232	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG233	1115A-DEMONSTRATION-IND	X(1)	42	42	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG234	1115A-EFF-DATE	9(8)	43	50	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG235	1115A-END-DATE	9(8)	51	58	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG236	STATE-NOTATION	X(500)	59	558	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG237	FILLER	X(442)	559	1000	ELIGIBLE	1115A-DEMONSTRATION-INFORMATION-ELG00018
ELG238	RECORD-ID	X(8)	1	8	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG239	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG240	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG241	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG242	HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-CODE	X(3)	42	44	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG243	HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-EFF-DATE	9(8)	45	52	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG244	HCBS-CHRONIC-CONDITION-NON-HEALTH-HOME-END-DATE	9(8)	53	60	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG245	STATE-NOTATION	X(500)	61	560	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG246	FILLER	X(440)	561	1000	ELIGIBLE	HCBS-CHRONIC-CONDITIONS-NON-HEALTH-HOME-ELG00020
ELG248	RECORD-ID	X(8)	1	8	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG249	SUBMITTING-STATE	X(2)	9	10	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG250	RECORD-NUMBER	9(11)	11	21	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG251	MSIS-IDENTIFICATION-NUM	X(20)	22	41	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG252	ENROLLMENT-TYPE	X(1)	42	42	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG253	ENROLLMENT-EFF-DATE	9(8)	43	50	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG254	ENROLLMENT-END-DATE	9(8)	51	58	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG255	STATE-NOTATION	X(500)	59	558	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
ELG256	FILLER	X(442)	559	1000	ELIGIBLE	Enrollment-Time-Span-Segment-ELG00021
MCR001	RECORD-ID	X(8)	1	8	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR002	DATA-DICTIONARY-VERSION	X(10)	9	18	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR006	FILE-NAME	X(8)	32	39	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR007	SUBMITTING-STATE	X(2)	40	41	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR008	DATE-FILE-CREATED	9(8)	42	49	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR009	START-OF-TIME-PERIOD	9(8)	50	57	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR010	END-OF-TIME-PERIOD	9(8)	58	65	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR011	FILE-STATUS-INDICATOR	X(1)	66	66	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR013	TOT-REC-CNT	9(11)	67	77	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR112	SEQUENCE-NUMBER	X(4)	78	81	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR014	STATE-NOTATION	X(500)	82	581	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR012	FILLER	X(419)	582	1000	MNGDCARE	FILE-HEADER-RECORD-MANAGED-CARE-MCR00001
MCR016	RECORD-ID	X(8)	1	8	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR017	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR018	RECORD-NUMBER	9(11)	11	21	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR019	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR020	MANAGED-CARE-CONTRACT-EFF-DATE	9(8)	34	41	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR021	MANAGED-CARE-CONTRACT-END-DATE	9(8)	42	49	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR022	MANAGED-CARE-NAME	X(55)	50	104	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR023	MANAGED-CARE-PROGRAM	X(1)	105	105	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR024	MANAGED-CARE-PLAN-TYPE	X(2)	106	107	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR025	REIMBURSEMENT-ARRANGEMENT	X(2)	108	109	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR026	MANAGED-CARE-PROFIT-STATUS	X(2)	110	111	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR027	CORE-BASED-STATISTICAL-AREA-CODE	X(1)	112	112	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR028	PERCENT-BUSINESS	9(3)	113	115	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR029	MANAGED-CARE-SERVICE-AREA	X(1)	116	116	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR030	MANAGED-CARE-MAIN-REC-EFF-DATE	9(8)	117	124	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR031	MANAGED-CARE-MAIN-REC-END-DATE	9(8)	125	132	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR032	STATE-NOTATION	X(500)	133	632	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR033	FILLER	X(368)	633	1000	MNGDCARE	MANAGED-CARE-MAIN-MCR00002
MCR034	RECORD-ID	X(8)	1	8	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR035	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR036	RECORD-NUMBER	9(11)	11	21	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR037	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR038	MANAGED-CARE-LOCATION-ID	X(15)	34	48	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR039	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-EFF-DATE	9(8)	49	56	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR040	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-END-DATE	9(8)	57	64	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR041	MANAGED-CARE-ADDR-TYPE	X(1)	65	65	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR042	MANAGED-CARE-ADDR-LN1	X(60)	66	125	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR043	MANAGED-CARE-ADDR-LN2	X(60)	126	185	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR044	MANAGED-CARE-ADDR-LN3	