CLT.002.065

TOT-MEDICAID-PAID-AMT

Data Element

DE Number

CLT065

System DE Number

CLT.002.065

File Name

CLT - CLAIM LONG-TERM CARE

File Segment Number

CLT00002

File Segment Name

CLAIM-HEADER-RECORD-LT

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The total amount paid by Medicaid/CHIP or the managed care plan on this claim or adjustment at the claim header level, which is the sum of the amounts paid by Medicaid or the managed care plan at the detail level for the claim. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the total amount that the sub-capitated entity paid the provider for the service. Report a null value in this field if the provider is a sub-capitated network provider. For sub-capitated encounters from a sub-capitated network provider, if the sub-capitated network provider directly employs the provider that renders the service to the enrollee, report a null value in this field.
Size	S9(11)V99
FLF Start Position	294
FLF Stop Position	306
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be between -99999999999.99 and 99999999999.99 2. Value must be expressed as a number with 2-digit precision (e.g. 100.50) 3. Must have an associated Medicaid Paid Date 4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount 5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts 6. Conditional 7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654] 8. Value must not be greater than Total Allowed Amount (CLT.002.064)

Valid Value Code Set	Valid Value Code	Valid Value Name	Valid Value Description	Effective Start Date	Effective End Date

RULE ID	RULE Definition
RULE-7268	If a claim is a non-denied claim from an LT file that is an original claim and is a separate CHIP FFS, Medicaid or Medicaid-expansion FFS claim with a crossover indicator equal to 0 or null, then the total medicaid paid amount must be populated.
RULE-7269	If a claim is a non-denied claim from an LT file that is an original claim and is a separate CHIP FFS, Medicaid or Medicaid-expansion FFS claim with a crossover indicator equal to 1, then the total medicaid paid amount must be populated.
RULE-7279	If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP, Medicaid or Medicaid-expansion CHIP encounter, separate CHIP FFS or encounter claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount.
RULE-7283	If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP FFS, Medicaid or Medicaid-expansion CHIP encounter, separate CHIP FFS or encounter claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.
RULE-7436	If the non-denied claim is an LT file, and is an Medicaid-SCHIP or Separate CHIP service tracking claim, then the claim has a null value or 0.00 value for total medicaid paid amount.
RULE-7523	If the non-denied claim is an LT file, and is an original, adjustment, gross adjustment or debit adjustment Medicaid/Medicaid-expansion CHIP or Separate CHIP supplemental claim, then the claim has a non-null value and not 0.00 value for total medicaid paid amount.
RULE-7566	If an LT claim header is for a denied claim, then total medicaid paid amount has a missing or zero value.
RULE-7683	If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP encounter, separate CHIP encounter claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount.
RULE-7687	If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP encounter, separate CHIP encounter claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.
RULE-7791	If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP or Separate CHIP Fee-for-Service claim, and the payment level indicator is for line, then the sum of the claim line medicaid paid amount is equal to the claim header total medicaid paid amount.
RULE-7795	If a claim is a non-denied claim from an LT file that is an original claim and is a Medicaid or Medicaid-expansion CHIP or Separate CHIP Fee-for-Service claim and the total medicaid paid amount is populated, then the total medicaid paid amount is less than or equal to the total allowed amount.
RULE-975	If a claim is a non-denied claim from an LT file, then the total Medicaid paid amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.

