FTX.002.025

PAYMENT-OR-RECOUPMENT-AMOUNT

Data Element

DE Number

FTX025

System DE Number

FTX.002.025

File Name

FTX - FINANCIAL TRANSACTION

File Segment Number

FTX00002

File Segment Name

INDIVIDUAL-CAPITATION-PMPM

Last updated

Overview Valid Values Related Rules Related DQ Measures Other Instances

Definition	The dollar amount being paid to the payee or recouped from the payee for a previous payment. A recoupment should be reported as a negative amount.
Size	S9(11)V99
FLF Start Position	131
FLF Stop Position	143
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. 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-8023	If a financial transaction is from an FTX file, then the payment or recoupment amount value reported must be compatible with specified T-MSIS picture format: S9(11)V99.
RULE-8701	If the Individual Capitation Payment segment is populated from a FTX file, then the PAYMENT-OR-RECOUPMENT-AMOUNT must be populated

Measure ID	Measure Name
MCR-55-001-1	Traditional PCCM capitation ratio
MCR-54-001-1	# of plans with at least 100 enrollments, 0 capitations, 0 encounters
MCR-54-002-2	# of plans with at least 100 enrollments or 100 capitations, 0 encounters
MCR-54-003-3	# of plans with at least 100 enrollments or 100 encounters, 0 capitations
MCR-54-004-4	# of plans with at least 100 enrollments and some capitations that have capitation ratios outside of the expected range (0.7 - 1.3)
MCR-54-005-5	# of plans with at least 100 capitations or 100 encounters, 0 enrollments
MCR-54-006-6	# of plans with at least 100 enrollments and some encounters that have IP ratios outside of the expected range (0.01 - 2)
MCR-54-007-7	# of plans with at least 100 enrollments and some encounters that have OT ratios outside of the expected range (0.1 - 20)
MCR-54-008-8	# of plans with at least 100 enrollments and some encounters that have RX ratios outside of the expected range (0.02 - 5)
MCR-54-009-9	# of plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-54-010-10	# of plans where MC plan type does not match EL plan type
MCR-54-011-11	# of PCCM plan IDs
MCR-54-012-12	# of PCCM plans with at least 100 enrollments, capitations, or encounters, that do not have a managed care record
MCR-53-003-3	Total # of managed care encounters
MCR-55-002-2	Enhanced PCCM capitation ratio
MCR-55-003-3	PACE capitation ratio
MCR-55-004-4	Health home capitation ratio
EXP-46-005-5	% difference between T-MSIS payments to comprehensive managed care plans and CMS-64 payments to managed care organizations
EXP-46-006-6	% difference between T-MSIS payments to prepaid health plans and CMS-64 payments to prepaid health plans
EXP-46-007-7	% difference between T-MSIS payments for premium assistance and CMS-64 Medicaid premium assistance payments
EXP-46-008-8	% difference between T-MSIS primary care case management fees and CMS-64 payments for primary care case management
EXP-47-005-5	% difference between T-MSIS premium payments paid and CMS-64.21 premium payments paid
EXP-47-006-6	% difference between T-MSIS payments Cost-Sharing Offset and CMS-64.21 Cost-Sharing Offset
EXP-48-005-5	% difference between T-MSIS premium payments paid and CMS-21 premium payments paid
EXP-48-006-6	% difference between T-MSIS payments Cost-Sharing Offset and CMS-21 Cost-Sharing Offset
EXP-24-007-5	Average Payment or Recoupment Amount for PCCM
EXP-22-003-4	Sum of Payment or Recoupment Amount for PCCM
EXP-22-004-6	Sum of Payment or Recoupment Amount for PHP
EXP-22-006-3	Average Payment or Recoupment Amount for HMOs, HIOs, or PACE
EXP-22-007-5	Average Payment or Recoupment Amount for PCCM
EXP-22-008-7	Average Payment or Recoupment Amount for PHP
EXP-23-001-2	Sum of Payment or Recoupment Amount
EXP-23-002-1	Average absolute value of Payment or Recoupment Amount
EXP-24-002-2	Sum of Payment or Recoupment Amount for HMOs, HIOs, or PACE
EXP-24-003-4	Sum of Payment or Recoupment Amount for PCCM
EXP-24-004-6	Sum of Payment or Recoupment Amount for PHP
EXP-24-006-3	Average Payment or Recoupment Amount for HMOs, HIOs or PACE
EXP-22-001-2	Sum of Payment or Recoupment Amount for HMOs, HIOs, or PACE
EXP-24-008-7	Average Payment or Recoupment Amount for PHP
EXP-25-001-2	Sum of Payment or Recoupment Amount
EXP-25-002-1	Average absolute value of Payment or Recoupment Amount
MCR-28-001-1	% of plan IDs with capitation payment ratios <0.9 or >1.1 (non-PCCM)
EXP-22-009-9	% of records with Payment or Recoupment Amount = $0 or missing
EXP-24-009-9	% of records with Payment or Recoupment Amount = $0 or missing
EXP-22P-009-9	% of records with Payment or Recoupment Amount = $0 or missing, by Plan ID
EXP-22R-009-9	% of Plan IDs over the threshold for EXP-22P-009-9 (% of records with Payment or Recoupment Amount = $0 or missing, by Plan ID)
EL-8-002-2	Enrollment, capitation payments, capitation ratios, encounters (by claim file type) and encounter ratios (by claim file type) by plan ID with plan ID linking to MC file
MCR-53-001-1	Total # of managed care enrollments
MCR-53-002-2	Total # of managed care capitations

DE Number	System DE Number	DE Name	File Segment Number	File Segment Name
FTX157	FTX.005.157	PAYMENT-OR-RECOUPMENT-AMOUNT	FTX00005	COST-SHARING-OFFSET
FTX200	FTX.006.200	PAYMENT-OR-RECOUPMENT-AMOUNT	FTX00006	VALUE-BASED-PAYMENT
FTX244	FTX.007.244	PAYMENT-OR-RECOUPMENT-AMOUNT	FTX00007	STATE-DIRECTED-PAYMENT-SEPARATE-PAYMENT-TERM
FTX287	FTX.008.287	PAYMENT-OR-RECOUPMENT-AMOUNT	FTX00008	COST-SETTLEMENT-PAYMENT
FTX326	FTX.009.326	PAYMENT-OR-RECOUPMENT-AMOUNT	FTX00009	FQHC-WRAP-PAYMENT
FTX365	FTX.095.365	PAYMENT-OR-RECOUPMENT-AMOUNT	FTX00095	MISCELLANEOUS-PAYMENT

Published Date	Data Guide Version	Data Element	Action	Field	Before	After
09/16/2024	4.0.0	FTX.002.025	UPDATE	File segment	None	68
09/16/2024	4.0.0	FTX.002.025	ADD	N/A		Created