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TMSIS Dataguide Medicaid.gov

Version:

3.38.0

ICN-ADJ

Data Element

DE Number

CRX113

System DE Number

CRX.003.113

File Name

CRX - CLAIM PHARMACY

File Segment Number

CRX00003

File Segment Name

CLAIM-LINE-RECORD-RX

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances
Definition A unique claim number assigned by the state's payment system that identifies the adjustment claim for an original transaction.
Size X(50)
FLF Start Position 92
FLF Stop Position 141
Segment Key Field Identifier 3
Coding Requirements 1. Value must be 50 characters or less
2. Value must not contain a pipe or asterisk symbols
3. If associated Adjustment Indicator value equals "0", then value must not be populated
4. Conditional
5. If associated Adjustment Indicator value equals "4", then value must be populated
Valid Value Code Set Valid Value Code Valid Value Name Valid Value Description Effective Start Date Effective End Date
DE Number System DE Number DE Name File Segment Number File Segment Name
CIP020 CIP.002.020 ICN-ADJ CIP00002 CLAIM-HEADER-RECORD-IP
CIP236 CIP.003.236 ICN-ADJ CIP00003 CLAIM-LINE-RECORD-IP
CIP326 CIP.004.326 ICN-ADJ CIP00004 CLAIM-DX-IP
CLT020 CLT.002.020 ICN-ADJ CLT00002 CLAIM-HEADER-RECORD-LT
CLT189 CLT.003.189 ICN-ADJ CLT00003 CLAIM-LINE-RECORD-LT
CLT272 CLT.004.272 ICN-ADJ CLT00004 CLAIM-DX-LT
COT020 COT.002.020 ICN-ADJ COT00002 CLAIM-HEADER-RECORD-OT
COT159 COT.003.159 ICN-ADJ COT00003 CLAIM-LINE-RECORD-OT
COT278 COT.004.278 ICN-ADJ COT00004 CLAIM-DX-OT
CRX020 CRX.002.020 ICN-ADJ CRX00002 CLAIM-HEADER-RECORD-RX
CRX200 CRX.004.200 ICN-ADJ CRX00004 CLAIM-DX-RX
FTX021 FTX.002.021 ICN-ADJ FTX00002 INDIVIDUAL-CAPITATION-PMPM
FTX068 FTX.003.068 ICN-ADJ FTX00003 INDIVIDUAL-HEALTH-INSURANCE-PREMIUM-PAYMENT
FTX109 FTX.004.109 ICN-ADJ FTX00004 GROUP-INSURANCE-PREMIUM-PAYMENT
FTX153 FTX.005.153 ICN-ADJ FTX00005 COST-SHARING-OFFSET
FTX196 FTX.006.196 ICN-ADJ FTX00006 VALUE-BASED-PAYMENT
FTX240 FTX.007.240 ICN-ADJ FTX00007 STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX283 FTX.008.283 ICN-ADJ FTX00008 COST-SETTLEMENT-PAYMENT
FTX322 FTX.009.322 ICN-ADJ FTX00009 FQHC-WRAP-PAYMENT
FTX361 FTX.095.361 ICN-ADJ FTX00095 MISCELLANEOUS-PAYMENT