X(60)	186	245	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR045	MANAGED-CARE-CITY	X(28)	246	273	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR046	MANAGED-CARE-STATE	X(2)	274	275	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR047	MANAGED-CARE-ZIP-CODE	X(9)	276	284	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR048	MANAGED-CARE-COUNTY	X(3)	285	287	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR049	MANAGED-CARE-TELEPHONE	X(10)	288	297	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR050	MANAGED-CARE-EMAIL	X(60)	298	357	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR051	MANAGED-CARE-FAX-NUMBER	X(10)	358	367	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR052	STATE-NOTATION	X(500)	368	867	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR053	FILLER	X(133)	868	1000	MNGDCARE	MANAGED-CARE-LOCATION-AND-CONTACT-INFO-MCR00003
MCR054	RECORD-ID	X(8)	1	8	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR055	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR056	RECORD-NUMBER	9(11)	11	21	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR057	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR058	MANAGED-CARE-SERVICE-AREA-NAME	X(30)	34	63	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR059	MANAGED-CARE-SERVICE-AREA-EFF-DATE	9(8)	64	71	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR060	MANAGED-CARE-SERVICE-AREA-END-DATE	9(8)	72	79	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR061	STATE-NOTATION	X(500)	80	579	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR062	FILLER	X(421)	580	1000	MNGDCARE	MANAGED-CARE-SERVICE-AREA-MCR00004
MCR063	RECORD-ID	X(8)	1	8	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR064	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR065	RECORD-NUMBER	9(11)	11	21	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR066	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR067	OPERATING-AUTHORITY	X(2)	34	35	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR068	WAIVER-ID	X(20)	36	55	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR069	MANAGED-CARE-OP-AUTHORITY-EFF-DATE	9(8)	56	63	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR070	MANAGED-CARE-OP-AUTHORITY-END-DATE	9(8)	64	71	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR071	STATE-NOTATION	X(500)	72	571	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR072	FILLER	X(429)	572	1000	MNGDCARE	MANAGED-CARE-OPERATING-AUTHORITY-MCR00005
MCR073	RECORD-ID	X(8)	1	8	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR074	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR075	RECORD-NUMBER	9(11)	11	21	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR076	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR077	MANAGED-CARE-PLAN-POP	9(2)	34	35	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR078	MANAGED-CARE-PLAN-POP-EFF-DATE	9(8)	36	43	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR079	MANAGED-CARE-PLAN-POP-END-DATE	9(8)	44	51	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR080	STATE-NOTATION	X(500)	52	551	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR081	FILLER	X(449)	552	1000	MNGDCARE	MANAGED-CARE-PLAN-POPULATION-ENROLLED-MCR00006
MCR082	RECORD-ID	X(8)	1	8	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR083	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR084	RECORD-NUMBER	9(11)	11	21	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR085	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR086	ACCREDITATION-ORGANIZATION	X(2)	34	35	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR087	DATE-ACCREDITATION-ACHIEVED	9(8)	36	43	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR088	DATE-ACCREDITATION-END	9(8)	44	51	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR089	STATE-NOTATION	X(500)	52	551	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR090	FILLER	X(449)	552	1000	MNGDCARE	MANAGED-CARE-ACCREDITATION-ORGANIZATION-MCR00007
MCR091	RECORD-ID	X(8)	1	8	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR092	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR093	RECORD-NUMBER	9(11)	11	21	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR094	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR095	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	34	43	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR096	NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE	X(1)	44	44	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR097	NATIONAL-HEALTH-CARE-ENTITY-NAME	X(50)	45	94	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR098	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-EFF-DATE	9(8)	95	102	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR099	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-END-DATE	9(8)	103	110	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR100	STATE-NOTATION	X(500)	111	610	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR101	FILLER	X(390)	611	1000	MNGDCARE	NATIONAL-HEALTH-CARE-ENTITY-ID-INFO-MCR00008
MCR102	RECORD-ID	X(8)	1	8	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR103	SUBMITTING-STATE	X(2)	9	10	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR104	RECORD-NUMBER	9(11)	11	21	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR105	STATE-PLAN-ID-NUM	X(12)	22	33	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR106	CHPID	X(10)	34	43	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR107	SHPID	X(10)	44	53	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR108	CHPID-SHPID-RELATIONSHIP-EFF-DATE	9(8)	54	61	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR109	CHPID-SHPID-RELATIONSHIP-END-DATE	9(8)	62	69	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR110	STATE-NOTATION	X(500)	70	569	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