Measure ID	Measure Name
EXP-10-001-25	Total paid for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-10-002-18	Total paid for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-10-003-19	Total paid for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-10-004-20	Total paid for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-10-005-21	Total paid for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-10-006-22	Total paid for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-10-007-23	Total paid for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-10-008-24	Total paid for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-10-009-17	Average paid per record for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-10-010-10	Average paid per record for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-10-011-11	Average paid per record for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-10-012-12	Average paid per record for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-10-013-13	Average paid per record for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-10-014-14	Average paid per record for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-10-015-15	Average paid per record for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-10-016-16	Average paid per record for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-10-017-9	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-10-018-2	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-10-019-3	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-10-020-4	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-10-021-5	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-10-022-6	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-10-023-7	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-10-024-8	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-10-025-1	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 133 (Supplemental payment - nursing)
EXP-6-001-21	Sum of Total Medicaid Paid Amount
EXP-6-002-29	Total paid for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-6-003-22	Total paid for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-6-004-23	Total paid for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-6-005-24	Total paid for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-6-006-25	Total paid for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-6-007-26	Total paid for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-6-008-27	Total paid for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-6-009-28	Total paid for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-6-010-3	% of claim headers with Total Medicaid Paid Amount > $20,000
EXP-6-011-20	Average paid per record for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-6-012-13	Average paid per record for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-6-013-14	Average paid per record for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-6-014-15	Average paid per record for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-6-015-16	Average paid per record for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-6-016-17	Average paid per record for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-6-017-18	Average paid per record for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-6-018-19	Average paid per record for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-6-019-12	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-6-020-5	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-6-021-6	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-6-022-7	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-6-023-8	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-6-024-9	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-6-025-10	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-6-026-11	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-6-027-4	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 133 (Supplemental payment - nursing)
EXP-6-029-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-7-001-27	Total paid for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-7-002-20	Total paid for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-7-003-21	Total paid for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-7-004-22	Total paid for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-7-005-23	Total paid for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-7-006-24	Total paid for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-7-007-25	Total paid for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-7-008-26	Total paid for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-7-009-1	% of claim headers with Total Medicaid Paid Amount > $20,000
EXP-7-010-19	Average paid per record for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-7-011-12	Average paid per record for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-7-012-13	Average paid per record for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-7-013-14	Average paid per record for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-7-014-15	Average paid per record for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-7-015-16	Average paid per record for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-7-016-17	Average paid per record for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-7-017-18	Average paid per record for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-7-018-11	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 9 (Nursing facility services; age 21 or older)
EXP-7-019-4	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 44 (Inpatient hospital services for individuals age 65 or older in institutions for mental diseases)
EXP-7-020-5	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 45 (Nursing facility services for individuals age 65 or older in institutions for mental diseases)
EXP-7-021-6	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 46 (Intermediate care facility (ICF/IIDICF/IID) services)
EXP-7-022-7	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 47 (Nursing facility services, other than in institutions for mental diseases)
EXP-7-023-8	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 48 (Inpatient psychiatric services for individuals under age 21)
EXP-7-024-9	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 50 (Inpatient substance abuse treatment services and residential substance abuse treatment services.)
EXP-7-025-10	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 59 (Skilled nursing facility services for individuals under age 21)
EXP-7-026-3	Average paid per Long-Term Care day for TYPE-OF-SERVICE = 133 (Supplemental payment - nursing)
EXP-7-027-2	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-8-001-4	Sum of Total Medicaid Paid Amount
EXP-8-002-3	% of claim headers with Total Medicaid Paid Amount > $20,000
EXP-8-004-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-9-001-1	% of claim headers with Total Medicaid Paid Amount > $20,000
EXP-9-002-2	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-S-003-3	Sum of Total Medicaid Paid Amount
EXP-S-007-4	Sum of Total Medicaid Paid Amount
MIS-4-037-37	% missing: TOT-MEDICAID-PAID-AMT (CLT00002)
EXP-33-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-34-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-35-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-36-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
FFS-44-001-1	% of crossover claim headers where Total Medicare Deductible Amount and Total Medicare Coinsurance Amount do not sum to Total Medicaid Paid Amount
FFS-49-002-2	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
FFS-49-006-6	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
MCR-59-002-2	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MCR-59-006-6	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
EXP-44-002-2	% of service tracking claim headers with a non-zero Total Medicaid Paid Amount
EXP-45-002-2	% of header claims with Total Medicaid Paid Amount = $0 or missing
FFS-49-002-14	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MCR-59-002-14	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MIS-23-042-42	% missing: TOT-MEDICAID-PAID-AMT (CLT00002)
MIS-81-042-42	% missing: TOT-MEDICAID-PAID-AMT (CLT00002)
RULE-7436	% of service tracking claim headers with a non-zero Total Medicaid Paid Amount
RULE-7523	% of header claims with Total Medicaid Paid Amount = $0 or missing
RULE-7566	% of denied claim headers where Total Medicaid Paid Amount is non-missing and non-zero
EXP-33P-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing, by Plan ID
MCR-59P-002-14	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header, by Plan ID
EXP-33R-001-1	% of Plan IDs over the threshold for EXP-33P-001-1 (% of claim headers with Total Medicaid Paid Amount = $0 or missing, by Plan ID)
MCR-59R-002-14	% of Plan IDs over the threshold for MCR-59P-002-14 (% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header, by Plan ID)
RULE-7791	% of claim headers with PAYMENT-LEVEL-IND = 2 where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP114	CIP.002.114	TOT-MEDICAID-PAID-AMT	CIP00002	CLAIM-HEADER-RECORD-IP
COT050	COT.002.050	TOT-MEDICAID-PAID-AMT	COT00002	CLAIM-HEADER-RECORD-OT
CRX041	CRX.002.041	TOT-MEDICAID-PAID-AMT	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/25/2025	4.0.18	CLT.002.065	UPDATE	Coding requirement	1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts.6. Conditional7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654]8. Value must not be greater than Total Allowed Amount (CLT.002.064)	1. Value must be between -99999999999.99 and 99999999999.992. Value must be expressed as a number with 2-digit precision (e.g. 100.50)3. Must have an associated Medicaid Paid Date4. If Total Medicare Coinsurance Amount and Total Medicare Deductible Amount is reported it must equal Total Medicaid Paid Amount5. When Payment Level Indicator equals "2", value must equal the sum of line level Medicaid Paid Amounts6. Conditional7. Value must not be populated or equal to "0.00" when associated Claim Status is in [542,585,654]8. Value must not be greater than Total Allowed Amount (CLT.002.064)
09/16/2024	4.0.0	CLT.002.065	UPDATE	File segment	None	30
09/16/2024	4.0.0	CLT.002.065	ADD	N/A		Created