| 1 |
BENE_ID |
Encrypted CCW Beneficiary Identifier |
| 2 |
MSIS_ID |
Encrypted State Assigned Beneficiary Unique Identifier |
| 3 |
STATE_CD |
Submitting State Alpha Abbreviation |
| 4 |
SUBMTG_STATE_CD |
Submitting State FIPS Code |
| 5 |
CLM_ID |
CCW Claim Identifier |
| 6 |
CLM_NUM_ORIG |
Original Claim Identifier |
| 7 |
CLM_NUM_ADJ |
Adjustment Claim Identifier |
| 8 |
CLM_TYPE_CD |
Claim Type Code (TAF) |
| 9 |
CROSSOVER_CLM_IND |
Code To Indicate if a Portion of Claim is Paid by Medicare |
| 10 |
ADJUST_CD |
Claim Adjustment Code |
| 11 |
ADJUST_RSN_CD |
Adjustment Reason Code |
| 12 |
ADJDCTN_DT |
Adjudication Date |
| 13 |
MDCD_PD_DT |
Medicaid Paid Date |
| 14 |
CMPND_DRUG_IND |
Compound Drug Indicator |
| 15 |
CLL_CNT |
Claim Line Count - Original |
| 16 |
CLL_CNT_CALC |
Claim Line Count - Calculated |
| 17 |
PRSN_CLM_IND |
Indicator of a Claim for a Person |
| 18 |
SRVC_TRKNG_TYPE_CD |
Service Tracking Type Code |
| 19 |
FED_SRVC_CTGRY_CD |
Federally Assigned Service Category Code Added During TAF Production |
| 20 |
BIRTH_DT |
Date of Birth |
| 21 |
PGM_TYPE_CD |
Program Type Code |
| 22 |
MC_PLAN_ID |
Managed Care Plan Identification Number |
| 23 |
WVR_TYPE_CD |
Waiver Type Code |
| 24 |
WVR_ID |
Waiver Identification Number |
| 25 |
OTHR_INSRNC_IND |
Indicator Insured is Covered by Another Plan (Not Medicare or Medicaid) |
| 26 |
SECT_1115A_DEMO_IND |
1115(A) Demonstration Participation Indicator |
| 27 |
PRSCRBD_DT |
Prescribed Date (TAF) |
| 28 |
RX_FILL_DT |
Prescription Fill Date (TAF) |
| 29 |
BLG_PRVDR_ID |
Billing Provider Identification Number (TAF) |
| 30 |
BLG_PRVDR_NPI |
Billing Provider NPI |
| 31 |
BLG_PRVDR_TXNMY_CD |
Billing Provider Taxonomy Code |
| 32 |
BLG_PRVDR_SPCLTY_CD |
Billing Provider Specialty Code |
| 33 |
PRSCRBNG_PRVDR_ID |
Prescribing Provider Identification Number |
| 34 |
PRSCRBNG_PRVDR_NPI |
Prescribing Provider NPI |
| 35 |
DSPNSNG_PRVDR_ID |
Dispensing Provider Identification Number |
| 36 |
DSPNSNG_PRVDR_NPI |
Dispensing Provider NPI |
| 37 |
PRVDR_LCTN_CD |
Provider Location Code |
| 38 |
BRDR_STATE_IND |
Border State Indicator |
| 39 |
FIXD_PYMT_IND |
Fixed Payment Indicator |
| 40 |
SRVC_TRKNG_PYMT_AMT |
Service Tracking Payment Amount |
| 41 |
PYMT_LVL_IND |
Payment Level Indicator - Header or Line |
| 42 |
BILLED_AMT |
Total Claim Billed Amount |
| 43 |
MDCD_ALOWD_AMT |
Total Medicaid Allowed Amount |
| 44 |
MDCD_PD_AMT |
Total Amount Paid By Medicaid |
| 45 |
MDCD_COPAY_AMT |
Total Copay Amount Paid by Beneficiary |
| 46 |
MDCR_DDCTBL_PD_AMT |
Total Medicare Deductible Amount |
| 47 |
MDCR_COINSRNC_PD_AMT |
Total Medicare Coinsurance Amount |
| 48 |
COINSRNC_AMT |
Beneficiary Coinsurance Amount |
| 49 |
COPAY_AMT |
Beneficiary Copayment Amount |
| 50 |
DDCTBL_AMT |
Beneficiary Deductible Amount |
| 51 |
COPAY_WVD_IND |
Indicator Signifying Copay was Waived by Provider |
| 52 |
TP_PD_AMT |
Total Third Party Liability Paid Amount |
| 53 |
TP_COINSRNC_PD_AMT |
Third Party Coinsurance Paid Amount |
| 54 |
TP_COPAY_PD_AMT |
Third Party Copayment Paid Amount |
| 55 |
OTHR_INSRNC_PD_AMT |
Total Other Than Medicare or Medicaid -Insurance Paid Amount |
| 56 |