MCR111	FILLER	X(431)	570	1000	MNGDCARE	CHPID-SHPID-RELATIONSHIPS-MCR00009
PRV001	RECORD-ID	X(8)	1	8	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV002	DATA-DICTIONARY-VERSION	X(10)	9	18	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV006	FILE-NAME	X(8)	32	39	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV007	SUBMITTING-STATE	X(2)	40	41	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV008	DATE-FILE-CREATED	9(8)	42	49	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV009	START-OF-TIME-PERIOD	9(8)	50	57	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV010	END-OF-TIME-PERIOD	9(8)	58	65	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV011	FILE-STATUS-INDICATOR	X(1)	66	66	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV013	TOT-REC-CNT	9(11)	67	77	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV138	SEQUENCE-NUMBER	X(4)	78	81	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV014	STATE-NOTATION	X(500)	82	581	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV012	FILLER	X(519)	582	1100	PROVIDER	FILE-HEADER-RECORD-PROVIDER-PRV00001
PRV016	RECORD-ID	X(8)	1	8	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV017	SUBMITTING-STATE	X(2)	9	10	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV018	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV019	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV020	PROV-ATTRIBUTES-EFF-DATE	9(8)	52	59	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV021	PROV-ATTRIBUTES-END-DATE	9(8)	60	67	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
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PRV025	PROV-TAX-NAME	X(100)	328	427	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV026	FACILITY-GROUP-INDIVIDUAL-CODE	X(2)	428	429	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
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PRV031	SEX	X(1)	492	492	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV032	OWNERSHIP-CODE	X(2)	493	494	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
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PRV034	DATE-OF-BIRTH	9(8)	497	504	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV035	DATE-OF-DEATH	9(8)	505	512	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV036	ACCEPTING-NEW-PATIENTS-IND	X(1)	513	513	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV037	STATE-NOTATION	X(500)	514	1013	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV038	FILLER	X(87)	1014	1100	PROVIDER	PROV-ATTRIBUTES-MAIN-PRV00002
PRV039	RECORD-ID	X(8)	1	8	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV040	SUBMITTING-STATE	X(2)	9	10	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV041	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV042	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV043	PROV-LOCATION-ID	X(5)	52	56	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV044	PROV-LOCATION-AND-CONTACT-INFO-EFF-DATE	9(8)	57	64	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV045	PROV-LOCATION-AND-CONTACT-INFO-END-DATE	9(8)	65	72	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV046	PROV-ADDR-TYPE	X(1)	73	73	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
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PRV048	ADDR-LN2	X(60)	134	193	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV049	ADDR-LN3	X(60)	194	253	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV050	ADDR-CITY	X(28)	254	281	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV051	ADDR-STATE	X(2)	282	283	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV052	ADDR-ZIP-CODE	X(9)	284	292	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV053	ADDR-TELEPHONE	X(10)	293	302	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
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PRV057	ADDR-COUNTY	X(3)	374	376	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV058	STATE-NOTATION	X(500)	377	876	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
PRV059	FILLER	X(224)	877	1100	PROVIDER	PROV-LOCATION-AND-CONTACT-INFO-PRV00003
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PRV063	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-LICENSING-INFO-PRV00004
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PRV071	FILLER	X(447)	654	1100	PROVIDER	PROV-LICENSING-INFO-PRV00004
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PRV081	PROV-IDENTIFIER	X(12)	92	103	PROVIDER	PROV-IDENTIFIERS-PRV00005
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PRV083	FILLER	X(497)	604	1100	PROVIDER	PROV-IDENTIFIERS-PRV00005
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PRV086	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-TAXONOMY-CLASSIFICATION-PRV00006
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PRV088	PROV-CLASSIFICATION-TYPE	X(1)	52	52	PROVIDER	PROV-TAXONOMY-CLASSIFICATION-PRV00006
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PRV090	PROV-TAXONOMY-CLASSIFICATION-EFF-DATE	9(8)	73	80	PROVIDER	PROV-TAXONOMY-CLASSIFICATION-PRV00006
PRV091	PROV-TAXONOMY-CLASSIFICATION-END-DATE	9(8)	81	88	PROVIDER	PROV-TAXONOMY-CLASSIFICATION-PRV00006
PRV092	STATE-NOTATION	X(500)	89	588	PROVIDER	PROV-TAXONOMY-CLASSIFICATION-PRV00006
PRV093	FILLER	X(512)	589	1100	PROVIDER	PROV-TAXONOMY-CLASSIFICATION-PRV00006
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PRV096	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV097	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV098	PROV-MEDICAID-EFF-DATE	9(8)	52	59	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
