Enter the name of the client’s current or last known city of residence. VARIABLE NAME: CLUID (KEY) DEFINITION: A unique client identifier that is assigned by the provider organization, electronic health record vendor system, or the MCO. VALID ENTRIES: A UNIQUE NUMERIC IDENTIFIER FIELD NUMBER: C-02 FIELD LENGTH: 18 FIELD TYPE: Numeric FORMAT: PURPOSE: BLOCK GRANT, TEDS, OBH
VARIABLE NAME: HH_INCOME_4 DEFINITION: Identifies a fourth source of income for the client. VALID ENTRIES: 01 NONE There is no source of income 02 WAGES/SALARY Source of income from hourly, weekly, or monthly employment 06 SOCIAL SECURITY / RAILROAD INSURANCE Income earned from these sources 07 SSI, FITAP, OR OTHER PUBLIC ASSISTANCE Income received from Supplemental Security, Aid to Families with Dependent Children, Old Age Assistance, or Other Public Welfare Agencies 08 Income received from unemployment compensation, worker’s
If the client reports a fourth source of household income, please select the appropriate category. If the client reports no fourth source of household income, enter “01”. For the purposes of reporting income, the basic family unit is defined as consisting of one or more adults and children, if any, related by blood, marriage, of adoption, and residing in the same household. Where related adults, other than spouses, or unrelated adults reside together, each will be considered a separate family, unless they are included as part of the family unit for federal income tax purposes. Children living with non-legally responsible relatives, emancipated minors, and children living under the care of unrelated persons will be considered a member of the family, if any, that claims that child as a dependent for federal income tax purposes. In maternity homes, minors seen without the consent and knowledge of parents or legal guardians will be considered as separate family units and will be charged according to the minor’s own income whether the source is allowance or earnings. VARIABLE NAME: HH_INCOME_5 DEFINITION: Identifies a source of income for the client household.
8 OTHER SINGLE RACE Use this category for instances in which the client does not identify with any other category or whose origin group, because of area custom, are regarded as racial class distinct from the any of the other categories. 9 UNKNOWN 10 WHITE An individual having origins in any of the original peoples of Europe (including Portugal), Africa, or the Middle East FIELD NUMBER: C-37 FIELD LENGTH: 2 TYPE: Numeric FORMAT: PURPOSE: BLOCK GRANT, TEDS, OBH
17 VA Services (in or in part) will be paid by the Veteran’s Administration. 21 Medicaid-Aetna Better Health Services (in total or in part) will be paid by Medicaid. 22 Medicaid-Amerigroup Real Solutions Services (in total or in part) will be paid by Medicaid. 23 Medicaid-AmeriHealth Caritas Services (in total or in part) will be paid by Medicaid. 24 Medicaid-Louisiana Healthcare Connections Services (in total or in part) will be paid by Medicaid. 25 Services (in total or in part) will be paid by Medicaid. 26 Medicaid - Other Services (in total or in part) will be paid by Medicaid 30 State invoice for reimbursement Services (in total or in part) will be paid by DHH (e.g. federal grant or state general funds) invoicing for reimbursement. FIELD NUMBER: C-39
15 TANF (For SA ONLY residential programs) - Temporary Assistance for Needy Families - This source of referral should only be used for residential programs receiving TANF funding. 17 VA Services (in or in part) will be paid by the Veteran’s Administration. 21 Medicaid-Aetna Better Health Services (in total or in part) will be paid by Medicaid. 22 Medicaid-Amerigroup Real Solutions Services (in total or in part) will be paid by Medicaid. 23 Medicaid-AmeriHealth Caritas Services (in total or in part) will be paid by Medicaid. 24 Medicaid-Louisiana Healthcare Connections Services (in total or in part) will be paid by Medicaid. 25 Services (in total or in part) will be paid by Medicaid. 26 Medicaid - Services (in or in part) will be paid by Medicaid 30 State invoice for reimbursement Services (in total or in part) will be paid by DHH (e.g. federal grant or state
PURPOSE: TEDS, NOMS, BLOCK GRANT, OBH GUIDELINES: Enter the nine-digit ZIP code of the client’s current or last known residence. If using the ZIP code, enter those numbers followed by 0000. This data element is used in calculating values for URS, NOMS, BLOCK GRANT, TEDS, and OBH reporting. VARIABLE NAME: REGION DEFINITION: Identifies the Local Governing Entity (LGE) responsible for the provision of services. VALID ENTRIES: 2 CAPITAL AREA HUMAN SERVICES DISTRICT (CAHSD) 3 SOUTH CENTRAL HUMAN SERVICES AUTHORITY (SCLHSA)