OTHR_TP_CLCTN_CD |
Other Third Party Collection Code |
| 57 |
FUNDNG_CD |
Code To Indicate Source of Non-Federal Funding |
| 58 |
FUNDNG_SRC_NON_FED_SHR_CD |
Funding Source Non-Federal Share Code |
| 59 |
DA_RUN_ID |
TAF Production Run Identifier (unique for each TAF run) |
| 60 |
TMSIS_RUN_ID |
TMSIS State Data Processing Run Identifier |
| 61 |
RX_VRSN |
Rx Version Representing the Iteration of the File |
| 62 |
RX_FIL_DT |
RX File Date - Represents the Year and Month of the Reporting Period |
| 63 |
CCW_LD_DT |
CCW Load Date (Claims) |
| 1 |
BENE_ID |
Encrypted CCW Beneficiary Identifier |
| 2 |
MSIS_ID |
Encrypted State Assigned Beneficiary Unique Identifier |
| 3 |
STATE_CD |
Submitting State Alpha Abbreviation |
| 4 |
SUBMTG_STATE_CD |
Submitting State FIPS Code |
| 5 |
CLM_ID |
CCW Claim Identifier |
| 6 |
LINE_NUM |
Sequential Claim Line Number |
| 7 |
CLM_NUM_ORIG |
Original Claim Identifier |
| 8 |
LINE_NUM_ORIG |
Original Claim Line Number (TAF) |
| 9 |
CLM_NUM_ADJ |
Adjustment Claim Identifier |
| 10 |
LINE_NUM_ADJ |
Adjustment Claim Line Number |
| 11 |
ADJDCTN_DT |
Adjudication Date |
| 12 |
LINE_CLAIM_STUS_CD |
Claim Line Status Code |
| 13 |
LINE_ADJUST_CD |
Claim Line Adjustment Code |
| 14 |
BNFT_TYPE_CD |
Benefit Type Code |
| 15 |
TOS_CD |
Type of Service Code |
| 16 |
XIX_SRVC_CTGRY_CD |
CMS-64 Form Category of Service for the Paid Claim |
| 17 |
XXI_SRVC_CTGRY_CD |
CMS-21 Form Category of Service for the Paid Claim |
| 18 |
CMS_64_FED_CTGRY_CD |
CMS-64 Form Code for Federal Reimbursement |
| 19 |
RX_FILL_DT |
Prescription Fill Date (TAF) |
| 20 |
NDC |
National Drug Code |
| 21 |
NDC_UOM_CD |
NDC Unit of Measure Code |
| 22 |
NDC_QTY |
NDC Quantity Dispensed |
| 23 |
MTRC_DCML_QTY |
Metric Decimal Quantity of Product |
| 24 |
NDC_QTY_ALOWD |
NDC Quantity Allowed |
| 25 |
DAYS_SUPPLY |
Days Supply (TAF) |
| 26 |
NEW_RX_REFILL_NUM |
New Prescription Indicator (00) or Number of Refills |
| 27 |
BRND_GNRC_CD |
Brand - Generic Code |
| 28 |
DOSAGE_FORM_CD |
Medication Dosage Form Code |
| 29 |
REBT_ELGBL_CD |
Rebate Eligible Code |
| 30 |
DRUG_UTLZTN_CD |
Drug Utilization Code |
| 31 |
RSN_SRVC_CD |
Reason for Service Code |
| 32 |
PROF_SRVC_CD |
Professional Service Code |
| 33 |
RSLT_SRVC_CD |
Result of Service Code |
| 34 |
IMNZTN_TYPE_CD |
Immunization Type Code |
| 35 |
DSPNSNG_FEE_AMT |
Dispensing Fee Amount |
| 36 |
LINE_BILLED_AMT |
Line Billed Amount |
| 37 |
LINE_MDCD_ALOWD_AMT |
Line Medicaid Allowed Amount |
| 38 |
LINE_MDCD_PD_AMT |
Line Medicaid Paid Amount |
| 39 |
LINE_MDCD_FFS_EQUIV_AMT |
Line Medicaid Fee For Service Equivalent Amount |
| 40 |
LINE_MDCR_PD_AMT |
Line Medicare Paid Amount |
| 41 |
LINE_MDCR_DDCTBL_PD_AMT |
Line Medicare Deductible Amount |
| 42 |
LINE_MDCR_COINSRNC_PD_AMT |
Line Medicare Coinsurance Amount |
| 43 |
LINE_COPAY_AMT |
Line Beneficiary Copayment Amount |
| 44 |
LINE_TP_PD_AMT |
Line Third Party Liability Paid Amount |
| 45 |
LINE_OTHR_INSRNC_PD_AMT |
Line Other Than Medicare or Medicaid -Insurance Paid Amount |
| 46 |
DA_RUN_ID |
TAF Production Run Identifier (unique for each TAF run) |
| 47 |
TMSIS_RUN_ID |
TMSIS State Data Processing Run Identifier |