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PRV100	PROV-MEDICAID-ENROLLMENT-STATUS-CODE	X(2)	68	69	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV101	STATE-PLAN-ENROLLMENT	X(1)	70	70	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV102	PROV-ENROLLMENT-METHOD	X(1)	71	71	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV103	APPL-DATE	9(8)	72	79	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV104	STATE-NOTATION	X(500)	80	579	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV105	FILLER	X(521)	580	1100	PROVIDER	PROV-MEDICAID-ENROLLMENT-PRV00007
PRV106	RECORD-ID	X(8)	1	8	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV107	SUBMITTING-STATE	X(2)	9	10	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV108	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV109	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV110	SUBMITTING-STATE-PROV-ID-OF-AFFILIATED-ENTITY	X(12)	52	63	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV111	PROV-AFFILIATED-GROUP-EFF-DATE	9(8)	64	71	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV112	PROV-AFFILIATED-GROUP-END-DATE	9(8)	72	79	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV113	STATE-NOTATION	X(500)	80	579	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV114	FILLER	X(521)	580	1100	PROVIDER	PROV-AFFILIATED-GROUPS-PRV00008
PRV115	RECORD-ID	X(8)	1	8	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV116	SUBMITTING-STATE	X(2)	9	10	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV117	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV118	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV119	AFFILIATED-PROGRAM-TYPE	X(1)	52	52	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV120	AFFILIATED-PROGRAM-ID	X(50)	53	102	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV121	PROV-AFFILIATED-PROGRAM-EFF-DATE	9(8)	103	110	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV122	PROV-AFFILIATED-PROGRAM-END-DATE	9(8)	111	118	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV123	STATE-NOTATION	X(500)	119	618	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV124	FILLER	X(482)	619	1100	PROVIDER	PROV-AFFILIATED-PROGRAMS-PRV00009
PRV125	RECORD-ID	X(8)	1	8	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV126	SUBMITTING-STATE	X(2)	9	10	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV127	RECORD-NUMBER	9(11)	11	21	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV128	SUBMITTING-STATE-PROV-ID	X(30)	22	51	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV129	PROV-LOCATION-ID	X(5)	52	56	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV130	BED-TYPE-EFF-DATE	9(8)	57	64	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV131	BED-TYPE-END-DATE	9(8)	65	72	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV134	BED-TYPE-CODE	X(1)	73	73	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV135	BED-COUNT	9(5)	74	78	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV136	STATE-NOTATION	X(500)	79	578	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
PRV137	FILLER	X(522)	579	1100	PROVIDER	PROV-BED-TYPE-INFO-PRV00010
TPL001	RECORD-ID	X(8)	1	8	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL002	DATA-DICTIONARY-VERSION	X(10)	9	18	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL003	SUBMISSION-TRANSACTION-TYPE	X(1)	19	19	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL004	FILE-ENCODING-SPECIFICATION	X(3)	20	22	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL005	DATA-MAPPING-DOCUMENT-VERSION	X(9)	23	31	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL006	FILE-NAME	X(8)	32	39	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL007	SUBMITTING-STATE	X(2)	40	41	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL008	DATE-FILE-CREATED	9(8)	42	49	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL009	START-OF-TIME-PERIOD	9(8)	50	57	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL010	END-OF-TIME-PERIOD	9(8)	58	65	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL011	FILE-STATUS-INDICATOR	X(1)	66	66	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL012	SSN-INDICATOR	X(1)	67	67	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL013	TOT-REC-CNT	9(11)	68	78	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL088	SEQUENCE-NUMBER	X(4)	79	82	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL014	STATE-NOTATION	X(500)	83	582	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL015	FILLER	X(318)	583	900	TPL	FILE-HEADER-RECORD-TPL-TPL00001
TPL016	RECORD-ID	X(8)	1	8	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL017	SUBMITTING-STATE	X(2)	9	10	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL018	RECORD-NUMBER	9(11)	11	21	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL019	MSIS-IDENTIFICATION-NUM	X(20)	22	41	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL020	TPL-HEALTH-INSURANCE-COVERAGE-IND	X(1)	42	42	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL021	TPL-OTHER-COVERAGE-IND	X(1)	43	43	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL022	ELIGIBLE-FIRST-NAME	X(30)	44	73	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL023	ELIGIBLE-MIDDLE-INIT	X(1)	74	74	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL024	ELIGIBLE-LAST-NAME	X(30)	75	104	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL025	ELIG-PRSN-MAIN-EFF-DATE	9(8)	105	112	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL026	ELIG-PRSN-MAIN-END-DATE	9(8)	113	120	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL027	STATE-NOTATION	X(500)	121	620	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL028	FILLER	X(280)	621	900	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-MAIN-TPL00002
