CRX.002.029

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TMSIS Dataguide

Medicaid.gov

Version:

TYPE-OF-CLAIM

Data Element

DE Number

CRX029

System DE Number

CRX.002.029

File Name

CRX - CLAIM PHARMACY

File Segment Number

File Segment Name

CLAIM-HEADER-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C' or an S-CHIP sub-capitated encounter record.
Size	X(1)
FLF Start Position	176
FLF Stop Position	176
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 1 character 2. Value must be in Type of Claim List (VVL) 3. Mandatory

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

RULE ID	RULE Definition
RULE-1769	If the type of claim is populated on a non-denied claim from an RX file, then the type of claim value reported must be in the list of valid values for type of claim.
RULE-6755	If a claim is a non-denied claim from an RX file, then the type of claim value reported must be compatible with specified T-MSIS picture format: X(1).
RULE-7257	If a claim is a non-denied claim from an RX file, then the type of claim value must be populated.
RULE-7414	If a claim in a non-denied, original or adjustment FFS or Encounter crossover claim from an RX file, and the MSIS ID is populated and the prescription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7549	If the 1115A demonstration indicator is equal to 1 (yes) on a non-denied claim from an RX file, and the prescription fill date is within the 1115A effective and end dates, then the 1115A demonstration indicator value reported on the 1115A demonstration information segment must be populated with a 1 value.
RULE-7636	All non-denied, paid RX claim header records must have a corresponding non-denied claim line record.
RULE-7742	If a claim in a non-denied, original or adjustment Encounter crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-7773	If a claim is a non-denied claim from an RX file, and the waiver type is populated, and the claim prescription fill date is between the waiver enrollment effective and end dates, then the claim waiver type is equal to the waiver participation waiver type.
RULE-7984	If a claim in a non-denied, original or adjustment FFS crossover claim from an RX file, and the MSIS ID is populated and the presription fill date is populated with a date that overlaps with the reported eligibility determinant effective and end dates, and the primary eligibility group indicator is equal to '1', then the dual eligible code is equal to '01', '02', '04', '08'
RULE-9228	If the type of claim is populated on a non-denied claim from an RX file in T-MSIS File Layout V4.0.0, then the type of claim value reported must be Fee-For-Service or Encounter.

Measure ID	Measure Name
MCR-27-001-1	Encounters (by Claim File Type)
MCR-27-002-2	Encounters (by Claims file type) by Plan ID (non-PCCM)
MIS-8-033-33	% missing: TYPE-OF-CLAIM (CRX00002)
MIS-19-001-1	% missing: TYPE-OF-CLAIM (CRX00002)
ALL-18-004-4	# of claim headers with TYPE-OF-CLAIM = U, V, W, X or Y that aren’t MFP (PROGRAM-TYPE = 08)
ALL-25-001-1	Type of Claim values
EXP-43-004-4	# of non-service tracking claim headers with non-missing Service Tracking Type
EXP-43-008-8	# of non-service tracking claim headers with non-missing Service Tracking Payment Amount
RULE-7257	% missing: TYPE-OF-CLAIM (CRX00002)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP100	CIP.002.100	TYPE-OF-CLAIM	CIP00002	CLAIM-HEADER-RECORD-IP
CLT052	CLT.002.052	TYPE-OF-CLAIM	CLT00002	CLAIM-HEADER-RECORD-LT
COT037	COT.002.037	TYPE-OF-CLAIM	COT00002	CLAIM-HEADER-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
06/05/2025	4.0.10	CRX.002.029	UPDATE	Definition	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or �C� for an S-CHIP sub-capitated encounter record.	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or 'C' or an S-CHIP sub-capitated encounter record.
05/29/2025	4.0.9	CRX.002.029	UPDATE	Definition	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or â€œCâ€ for an S-CHIP sub-capitated encounter record.	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or �C� for an S-CHIP sub-capitated encounter record.
01/16/2025	4.0.2	CRX.002.029	UPDATE	Definition	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or â€śCâ€ť for an S-CHIP sub-capitated encounter record.	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or â€œCâ€ for an S-CHIP sub-capitated encounter record.
12/19/2024	4.0.1	CRX.002.029	UPDATE	Definition	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or “C” for an S-CHIP sub-capitated encounter record.	A code to indicate what type of payment is covered in this claim. For sub-capitated encounters from a sub-capitated entity or sub-capitated network provider, report TYPE-OF-CLAIM = '3' for a Medicaid sub-capitated encounter record or â€śCâ€ť for an S-CHIP sub-capitated encounter record.
09/16/2024	4.0.0	CRX.002.029	UPDATE	File segment	None	40
09/16/2024	4.0.0	CRX.002.029	ADD	N/A		Created