CRX.003.125

MEDICAID-PAID-AMT

Data Element

DE Number

CRX125

System DE Number

CRX.003.125

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	The amount paid to the provider by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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	225
FLF Stop Position	237
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. Conditional 4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654]

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

RULE ID	RULE Definition
RULE-1928	If a claim line is a non-denied claim line from an RX file, then the Medicaid paid amount value reported must be a valid dollar amount that matches the specified T-MSIS picture format: S9(11)V99.
RULE-7563	If an RX claim line is for a denied claim, then the medicaid paid amount has a missing or zero value.

Measure ID	Measure Name
FFS-49-012-12	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
RULE-7793	% 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-004-16	% of Plan IDs over the threshold for MCR-59P-004-16 (% 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-004-16	% 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-7563	% of denied claim lines where Medicaid Paid Amount is non-missing and non-zero
MIS-86-012-12	% missing: MEDICAID-PAID-AMT (CRX00003)
MIS-28-013-13	% missing: MEDICAID-PAID-AMT (CRX00003)
MCR-59-004-16	% 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-49-004-16	% 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-59-012-12	% of claim lines with PAYMENT-LEVEL-IND=2 (claim detail) that have Medicaid Paid Amount greater than a non-zero Allowed Amount
MCR-59-004-4	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MCR-18-009-9	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 11 (Family planning services and supplies for individuals of child-bearing age)
FFS-49-004-4	% of claim headers where the sum of Medicaid Paid Amount from the lines does not equal Total Medicaid Paid Amount from the header
MIS-9-014-14	% missing: MEDICAID-PAID-AMT (CRX00003)
MCR-18-016-10	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 127 (Indian Health Service (IHS) - Family Plan)
MCR-18-015-16	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 89 (Disposable medical supplies.)
MCR-18-014-15	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 85 (Prenatal care and pre-pregnancy family planning services and supplies.)
MCR-18-013-14	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 36 (Medical equipment/prosthetic devices)
MCR-18-012-13	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 34 (Over-the-counter medications.)
MCR-18-011-12	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 33 (Prescribed drugs)
MCR-18-010-11	Ratio of Average FFS Equivalent to Average Paid for TYPE-OF-SERVICE = 18 (Home health services - Medical supplies, equipment, and appliances suitable for use in the home)

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
CIP254	CIP.003.254	MEDICAID-PAID-AMT	CIP00003	CLAIM-LINE-RECORD-IP
CLT208	CLT.003.208	MEDICAID-PAID-AMT	CLT00003	CLAIM-LINE-RECORD-LT
COT178	COT.003.178	MEDICAID-PAID-AMT	COT00003	CLAIM-LINE-RECORD-OT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
02/27/2025	4.0.3	CRX.003.125	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. Conditional	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. Conditional4. Value should not be populated or should be equal to zero, when associated Claim Line Status is in [542,585,654]
12/19/2024	4.0.1	CRX.003.125	UPDATE	Definition	The amount paid by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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.	The amount paid to the provider by Medicaid/CHIP agency or the managed care plan on this claim or adjustment at the claim detail level. For sub-capitated encounters from a sub-capitated entity that is not a sub-capitated network provider, report the amount that the sub-capitated entity paid the provider at the claim line detail level. 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.
09/16/2024	4.0.0	CRX.003.125	UPDATE	File segment	None	41
09/16/2024	4.0.0	CRX.003.125	ADD	N/A		Created