CRX.002.094

An official website of the United States government

Official websites use .gov
A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS
A lock () or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.

TMSIS Dataguide

Medicaid.gov

Version:

CLAIM-DENIED-INDICATOR

Data Element

DE Number

CRX094

System DE Number

CRX.002.094

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	An indicator to identify a claim that the state refused pay in its entirety.
Size	X(1)
FLF Start Position	679
FLF Stop Position	679
Segment Key Field Identifier	Not Applicable
Coding Requirements	1. Value must be 1 character 2. Value must be in Claim Denied Indicator List (VVL) 3. If value equals "0", then Claim Status Category must equal "F2" 4. 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-1881	If the claim denied indicator is populated on a non-denied claim from an RX file, then the claim denied indicator reported must be found in the list of valid values.
RULE-1882	If the claim status category or the type of claim is for denied claims on a claim from an RX file, the claim denied indicator value reported must also indicate the claim is denied.
RULE-6822	The format for CLAIM-DENIED-INDICATOR on a non-denied RX claim was expected to be submitted as X(1).
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-7979	All denied, RX claim line records must have a corresponding claim header record with a claim denied indicator equal to '0' (Denied).
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'

Measure ID	Measure Name

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP212	CIP.002.212	CLAIM-DENIED-INDICATOR	CIP00002	CLAIM-HEADER-RECORD-IP
CLT159	CLT.002.159	CLAIM-DENIED-INDICATOR	CLT00002	CLAIM-HEADER-RECORD-LT
COT136	COT.002.136	CLAIM-DENIED-INDICATOR	COT00002	CLAIM-HEADER-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	CRX.002.094	UPDATE	File segment	None	40
09/16/2024	4.0.0	CRX.002.094	ADD	N/A		Created