TPL029	RECORD-ID	X(8)	1	8	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL030	SUBMITTING-STATE	X(2)	9	10	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL031	RECORD-NUMBER	9(11)	11	21	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL032	MSIS-IDENTIFICATION-NUM	X(20)	22	41	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL033	INSURANCE-CARRIER-ID-NUM	X(12)	42	53	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL034	INSURANCE-PLAN-ID	X(20)	54	73	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL035	GROUP-NUM	X(16)	74	89	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL036	MEMBER-ID	X(20)	90	109	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL037	INSURANCE-PLAN-TYPE	X(2)	110	111	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL089	COVERAGE-TYPE	X(2)	112	113	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL038	ANNUAL-DEDUCTIBLE-AMT	S9(11)V99	114	126	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL044	POLICY-OWNER-FIRST-NAME	X(30)	127	156	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL045	POLICY-OWNER-LAST-NAME	X(30)	157	186	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL046	POLICY-OWNER-SSN	X(9)	187	195	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL047	POLICY-OWNER-CODE	X(2)	196	197	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL048	INSURANCE-COVERAGE-EFF-DATE	9(8)	198	205	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL049	INSURANCE-COVERAGE-END-DATE	9(8)	206	213	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL050	STATE-NOTATION	X(500)	214	713	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL051	FILLER	X(187)	714	900	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-INFO-TPL00003
TPL052	RECORD-ID	X(8)	1	8	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL053	SUBMITTING-STATE	X(2)	9	10	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL054	RECORD-NUMBER	9(11)	11	21	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL055	INSURANCE-CARRIER-ID-NUM	X(12)	22	33	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL056	INSURANCE-PLAN-ID	X(20)	34	53	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL057	INSURANCE-PLAN-TYPE	X(2)	54	55	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL058	COVERAGE-TYPE	X(2)	56	57	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL059	INSURANCE-CATEGORIES-EFF-DATE	9(8)	58	65	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL060	INSURANCE-CATEGORIES-END-DATE	9(8)	66	73	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL061	STATE-NOTATION	X(500)	74	573	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL062	FILLER	X(327)	574	900	TPL	TPL-MEDICAID-ELIGIBLE-PERSON-HEALTH-INSURANCE-COVERAGE-CATEGORIES-TPL00004
TPL063	RECORD-ID	X(8)	1	8	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL064	SUBMITTING-STATE	X(2)	9	10	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL065	RECORD-NUMBER	9(11)	11	21	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL066	MSIS-IDENTIFICATION-NUM	X(20)	22	41	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL067	TYPE-OF-OTHER-THIRD-PARTY-LIABILITY	X(1)	42	42	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL068	OTHER-TPL-EFF-DATE	9(8)	43	50	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL069	OTHER-TPL-END-DATE	9(8)	51	58	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL070	STATE-NOTATION	X(500)	59	558	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL071	FILLER	X(342)	559	900	TPL	TPL-MEDICAID-ELIGIBLE-OTHER-THIRD-PARTY-COVERAGE-INFORMATION-TPL00005
TPL072	RECORD-ID	X(8)	1	8	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL073	SUBMITTING-STATE	X(2)	9	10	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL074	RECORD-NUMBER	9(11)	11	21	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL075	INSURANCE-CARRIER-ID-NUM	X(12)	22	33	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL076	TPL-ENTITY-ADDR-TYPE	X(2)	34	35	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL077	INSURANCE-CARRIER-ADDR-LN1	X(60)	36	95	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL078	INSURANCE-CARRIER-ADDR-LN2	X(60)	96	155	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL079	INSURANCE-CARRIER-ADDR-LN3	X(60)	156	215	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL080	INSURANCE-CARRIER-CITY	X(28)	216	243	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL081	INSURANCE-CARRIER-STATE	X(2)	244	245	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL082	INSURANCE-CARRIER-ZIP-CODE	X(9)	246	254	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL083	INSURANCE-CARRIER-PHONE-NUM	X(10)	255	264	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL084	TPL-ENTITY-CONTACT-INFO-EFF-DATE	9(8)	265	272	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL085	TPL-ENTITY-CONTACT-INFO-END-DATE	9(8)	273	280	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL086	STATE-NOTATION	X(500)	281	780	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL090	INSURANCE-CARRIER-NAIC-CODE	X(10)	781	790	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL091	INSURANCE-CARRIER-NAME	X(30)	791	820	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL092	NATIONAL-HEALTH-CARE-ENTITY-ID-TYPE	X(1)	821	821	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL093	NATIONAL-HEALTH-CARE-ENTITY-ID	X(10)	822	831	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL094	NATIONAL-HEALTH-CARE-ENTITY-NAME	X(50)	832	881	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
TPL087	FILLER	X (19)	882	900	TPL	TPL-ENTITY-CONTACT-INFORMATION-TPL00006
End of Sheet