COT.002.050

TOT-MEDICAID-PAID-AMT

Data Element

DE Number

COT050

System DE Number

COT.002.050

File Name

COT - CLAIM OTHER

File Segment Number

COT00002

File Segment Name

CLAIM-HEADER-RECORD-OT

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	274
FLF Stop Position	286
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 (COT.002.049)

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

RULE ID	RULE Definition
RULE-1394	If a claim is a non-denied claim from an OT 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.
RULE-7270	If a claim is a non-denied claim from an OT file that is an original claim and is a separate CHIP capitated or Medicaid or Medicaid-expansion CHIP capitated claim, then the total medicaid paid amount must be populated.
RULE-7271	If a claim is a non-denied claim from an OT 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-7280	If a claim is a non-denied claim from an OT 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-7284	If a claim is a non-denied claim from an OT 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-7437	If the non-denied claim is an OT 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-7524	If the non-denied claim is an OT 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-7567	If an OT claim header is for a denied claim, then total medicaid paid amount has a missing or zero value.
RULE-7684	If a claim is a non-denied claim from an OT 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-7688	If a claim is a non-denied claim from an OT 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-7792	If a claim is a non-denied claim from an OT 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-7796	If a claim is a non-denied claim from an OT 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.

Measure ID	Measure Name
EXP-44-003-3	% of service tracking claim headers with a non-zero Total Medicaid Paid Amount
RULE-7792	% 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-59R-003-15	% of Plan IDs over the threshold for MCR-59P-003-15 (% 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)
MCR-59P-003-15	% 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-7567	% of denied claim headers where Total Medicaid Paid Amount is non-missing and non-zero
RULE-7524	% of header claims with Total Medicaid Paid Amount = $0 or missing
RULE-7437	% of service tracking claim headers with a non-zero Total Medicaid Paid Amount
MIS-83-033-33	% missing: TOT-MEDICAID-PAID-AMT (COT00002)
MIS-25-033-33	% missing: TOT-MEDICAID-PAID-AMT (COT00002)
MCR-59-003-15	% 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
FFS-49-003-15	% 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
EXP-45-003-3	% of header claims with Total Medicaid Paid Amount = $0 or missing
MIS-6-028-28	% missing: TOT-MEDICAID-PAID-AMT (COT00002)
MCR-59-007-7	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
MCR-59-003-3	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
FFS-49-007-7	% of claim headers that have Total Medicaid Paid Amount greater than a non-zero Total Allowed Amount
FFS-49-003-3	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
FFS-45-001-1	% of crossover claim headers where Total Medicare Deductible Amount and Total Medicare Coinsurance Amount do not sum to Total Medicaid Paid Amount
EXP-40-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-38-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-28-002-2	Average Total Medicaid Paid Amount ($0 < Total Medicaid Paid Amount < $200,000)
EXP-28-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing
EXP-27-002-2	Average Total Medicaid Paid Amount ($0 < Total Medicaid Paid Amount < $200,000)
EXP-27-001-1	% of claim headers with Total Medicaid Paid Amount = $0 or missing

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
CLT065	CLT.002.065	TOT-MEDICAID-PAID-AMT	CLT00002	CLAIM-HEADER-RECORD-LT
CRX041	CRX.002.041	TOT-MEDICAID-PAID-AMT	CRX00002	CLAIM-HEADER-RECORD-RX

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	COT.002.050	UPDATE	File segment	None	35
09/16/2024	4.0.0	COT.002.050	ADD	N/A		Created